Complaints of reduced cognitive functioning during perimenopause: a cross-sectional analysis of the Japan Nurses' Health Study.

BACKGROUND: Many women experience various symptoms during the period of menopausal transition, including complaints of reduced cognitive functioning. However, these complaints are not necessarily recognized as core menopausal symptoms. In this study, we sought to characterize subjective complaints of reduced cognitive functioning by analyzing cross-sectional data from the Japan Nurses' Health Study (JNHS). METHODS: The JNHS 4-year follow-up questionnaire containing a 21-item climacteric symptom checklist, which included a question about "poor memory or forgetfulness", was mailed between 2005 and 2011 to all JNHS participants, regardless of their age at the time of the survey. We estimated the prevalence of slight and severe complaints in 5-year age-groups. We used principal component analysis to explore the underlying factors among the 21 symptoms during the menopausal transition period in women aged 45-54 years at the time of the survey. We also examined risk factors for complaints using multivariable modified Poisson regression analysis. RESULTS: In total, 12,507 women responded to the 4-year survey. The mean age at the time of the 4-year survey was 46.5 years (range 27-82). "Poor memory or forgetfulness" showed a peak prevalence of 81.7% (severe 27.9%; slight 53.8%) at 50-54 years, and gradually decreased after 55 years. Principal component analysis indicated that "poor memory or forgetfulness" belonged to somatic symptoms and was close to psychological symptoms in women aged 45-54 years. In women aged 45-54 years, the complaint was also significantly associated with hot flashes and sweats. Multivariable modified Poisson regression analysis showed that menopausal status (uncertain and postmenopausal), less sleep (sleep of < 5 h and sleep of 5- < 6 h), night-shift work, and severe vasomotor symptoms (VMS) were significantly associated with the prevalence of severe complaints of reduced cognitive functioning in women aged 45-54 years. CONCLUSIONS: We found that prevalence of "poor memory or forgetfulness" was highest during the menopausal transition period and among perimenopausal women. This subjective complaint was associated with somatic, psychological complaints and VMS. It may be useful for women with cognitive problems in the transition period to consider management of comorbid menopausal symptoms.

Acute psychiatric symptoms in a young woman with anti-N-methyl D-aspartate receptor encephalitis: A case of successful early diagnosis and therapeutic intervention.

This clinical image presents a report on the diagnosis and treatment of anti-NMDAR encephalitis, a rare disease. This report emphasizes the importance of a differential diagnosis for acute psychiatric symptoms. Accurate and timely diagnosis is critical for the selection and implementation of treatment and for optimal patient outcomes.

Multiple paraovarian cysts requiring emergency surgery: A rare clinical finding.

This report presents an unusual case of multiple paraovarian cysts that required emergency surgery due to a paraovarian cyst being entrapped by another paraovarian cyst. Laparoscopic surgery is considered useful for diagnostic and therapeutic purposes and is, therefore, recommended owing to difficulty in differentiating paraovarian cysts from ovarian cysts.

Laparoscopic surgery for a hydrocele of the canal of Nuck with an ovarian tumor: An extremely rare clinical finding.

This clinical image presents an unusual report of simultaneous laparoscopic resection of a hydrocele of the canal of Nuck and an ovarian tumor. Laparoscopic treatment with a proper approach is a useful technique in some cases.

Hypertensive disorders of pregnancy increase the risk of future menopausal hot flashes in Japanese women: results from the Japan Nurses' Health Study.

