The Menopause Transition: Signs, Symptoms, and Management Options.

CONTEXT: Menopause, the permanent cessation of menses, reflects oocyte depletion and loss of gonadal steroids. It is preceded by a transition state, the perimenopause, which is characterized by the gradual loss of oocytes, altered responsiveness to gonadal steroid feedback, wide hormonal fluctuations, and irregular menstrual patterns. The goal of this mini-review is to discuss the basic pathophysiology of the menopausal transition and the hormonal and nonhormonal management of clinicopathology attributed to it. EVIDENCE ACQUISITION: A Medline search of epidemiologic, population-based studies, and studies of reproductive physiology was conducted. A total of 758 publications were screened. EVIDENCE SYNTHESIS: The reproductive hormonal milieu of the menopausal transition precipitates bothersome vasomotor symptoms, mood disruption, temporary cognitive dysfunction, genitourinary symptoms, and other disease processes that reduce the quality of life of affected women. The endocrine tumult of the menopause transition also exposes racial and socioeconomic disparities in the onset, severity, and frequency of symptoms. Hormone therapy (HT) treatment can be effective for perimenopausal symptoms but its use has been stymied by concerns about health risks observed in postmenopausal HT users who are older than 60 and/or women who have been postmenopausal for greater than 10 years. CONCLUSIONS: The menopause transition is a disruptive process that can last for over a decade and causes symptoms in a majority of women. It is important for clinicians to recognize early signs and symptoms of the transition and be prepared to offer treatment to mitigate these symptoms. Many safe and effective options, including HT, are available.

The influence of educational level in peri-menopause syndrome and quality of life among Chinese women.

Objective: To investigate the influence of education level in the peri-menopausal symptoms and quality of life (QoL) among Chinese women.Methods: We carried out a cross-sectional study of 1632 peri-menopausal women (age 40-60 y) who visited Hangzhou Women's Hospital from November 2018 to November 2019. The menopausal symptoms were evaluated by modified Kupperman index (KI). World Health Organization Quality of Life (WHOQOL-BREF) questionnaire was used to evaluate the QoL.Result: In total, 1501 women were included in the analysis. The mean age of natural menopause was 49.63 years in China. The five most frequent symptoms in menopausal women were Hot flash (75.53%), sexual problems (72.62%), insomnia (67.29%), fatigue (65.56%), and irritability (61.89%). Natural menopausal age, parity, BMI, bone mineral density, depression, skin formication, total score of KI, and the score of WHOQOL-BREF questionnaire were different in different educational background women (p < .05).Conclusions: The results of the study suggest that education level is associated with the age of natural menopause and menopausal symptoms. A high educational level is correlated with a better score of WHOQOL-BREF in peri-menopause women.

Behavioral weight loss for the management of menopausal hot flashes: a pilot study.

OBJECTIVE: Although adiposity has been considered to be protective against hot flashes, newer data suggest positive relationships between hot flashes and adiposity. No studies have been specifically designed to test whether weight loss reduces hot flashes. This pilot study aimed to evaluate the feasibility, acceptability, and initial efficacy of behavioral weight loss in reducing hot flashes. METHODS: Forty overweight or obese women with hot flashes (≥ 4 hot flashes/d) were randomized to either behavioral weight loss intervention or wait-list control. Hot flashes were assessed before and after intervention via physiologic monitoring, diary, and questionnaire. Comparisons of changes in hot flashes and anthropometrics between conditions were performed via Wilcoxon tests. RESULTS: Study retention (83%) and intervention satisfaction (93.8%) were high. Most women (74.1%) reported that hot flash reduction was a major motivator for losing weight. Women randomized to the weight loss intervention lost more weight (-8.86 kg) than did women randomized to control (+0.23 kg; P < 0.0001). Women randomized to weight loss also showed greater reductions in questionnaire-reported hot flashes (2-wk hot flashes, -63.0) than did women in the control group (-28.0; P = 0.03)-a difference not demonstrated in other hot flash measures. Reductions in weight and hot flashes were significantly correlated (eg, r = 0.47, P = 0.006). CONCLUSIONS: This pilot study shows a behavioral weight loss program that is feasible, acceptable, and effective in producing weight loss among overweight or obese women with hot flashes. Findings indicate the importance of a larger study designed to test behavioral weight loss for hot flash reduction. Hot flash management could motivate women to engage in this health-promoting behavior.