OBJECTIVE: We aimed to investigate whether hypertensive disorders of pregnancy (HDP) are associated with problematic hot flashes in Japanese women. METHODS: In this study, we included participants in the Japan Nurses' Health Study who were women aged 41 to 55 years at baseline, parous, and completed a 4-year follow-up questionnaire. The main outcome was self-reported problematic hot flashes. At the 4-year follow-up survey, we investigated hot flashes using the Climacteric Symptom Checklist for Japanese Women, which was developed by a subcommittee of the Japan Society of Obstetrics and Gynecology. RESULTS: At the baseline survey, of the 4,627 women included in the analysis, 610 (13.2%) reported a history of HDP. At the 4-year follow-up survey, 394 women (8.5%) reported problematic hot flashes, 529 (11.4%) were diagnosed with premenopausal hypertension, and 2,389 (51.5%) were postmenopausal. Multivariable logistic regression analysis revealed a multivariable-adjusted odds ratio (95% confidence interval) of problematic hot flashes for women with a history of HDP of 1.42 (1.04-1.94), compared with women without this history. Among women without premenopausal hypertension, the odds ratio increased to 1.55 (1.10-2.19) among women with HDP as compared with those without these disorders. CONCLUSIONS: In this prospective study, we found that women with a history of HDP have a significantly increased risk of problematic hot flashes, compared with their counterparts without a history of HDP.

Low back pain as an initial symptom of pregnancy-associated breast cancer: a case report.

BACKGROUND: Low back pain during pregnancy and postpartum is common and might not arouse clinical interest. Pregnancy-associated breast cancer is often found as a breast mass, but its diagnosis is difficult during pregnancy and postpartum. As more women delay their first pregnancies, its incidence may increase in the future. CASE PRESENTATION: The patient was a 30-year-old gravida 3, para 3. She had low back pain from the second trimester of her previous two pregnancies, which improved spontaneously after delivery. In her third pregnancy, she again developed low back pain in the second trimester. Her delivery was normal. However, her low back pain continued for up to 7 months postpartum and then worsened sharply. A whole-body scan revealed a compression fracture due to multiple spinal metastases of breast cancer. As she had not complained about her breasts, they had not been closely examined. CONCLUSIONS: This case shows the importance of considering bone metastases from breast cancer in the differential diagnosis of patients with low back pain during pregnancy and postpartum.

Validity of Self-Reported Diagnosis of Osteoporosis in Japan Nurses' Health Study.

PURPOSE: Although the validity of self-reported osteoporosis is often questioned, validation studies are lacking. This study was performed to investigate how well self-reported diagnoses of osteoporosis agreed with validated clinical information in young and middle-aged women in the Japan Nurses' Health Study (JNHS), a nationwide prospective cohort study of nursing professionals. PATIENTS AND METHODS: Data were reviewed for 15,717 subjects from the combined cohorts of the JNHS and a preceding pilot study (Gunma Nurses' Health Study). The subjects' mean age at the baseline (BL) survey was 41.6 ± 8.3 years, and the mean follow-up period was 11.5 ± 4.4 years. Participating nurses were mailed a follow-up questionnaire every 2 years. Respondents who self-reported a positive osteoporosis diagnosis during the study period were sent an additional confirmation questionnaire to corroborate the details. RESULTS: The number (proportion) of women with osteoporosis was 884 (5.6%) [primary osteoporosis, 812 (5.2%); secondary osteoporosis, 72 (0.5%)]. The cumulative incidence of osteoporosis at the age of 40, 50, 60, 70, and 80 years was estimated to be 0.1% (95% confidence interval, 0.1-0.2), 1.1% (0.9-1.3), 7.7% (7.0-8.4), 23.6% (21.6-25.7), and 54.2% (40.2-68.1), respectively. For BL and regular follow-up + expert review versus BL and regular follow-up + confirmation questionnaire + expert review, the positive predictive value (PPV) was 61.3% versus 85.6% and the negative predictive value (NPV) was 98.9% versus 98.2%, respectively. CONCLUSION: Self-reporting was associated with a high NPV for the incidence of osteoporosis. Although the PPV was slightly lower, additional corroborations by confirmation questionnaire might improve the PPV.

Prevalence of osteoporosis and osteopenia assessed by densitometry in Japanese puerperal women.