IMS study of climate, altitude, temperature and vasomotor symptoms in the United Arab Emirates.

OBJECTIVE: To examine the relationships between temperature, season (summer versus winter), lifestyle, health, mood, beliefs, and experience of hot flushes and night sweats (HFNS), amongst mid-aged women living in the United Arab Emirates (UAE). METHODS: The UAE climate is hyper-arid, being a hot desert climate, with warm winters and hot summers. A total of 372 peri- and postmenopausal women, aged from 45 to 55 years, from urban UAE regions were included. Data were collected during both summer and winter months. Participants completed questionnaires eliciting information about sociodemographics, HFNS (prevalence, frequency and problem-rating), health and lifestyle (body mass index (BMI), diet, exercise), mood (Women's Health Questionnaire) and menopause attributions and beliefs (Menopause Representations Questionnaire). RESULTS: HFNS were currently being experienced by 46.5% of women, with an average weekly frequency of five and problem-rating of 5.7/10. Seasonal variation in temperature was not associated with prevalence, frequency or problem-rating. Hot flush prevalence was associated with poor health, life satisfaction, mood, employment, lower BMI and diet. Higher frequency was associated with higher BMI and more years since the last period. HFNS were more problematic mainly for women who reported lower life satisfaction and held more negative beliefs about the menopause. CONCLUSIONS: In this UAE study, temperature and seasonal temperature variation did not appear to influence HFNS-reporting, but health, life satisfaction, BMI, beliefs and lifestyle factors partially explained women's experiences of menopausal symptoms. A qualitative study might provide further information about the meanings of HFNS and menopause amongst UAE women.

A multicentric study regarding the use of hormone therapy during female mid-age (REDLINC VI).

BACKGROUND: Menopausal hormone therapy (HT) has shown benefits for women; however, associated drawbacks (i.e. risks, costs, fears) have currently determined its low use. OBJECTIVE: To determine the prevalence of current HT use among mid-aged women and describe the characteristics of those who have never used, have abandoned or are currently using HT. In addition, reasons for not using HT were analyzed. METHOD: This was a cross-sectional study that analyzed a total of 6731 otherwise healthy women (45-59 years old) of 15 cities in 11 Latin American countries. Participants were requested to fill out the Menopause Rating Scale (MRS) and a questionnaire containing sociodemographic data and items regarding the menopause and HT use. RESULTS: The prevalence of current HT use was 12.5%. Oral HT (43.7%) was the most frequently used type of HT, followed by transdermal types (17.7%). The main factors related to the current use of HT included: positive perceptions regarding HT (odds ratio (OR) 11.53, 95% confidence interval (CI) 9.41-14.13), being postmenopausal (OR 3.47, 95% CI 2.75-4.36) and having a better socioeconomic level. A total of 48.8% of surveyed women had used HT in the past, but abandoned it due to symptom improvement or being unconcerned; fear of cancer or any other secondary effects were also reported but in less than 10%. Among women who had never used HT, 28% reported the lack of medical prescription as the main reason, followed by the absence of symptoms (27.8%). Among those reporting lack of prescription as the main reason for not using HT, 30.6% currently had severe menopausal symptoms (total MRS score > 16); 19.5% of women were using alternative 'natural' therapies, with 35.1% of them displaying severe menopausal symptoms as compared to a 22.5% observed among current HT users. CONCLUSION: The use of HT has not regained the rates observed a decade ago. Positive perceptions regarding HT were related to a higher use. Lack of medical prescription was the main reason for not using HT among non-users, many of whom were currently displaying severe menopausal symptoms.

An International Menopause Society study of climate, altitude, temperature (IMS-CAT) and vasomotor symptoms in urban Indian regions.

OBJECTIVE: To examine the relationships between climate (season, temperature, humidity), lifestyle, health, mood and beliefs and experience of hot flushes and night sweats amongst mid-aged women living in eight urban Indian centers. METHODS: A total of 717 peri- and postmenopausal women, aged 45-55 years, from urban centers in different regions of India were included. Data were collected during both summer and winter months. Participants completed questionnaires eliciting information about sociodemographics, hot flushes (prevalence, frequency and problem-rating), health and lifestyle (body mass index, diet, exercise, alcohol use), mood (Women's Health Questionnaire) and attributions and beliefs (Menopause Representations Questionnaire). RESULTS: The prevalence of vasomotor symptoms was low, with 34% of the sample reporting hot flushes and/or night sweats. Seasonal variation in temperature was not associated with hot flush prevalence, frequency or problem rating. Hot flush prevalence was mainly associated with higher anxiety and intake of spicy foods, frequency with (older) age and (more) frequent exercise, while hot flushes were more problematic for women who reported poorer general health and more negative beliefs about menopause. CONCLUSIONS: In this study of Indian women, seasonal temperature variation did not appear to influence hot flush reporting. Health, mood, beliefs and lifestyle factors appear to explain some, but not all, of the variance in experience of menopausal symptoms.

Characteristics of breast cancer patients who experience menopausal transition due to treatment.

OBJECTIVE: To identify patient-related and treatment-related factors associated significantly with climacteric symptoms in young patients who experience menopausal transition due to adjuvant treatment for breast cancer. METHODS: This cross-sectional study used questionnaire data collected to screen breast cancer patients for participation in a multicenter trial on the efficacy of supportive interventions for treatment-induced menopausal symptoms. The screening instrument included questions on sociodemographics, menopausal history and current menopausal status and symptoms, treatment history and lifestyle factors. Univariate and multivariate analyses were used to identify factors associated significantly with two major menopausal symptoms, hot flushes/night sweats and vaginal dryness. RESULTS: In total, 435 patients were included in this study. Hot flushes/night sweats exhibited a significant, negative association with education and a significant positive association with alcohol consumption, and having been treated with the combination of chemotherapy and hormonal therapy. Vaginal dryness was positively associated with combined treatment with chemotherapy and hormonal therapy. CONCLUSIONS: Menopausal symptoms among young breast cancer patients who experience menopausal transition due to adjuvant treatment are associated with a number of sociodemographic, lifestyle and treatment-related factors. Carefully designed interventions to prevent or alleviate these symptoms should take these factors into account.

A pilot phase II trial of magnesium supplements to reduce menopausal hot flashes in breast cancer patients.

BACKGROUND: We tested if magnesium would diminish bothersome hot flashes in breast cancer patients. METHODS: Breast cancer patients with at least 14 hot flashes a week received magnesium oxide 400 mg for 4 weeks, escalating to 800 mg if needed. Hot flash score (frequency × severity) at baseline was compared to the end of treatment. RESULTS: Of 29 who enrolled, 25 women completed treatment. The average age was 53.5 years; six African American, the rest Caucasian; eight were on tamoxifen, nine were on aromatase inhibitors, and 14 were on anti-depressants. Seventeen patients escalated the magnesium dose. Hot flash frequency/week was reduced from 52.2 (standard error (SE), 13.7) to 27.7 (SE, 5.7), a 41.4% reduction, p = 0.02, two-sided paired t test. Hot flash score was reduced from 109.8 (SE, 40.9) to 47.8 (SE, 13.8), a 50.4% reduction, p = 0.04. Of 25 patients, 14 (56%) had a >50% reduction in hot flash score, and 19 (76%) had a >25% reduction. Fatigue, sweating, and distress were all significantly reduced. Side effects were minor: two women stopped the drug including one each with headache and nausea, and two women had grade 1 diarrhea. Compliance was excellent, and many patients continued treatment after the trial. CONCLUSIONS: Oral magnesium appears to have helped more than half of the patients and was well tolerated. Side effects and cost ($0.02/tablet) were minimal. A randomized placebo-controlled trial is planned.