AIM: The aim is to examine the prevalence of low bone mineral density (BMD) (osteoporosis and osteopenia) of lumbar and femoral bones in puerperal women for the prenatal and postnatal care to ensure their optimal bone health. METHODS: We analyzed the first scan data of 1079 Japanese puerperal women without bone fracture (mean age 33.5 ± 4.5 years) who had undergone deliveries at Niigata City General Hospital for 10 years. We measured BMDs of the lumbar spine [LS], femoral neck [FN], and total hip [TH] with dual-energy X-ray absorptiometry (DXA) within 30 days after delivery. RESULTS: The rates of osteoporosis of LS, FN, TH, and comprehensive diagnosis (CD) were 0.6%, 4.8%, 1.5%, and 5.4%, respectively, and osteopenia were 20.2%, 39.5%, 29.3%, and 44.3%, respectively. The multivariable-adjusted odds ratio (OR) for body mass index (BMI) before pregnancy reflected significant decreases in risk for low BMD with an OR of 0.78 (95% CI: 0.74-0.82) with the 1 kg/m2 increases. In lean women (BMI < 18.5), 71% of them had low BMD. CONCLUSIONS: Approximately 50% of puerperal women had low BMD without bone fracture. BMD measurements at puerperium, especially for lean women, may be very useful for identifying at risk of osteoporosis in future.

Low Birth Weight and Prematurity Are Associated with Hypertensive Disorder of Pregnancy in Later Life: A Cross-Sectional Study in Japan.

OBJECTIVE: We previously reported that hypertensive disorder of pregnancy (HDP) was a risk factor for hypertension and hypercholesterolemia in later life. Additionally, the age-adjusted odds ratio (OR) of HDP was 2.72 for Japanese women whose mothers had a history of HDP versus those whose mothers did not. This study aimed to clarify the association of HDP with birth weight and gestational age. STUDY DESIGN: A self-administered baseline survey of the Japanese Nurses' Health Study (JNHS) cohort was conducted from 2001 to 2007. Data on 17,278 parous female nurses who knew their own birth weights were extracted from the JNHS baseline survey (n = 49,927) and subjected to cross-sectional, retrospective analysis. Data on weeks of gestation, birth weight, and history of HDP were collected. RESULTS: The age-adjusted ORs for HDP were 1.62 (95% confidence interval [CI]: 1.20-2.19) for birth weight <2,000 g, 1.24 (CI: 1.04-1.48) for 2,000 to 2,499 g, 1.11 (CI: 1.00-1.23) for 2,500 to 2,999 g, and 1.08 (CI: 0.94-1.24) for ≥3,500 g compared with 3,000 to 3,499 g. The age-adjusted ORs for HDP were 1.27 (95% CI: 1.04-1.54) for a gestational age < 37 weeks and 0.93 (0.70-1.23) for ≥42 weeks compared with 37-41 weeks. The age-adjusted OR of the birth weight score for HDP in later life was 0.98 (CI: 0.94-1.03; Cochran-Armitage trend test: z = 0.401, p = 0.688). CONCLUSION: Among women in Japan, a history of low birth weight and prematurity are risk factors for HDP in later life. The risk of HDP among women born with low birth weight and/or premature deserves attention.

Association of trajectory of body mass index with knee pain risk in Japanese middle-aged women in a prospective cohort study: the Japan Nurses' Health Study.

OBJECTIVES: To investigate whether body mass index (BMI) trajectory, lifestyle and reproductive factors are associated with knee pain risk among middle-aged women. DESIGN: Prospective study of the Japan Nurses' Health Study (JNHS). SETTING: The JNHS investigates the health of female nurses in Japan. Biennial follow-up questionnaires are mailed to the participants. PARTICIPANTS: The 7434 women aged over 40 years who responded to the 10-year self-administered follow-up questionnaire. PRIMARY OUTCOME MEASURE: Self-reported knee pain at the 10-year follow-up was the primary outcome. We analysed BMI (normal or overweight) trajectory data from a baseline survey to the 10-year follow-up survey using group-based trajectory modelling. Exposure measurements were BMI trajectory, BMI at age 18 years, lifestyle variables and reproductive history. RESULTS: BMI trajectories from baseline to the 10-year follow-up were divided into four groups: remained normal, remained overweight, gained weight or lost weight. At the 10-year follow-up, 1281 women (17.2%) reported knee pain. Multivariable logistic regression analysis revealed that compared with the remained normal group, multivariable-adjusted ORs (95% CI) of knee pain were 1.93 (1.60 to 2.33) for the remained overweight group, 1.60 (1.23 to 2.08) for the gained weight group and 1.40 (0.88 to 2.21) for the lost weight group. The attributable risk percent (95% CI) of the remained overweight group was 48.1% (37.3% to 57.0%) compared with the reference group of remained normal. Alcohol intake at baseline was significantly associated with knee pain. CONCLUSIONS: The lost weight group had a lower risk than the remained overweight group and the gained weight group and did not carry statistically significant risks for knee pain. Weight reduction and maintaining a normal BMI in middle age was important for preventing knee pain in women.

Parity and Number of Teeth in Japanese Women: Results from the Japan Nurses' Health Study.

Background: Parity is thought to be associated with a decreased number of teeth present in women. However, educational level and social status, which are particularly significant risk factors for loss of teeth, have been heterogeneous in previous observations. This cross-sectional survey aimed to clarify the associations of parity with the risk of having <20 teeth in Japanese female nurses participating in the Japan Nurses' Health Study (JNHS). Methods: In the third follow-up questionnaire of the JNHS, 11,299 women aged 27-82 years participated in this study. The number of participants according to age range was 7,225 (63.9%) aged <50 years and 4,074 (36.1%) aged ≥50 years. Information on parity and risk factors for loss of teeth was collected through a baseline questionnaire and then a follow-up questionnaire. Multivariate logistic regression analysis was used to calculate the adjusted odds ratio (OR) and 95% confidence interval (CI) of having <20 teeth according to parity category. Results: Participants ≥50 years who had experienced three or more deliveries had a significantly higher risk of having <20 teeth than those who had not experienced delivery (OR = 1.59, 95% CI = 1.14-2.20), although this finding was not observed in participants <50 years. In addition to parity, age and current smoking may be independent risk factors for having <20 teeth in Japanese nurses. Conclusions: Higher-parity female nurses ≥50 years may be more likely to lose teeth than those who have not experienced delivery.

Guidelines for office gynecology in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2017 edition.

Six years after the first edition of The Guideline for Gynecological Practice, which was jointly edited by The Japan Society of Obstetrics and Gynecology and The Japan Association of Obstetricians and Gynecologists, the third revised edition was published in 2017. The 2017 Guidelines includes 10 additional clinical questions (CQ), which brings the total to 95 CQ (12 on infectious disease, 28 on oncology and benign tumors, 27 on endocrinology and infertility and 28 on healthcare for women). Currently a consensus has been reached on the Guidelines and therefore the objective of this report is to present the general policies regarding diagnostic and treatment methods used in standard gynecological outpatient care that are considered appropriate. At the end of each answer, the corresponding recommendation level (A, B, C) is indicated.

[Epidemiology and pathophysiology of post-pregnancy osteoporosis.]

Post-pregnancy osteoporosis is a rare condition with little known pathophysiology. Most cases are diagnosed in the late stage of pregnancy or in the post partum while breastfeeding, particularly in first pregnancy. Non-traumatic vertebral fragility fractures are most commonly observed and characterized by prolonged severe pain and functional limitations. Conventional radiography will confirm the fracture in most cases, and magnetic resonance, which can be safely used during pregnancy, is effective in detecting vertebral fractures and bone marrow edema. It is important to exclude secondary osteoporosis, e.g. endocrine diseases, chronic liver and kidney diseases, autoimmune diseases, genetic diseases, drugs and malignant tumors. The prevalence of post-pregnancy osteoporosis is unknown, and may be estimated more than 3 for every ten thousand pregnant women. The pathophysiology of post-pregnancy osteoporosis is also unknown. The physiological bone resorption during reproduction does not normally cause fracture;instead, women who do fracture may be more likely to have additional secondary causes of bone loss and fragility, e.g. low body weight, low peak bone mass, malnutrition and heredity.