Challenges and opportunities to manage depression during the menopausal transition and beyond.

Women are at a higher risk than men of developing depression and anxiety and such increased risk might be particularly associated with reproductive cycle events. Recent evidence suggests that the transition to menopause may constitute a window of vulnerability for some women for the development of new onset and recurrent depression. Several biological and environmental factors seem to be independent predictors or modulating factors for the occurrence of depression in menopausal women; they include the presence and severity of hot flushes, sleep disturbances, history of severe premenstrual syndrome or postpartum blues, stressful life events, history of depression, socioeconomic status, and use of hormones and psychotropic agents. The regulation of monoaminergic systems by ovarian hormones might explain, at least in part, the emergence of depressive symptoms and/or anxiety in biologically predisposed subpopulations. The use of transdermal estradiol, as well as serotonergic and noradrenergic antidepressants, is an efficacious strategy in the treatment of depression and vasomotor symptoms in symptomatic women in midlife. In this review, the authors discuss the existing evidence of a greater risk for the development of depression during the menopausal transition and the putative underlying mechanisms contributing to this window of vulnerability. Hormonal and nonhormonal treatment strategies for depression and anxiety in this particular population are critically examined, although more tailored treatment options are still needed.

Assessment of bone mineral density should be considered earlier in perimenopausal women with vasomotor symptoms.

OBJECTIVE: To investigate the relationship between vasomotor symptoms (hot flashes) and osteopenia or osteoporosis in perimenopausal women. METHOD: In this cross-sectional study 79 perimenopausal women aged between 45 and 55 years and seen at the Gynecology or Menopause Outpatient Clinic of Marmara University School of Medicine were allotted to one of 2 groups according to the presence or absence of hot flashes. The groups were then compared for bone mineral density (BMD) of the lumbar vertebrae, as measured by dual energy X-ray absorptiometry. RESULTS: The mean BMD measurement for vertebrae L2 to L4 was 0.32+/-0.19 for the group with no hot flashes and -0.53+/-0.21 for the group with hot flashes (P=0.007). In the former, 6.1% of the women and in the latter, 32.6% of the women had a BMD value less than a 1.5 standard deviation from the mean (P=0.005). CONCLUSION: Women with vasomotor symptoms are more prone to have osteopenia or osteoporosis.

Assessment of the variation in menopausal symptoms with age, education and working/non-working status in north-Indian sub population using menopause rating scale (MRS).

OBJECTIVE: To study the variation of the menopause rating scale (MRS) scores with age, working/non-working and educated/uneducated status in a cohort of north-Indian subpopulation and to look for the possible reasons for the incurred variations. MRS is a well-known and validated instrument for assessing the frequency and intensity of menopausal symptoms. METHOD: A menopause clinic was organized in collaboration with a primary care centre (under the guidance of a gynecologist). A random sample of 208 women aged 35-65 years participated in the study. The MRS scale, a self-administered standardized questionnaire was applied with additional patient related information (age at menopause, level of education, working/non-working and exercising or not). RESULTS: The results were evaluated for psychological (P), somatic (S), and urogenital (U) symptoms. The average age at which menopause set in, in the cohort was found to be 48.7+/-2.3 years (46.4-51 years). Based on the average age at the menopause, the cohort was divided into peri (35-45), menopausal/early menopause (46-51) and the postmenopausal (52-65) groups. A significantly higher % of perimenopausal women (36%) showed a P score of > or =7; while a higher % of postmenopausal showed S score and U score > or =7 (>40%; p< or =0.001). Working women seem to suffer more from psychological symptoms whereas non-working women showed a greater incidence of somatic symptoms. Educated women showed a lower incidence of psychological and somatic symptoms. CONCLUSIONS: Present study indicates that age, level of education and working/non-working status (in a group of women with same socio-cultural background) may also contribute to significant variations in menopausal symptoms.

Changing use of hormone therapy among minority women since the Women's Health Initiative.