Japan Society of Obstetrics and Gynecology and Japan Society for Menopause and Women's Health 2017 guidelines for hormone replacement therapy.

Hormone replacement therapy (HRT) plays a large part in maintaining and improving the quality of life (QOL) of postmenopausal women. Despite this obvious role, the use of HRT has stagnated in Japan as well as the United States, since the interim report of the HRT trial of Women's Health Initiative study was published in 2002. The Japan Society of Obstetrics and Gynecology and Japan Society for Menopause and Women's Health formulated the Guidelines for Hormone Replacement Therapy in 2009, which was subsequently revised in 2012, with the aim of organizing perceptions about HRT and allowing people to provide or receive HRT with a sense of security. Later on, in light of changes in indications for HRT and attitudes toward its impact on cancer risks, amendments were made again in 2017. With the establishment of the 2017 guidelines, practitioners in Japan are able to address various issues related to HRT with more appropriate judgment. Moreover, the practice of reliable, safe and effective HRT is expected to promote further efforts toward improvement or maintenance of QOL in patients.

[Calcium and bone metabolism across women's life stages. Pathophysiology, adiagnosis and treatment of post-pregnancy osteoporosis.]

Post-pregnancy osteoporosis is a rare condition with little known pathophysiology. Most cases are diagnosed in the late stage of pregnancy or in the post-partum while breastfeeding, particularly in first pregnancy. Vertebral fractures are most commonly observed and characterized by prolonged severe pain and functional limitations. Measurements of bone mineral density(BMD)of the lumbar spine and proximal femur with dual energy X-ray absorptiometry(DXA)are the clinical methods most commonly used for no fracture women. Conventional radiography will confirm the fracture in most cases, and magnetic resonance(MR), which can be safely used during pregnancy, is effective in detecting vertebral fractures and bone marrow edema. Although the bone resorption increased at the end of pregnancy and lactation, the bone formation increases and the bone structure is almost recovered after cessation of lactating in postpartum. There is much uncertainty about whether pharmacological treatments should be used for osteoporosis that presents during pregnancy and lactation. This is partly because of the lack of a firm evidence base for treatment and also because there is a spontaneous recovery of bone mass and strength after pregnancy or weaning.

Fetiform teratoma was a parthenogenetic tumor arising from a mature ovum.

The aim of this study was to investigate the parthenogenetic origin of fetiform teratoma by using molecular genetic studies and methylation status analyses. A fetiform teratoma was removed from a 35-year-old nulligravida woman. Genotyping of microsatellite marker loci, microarray analysis of single-nucleotide polymorphism (SNP) loci and methylation status analysis of the differentially methylated region (DMR) within the human IGF2-H19 locus were performed. Karyotypes of the host and the fetiform teratoma were 46, XX. The fetiform teratoma was homozygous at all loci and meiotic recombinations in the tumor were confirmed by SNP microarray analysis. Methylation analysis indicated that the host had both methylated and unmethylated IGF2-H19 DMR alleles, while the fetiform teratoma had unmethylated alleles only. Genetically, the fetiform teratoma had homozygous genotypes with meiotic recombination and a duplicated unmethylated host allele, indicating that it was a parthenogenetic tumor arising from a mature ovum after meiosis II. This is the first demonstration of a fetiform teratoma originating from a mature haploid ovum.

Ovarian infertility is associated with cardiovascular disease risk factors in later life: A Japanese cross-sectional study.