OBJECTIVE: There has been a significant shift in the use of hormone therapy (HT) among nonminority women since the publication of results of the Women's Health Initiative (WHI). Little is known about how the WHI results affected minority populations. This survey measured patterns of HT use among inner city women after publication of the WHI results, identified factors involved in the decision to continue or discontinue HT, and characterized the symptom burden and the experience of women who attempted to discontinue HT. DESIGN: We conducted a cross-sectional survey of 101 English- and Spanish-speaking women in an inner city general internal medicine clinic from August 2003 to April 2004. All women had been taking HT at the time of the publication of the WHI results. The survey included questions on patient-reported experience with HT, symptoms of menopause, and use of alternative treatments. RESULTS: Overall, 101 of 142 (71%) eligible women agreed to participate. The mean age of participants was 60 years; 43% were African American and 46% were Hispanic. The mean duration of HT use was 9.6 years. Three quarters (74%) had heard about the WHI findings, and 87% had attempted to stop taking HT after their publication. The most common reason for attempting to stop HT was concern about an increased risk of cancer or a general increase in risk to health. Of those who stopped HT, the vast majority (85%) reported vasomotor symptoms, and 26% restarted HT, mostly to treat those symptoms. CONCLUSIONS: Nearly all minority women in this small sample attempted to stop HT use after the results of the WHI were published. Restarting HT for treatment of symptoms was common.

Menopausal symptoms in Hispanic women and the role of socioeconomic factors.

The objective of this study was to assess differences in menopausal symptoms between postmenopausal (PM) Hispanic (H) and PM Caucasian (C) women. This was a prospective survey. Data from a convenience sample of 404 PM women (50% H, 50% C) were evaluated. Comparing H with C women, statistically significant differences (P < 0.05) in symptoms were noted with mood changes (76% H, 54% C), a decrease in energy (56% H, 36% C), palpitations (54% H, 26% C), breast tenderness (39% H, 28% C), memory loss (34% H, 22% C), and vaginal dryness (34% H, 44% C). When controlling for education and income, there were differences in mood changes, a decrease in energy and palpitations between the groups. Consistent with previous data, hot flashes (80% H, 75% C) and night sweats (67% H, 64% C) were the most common symptoms in the PM C women, and there were no significant differences compared with PM H women. Symptoms reported by PM C women in this sample are consistent with rates in the literature, but PM H women reported several symptoms at a higher rate. These differences remain when socioeconomic factors are considered, suggesting ethnicity may be an independent variable in menopausal symptomatology.

Breast cancer: relationship between menopausal symptoms, physiologic health effects of cancer treatment and physical constraints on quality of life in long-term survivors.

AIMS AND OBJECTIVES: The purpose of this study is to describe the relationship between menopausal symptoms, physiologic health effects of cancer treatment and the physical contributors to quality of life in long-term survivors of breast cancer. BACKGROUND: The treatment of menopausal symptoms is hotly debated, especially for women with breast cancer. Common treatments for menopausal symptoms are considered to be contraindicated in women with breast cancer. DESIGN: This is a descriptive, cross-sectional study of long-term breast cancer survivors; a subset of a study that responded to a mailed survey targeting long-term cancer survivors treated at The University of Texas M.D. Anderson Cancer Center. METHODS: In 291 breast cancer patients information was available that included items that commonly relate to menopausal symptoms including hot flushes, painful sexual intercourse, inability to concentrate, fatigue and sleep disturbances. RESULTS: Ninety per cent were Caucasian American and the mean time since diagnosis was 16 +/- 8 years. All patients had been treated with surgery, (60%) with radiotherapy, (68%) with chemotherapy and (37%) with hormonal therapy. Forty-six per cent of the breast cancer survivors indicated that having breast cancer affected their overall health. Self-reported health effects were more common in those survivors who had received a combination of chemotherapy and radiotherapy. A menopausal quality of life score was determined using the items about hot flushes, ability to concentrate, painful sexual intercourse, fatigue, unhappiness and sleep disturbances. CONCLUSIONS: This study reminds us that breast cancer and menopause are independent issues. Quality of life parameters need to be rigidly defined and time sensitive. There are complex interactions between quality of life indicators and specific physiologic consequences of treatment. However, menopausal signs and symptoms may not be different for the breast cancer survivor and they should not be confused with the quality of life/psychosocial issues of the cancer survivor. RELEVANCE TO CLINICAL PRACTICE: Menopause is not a disease process but a normal developmental stage for women. It is important for nurses not only to understand the client needs of the menopausal woman, but also to be able to differentiate between quality of life issues related to menopause and to cancer treatment in order to provide holistic nursing care.