OBJECTIVES: This study aimed to clarify the association between ovarian infertility and cardiovascular disease risk factors in later life in Japanese women. STUDY DESIGN: The Japan Nurses' Health Study (JNHS) is a cohort study of Japanese women's health. Data from the JNHS baseline survey (n = 49,927) between 2001 and 2007 were used in a cross-sectional, retrospective analysis. A total of 44,601 women were classified into three categories: ovarian infertility group (n=1167), other infertility group (n = 4619), and no infertility group (n = 38,815). Logistic regression analysis compared with the no infertility group was performed. MAIN OUTCOME MEASURES: Age-adjusted odds ratios (ORs) and multivariable-adjusted ORs for hypertension, hypercholesterolemia, and diabetes mellitus (DM). RESULTS: The prevalence of obese women (BMI ≥ 25) who were < 45 years old in the ovarian infertility group was significantly higher compared with that in the other groups. Women in the ovarian infertility group were at risk for hypertension at ≥ 45 years old (age-adjusted OR: 1.65%, confidence interval [CI]: 1.23-2.21); for hypercholesterolemia at < 45 and ≥ 45 years old (age-adjusted OR: 1.42, 95% CI: 1.06-1.88 at < 45 years; age-adjusted OR: 1.39, 95% CI: 1.06-1.81 at ≥ 45 years); and for DM at < 45 years old (age-adjusted OR: 2.92, 95% CI: 1.57-5.46). CONCLUSIONS: Japanese women with ovarian infertility (most women have polycystic ovary syndrome) are at high risk of hypertension from 45 years of age, hypercholesterolemia at all ages, and diabetes mellitus (DM) before 45 years old.

Outcomes of treatment with cyclic administration of dienogest after ovarian endometriotic cystectomy.

To evaluate the outcomes of patients treated with cyclic administration of dienogest after ovarian endometriotic cystectomy, following the completion of treatment. We retrospectively evaluated 26 patients treated with dienogest (2 mg/day) after cystectomy (revised American Society for Reproductive Medicine [r-ASRM] stage III-IV) in a pilot study. Dienogest was administered cyclically, for a total of six cycles, each comprising three weeks on and one week off. Outcomes of interest included severity of menstrual pain and recurrence of cysts at baseline, during the immediate post-treatment period and at the final outpatient follow-up. The mean outpatient follow-up period was 45.0 months. The visual analog scale score for menstrual pain following 6 cycles of dienogest treatment was significantly lower than that at baseline; it remained low at the final follow-up. The recurrence rates of cysts were 4% and 21% at 24 and 48 months after the completion of dienogest treatment, respectively. Six patients with recurrent disease were all classified as having r-ASRM stage IV. Our results suggest that cyclic dienogest for six months after cystectomy could relieve menstrual pain and reduce the recurrence of cysts, for approximately four years. The necessary treatment period for patients with r-ASRM stage IV disease requires further study.

Relief of uterine bleeding by cyclic administration of dienogest for endometriosis.

OBJECTIVE: This study assessed the relief of uterine bleeding and clinical symptoms during cyclic administration of dienogest for the treatment of endometriosis. METHODS: In total, 25 patients undergoing ovarian cyst enucleation and given dienogest participated in this study. Dienogest 2 mg/day was administered for 3 weeks, and the drug was then withdrawn for 1 week (cyclic administration of dienogest). This 4-week cycle was repeated six times. Patients' records were prospectively analyzed for the number of days on which any uterine bleeding occurred, as well as menstrual pain before and after the start of dienogest administration were evaluated with a view to using the data obtained herein as the basis. RESULTS: During the period of cyclic administration of dienogest, uterine bleeding occurred on 5.8 to 7.7 days per 4-week period on an average through cycles. Of uterine bleeding episodes, menstruation-like uterine bleeding was present in about 80% of patients. The visual analog scale (VAS) value for menstrual pain significantly decreased from 3.8 before dienogest administration after surgery to 1.5 at the completion of cycle 1, VAS remained low thereafter. CONCLUSION: These results raise the possibility that cyclic administration of dienogest may relieve lessen uterine bleeding, a major adverse event and menstrual pain.