Assessment and treatment of hot flushes and menopausal mood disturbance.

More than 1 million women are expected to reach menopause each year, many of whom will experience hot flushes and other neuropsychological symptoms that may diminish their quality of life. Hot flushes are the core symptoms that reflect the brain's response to the changing hormonal milieu of the menopause transition, particularly to the rapidly fluctuating and falling levels of estradiol. The physical symptoms of hot flushes and the associated changes in sleep, mood, and cognition will lead many women to seek medical care. It is critical to understand the interrelationship of hot flushes and other neuropsychological symptoms of the menopause transition so that treatment priorities can be established. For example, if sleep disruption explains most daytime neuropsychological problems in women with hot flushes, treating insomnia should be considered a priority. Alternatively, mood, cognition, and quality of life may be disturbed independent of sleep problems. In such a situation, each symptom should be evaluated separately from any assessment of sleep. As recent data from the WHI establish the risks of long-term HRT use, concern about using HRT, even as a short-term intervention, has increased substantially. Although HRT remains the first-line treatment for hot flushes, the WHI findings have drawn attention to nonhormonal treatments of hot flushes and other menopausal symptoms. Growing evidence to support the efficacy of serotonergic antidepressants and other psychoactive medications in the treatment for hot flushes suggests that nonhormonal interventions will prove important alternatives to HRT. As further evidence of the benefits of psychoactive medications for menopausal symptoms is established, the choice between using hormonal and nonhormonal therapies for management of menopausal symptoms will continue to evolve.

Continuing education: Comprehensive menopausal assessment: an approach to managing vasomotor and urogenital symptoms in breast cancer survivors.

PURPOSE/OBJECTIVES: To describe the development and implementation of a comprehensive menopausal assessment (CMA) and intervention program for women with a history of breast cancer. DATA SOURCES: Published articles selected from computerized databases, conference proceedings, bibliographies of pertinent articles and books, and lay publications. DATA SYNTHESIS: The CMA program consisted of a structured, comprehensive assessment of three symptoms (hot flashes, vaginal dryness, and stress urinary incontinence) and an individualized plan of education, counseling, nonestrogen treatments, psychosocial support, referrals, and follow-up. CONCLUSIONS: A structured approach to evaluating and managing vasomotor and urogenital symptoms with, for example, the CMA, may help breast cancer survivors with severe symptoms more effectively manage these symptoms than "usual care." IMPLICATIONS FOR NURSING: Nurses providing care for women with a history of breast cancer can incorporate the key elements of the CMA program into their practice to facilitate more effective management of three common menopausal symptoms that often are undertreated in this patient population.

Incidence and management of hot flashes in prostate cancer.

Hot flashes are as common in men who have been castrated due to prostate cancer as hot flashes are in women after menopause. The symptom can cause significant discomfort for a considerable length of time. The hot flashes are most likely caused by a reduction in sex-hormone levels, which, in turn, causes an instability in the hypothalamic thermoregulatory center. Calcitonin gene-related peptide is involved in menopausal hot flashes in women and possibly also in castrated men. The mainstays of treatment for castrated men with hot flashes remain estrogens, progesterone, and cyproterone acetate, each of which has different side effects. Other treatments for hot flashes include clonidine and antidepressants and, according to one uncontrolled study, electrostimulated acupuncture. Nonetheless, there is a need for more effective and less toxic treatments. In this review, we will discuss the prevalence, duration, distress, physiology, and treatment options of hot flashes in men subjected to castration therapy due to prostate cancer.