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March/April 1995 45
The Massachusetts Women’s Health Study:
An Epidemiologic Investigation of the Menopause
NANCY E. AVIS, PhD
SONJA M. MCKINLAY, PhD
This paper presents findings from the
Massachusetts Women’s Health Study
(MWHS), one of the largest population-
based studies of mid-aged women. A
longitudinal study that followed a
population-based cohort of women as
they proceeded through menopause,
the MWHS’s goal was to describe
their responses and to identify health-
related, life-style, and other social fac-
tors that affect this transition. Find-
ings indicate that natural menopause
appears to have no major impact on
health or health behavior. The majori-
ty of women do not seek additional
help concerning menopause, and their
attitudes toward it are, overwhelming-
ly, positive or neutral. Physicians
treating mid-aged women must be
careful not to confuse “menopausal”
symptoms with indicators of underly-
ing disease or conditions unrelated to
menopause.
For many years, there was little scientific
research on menopause. Studying a nor-
mal physiologic event did not generate
much interest among scientists or the
National Institutes of Health, which
focused largely on disease. Since the early
1970s, the focus of menopause research
has increasingly rested on its potential
role in the etiology of some major age-
related diseases in women, such as cancer,1
cardiovascular disease,2osteoporosis,3
and depression.4Motivation for this
interest arose, at least in part, from the
fact that in Western or advanced soci-
eties, the overwhelming majority of
women now experience menopause and
can expect to live approximately 30 years
beyond it. Indeed, the number of years
women are expected to live beyond this
natural event is now nearly equivalent to
their reproductive life-span.
Much of the early research on meno-
pause (and some research today) was
based on clinical samples of women
who sought treatment for menopause-
related problems. These patient samples
presented a biased view of the natural
menopause and have resulted in a clinical
stereotype of the “typical” menopausal
woman, who experiences a broad range
of often diffuse symptoms. This clinical
stereotype has led to misdiagnosis and
treatment of conditions unrelated to
menopause as “menopausal.” This was
noted as early as 19445and is clearly evi-
dent in recent population-based studies
of the impact of estrogen replacement
therapy (ERT) on subsequent mortality.6,7
Data from such patient-based studies
represent a self-selected group of women
who sought medical care and thus pro-
vide an incomplete picture of the range
of normal responses to menopause. We
now know that fewer than 50% of
menopausal women seek menopause-
related treatment.8-11 Moreover, our study
and other population-based research
demonstrate that not all women have
annual checkups.12 Patient-based samples
are biased in terms of education, socio-
economic status, other health problems,
and incidence of general depression.8As
data from population and community-
based samples become available, a very
different picture emerges, one that chal-
lenges many of our long-held beliefs
about menopause.
While community-based studies pro-
vide data on the general population of
mid-aged women, the majority of them
have been cross-sectional and thus limit
researchers to inferring apparent associa-
tions.13 Cross-sectional studies can nei-
ther control for premenopausal charac-
teristics nor separate the effects of aging
from those of menopause. Longitudinal
cohort designs facilitate identification of
those associations that are most likely to
reflect a cause-effect relationship and can
also separate effects of aging from effects
of menopause.
In response to these methodological
issues, several community-based prospec-
tive studies were begun in the 1980s.
The largest and most comprehensive
prospective cohort study sampled from a
general population is the Massachusetts
Women’s Health Study (MWHS).14,15
The MWHS has sufficient numbers to
provide, for the first time, stable estimates
of parameters in the experience of natural
(as well as surgical) menopause.
This paper describes the MWHS and
some of its key findings, including the
normal menopause transition, symptoms
and health care behavior associated with
the menopause, women’s attitudes
toward the menopause, and depression.
The implications of these findings for
medical practice and future medical
investigations are also discussed.
The Massachusetts
Women’s Health Study
The goal of the MWHS was to describe
women’s responses to menopause as they
approached and experienced this event
and to identify those health-related, life-
style, and other social factors that affect
this experience. The study began with a
baseline cross-sectional survey in 198l-
1982 (T0) that employed a two-stage
cluster sampling design. First, 38 (10%)
Massachusetts cities/towns were selected,
with probabilities proportional to size,
within 12 strata defined by city/town
size, per capita income, and racial com-
position. Women born in the years
1926-1936, inclusive, were then ran-
domly selected from annually compiled
census lists in the selected cities/towns to
provide an approximately self-weighing
sample. A questionnaire was mailed to
each of the 13,000 selected women.
Postcard reminders were mailed a week
later and, if needed, a second question-
naire was sent two weeks after that. After
another three weeks, nonrespondents
were interviewed by telephone, if they
agreed to participate.
This design produced 8,050 usable
responses (adjusted response rate: 77%),
of which 74% were obtained by mail.
Unadjusted response rates in individual
Dr. Avis is principal research scientist and Dr.
McKinlay is president, both with the New England
Research Institutes, Watertown, Massachusetts.
towns ranged from 72% to 90%. A log-
linear analysis showed that response rates
were generally higher in smaller towns,
but did not vary with income or racial
composition. Responses were similar for
the two data collection methods. From
this cross-sectional sample, a cohort of
premenopausal women (N=2572;
response rate of 94% out of 2,721 eligi-
bles) was selected to be followed for five
years as they approached and experienced
menopause. Prospective study of the
cohort consisted of six telephone con-
tacts every nine months (T1to T6).
Retention of the cohort was excellent,
with response rates of 94% to 99% over
the six contacts. Of the initial cohort,
91% completed the final (sixth) contact.
A comparison of sociodemographic char-
acteristics of the sample with Massachu-
setts census data reveals that the sample
was more educated than the general pop-
ulation and slightly less likely to be never
married or separated.16 These differences,
however, do not have a significant impact
on analyses, as the sample was large enough
to include many women of various levels
of education and marital status, and
these variables are included in analyses.
To limit interview length to approxi-
mately 30 minutes, questions were
divided into four instruments. A core
instrument (administered at each inter-
view) included questions related to
menstrual status, physical health, health
care utilization, and sociodemographic
characteristics. The remaining three
instruments, covering social support net-
works, life-style (including depression),
and help-seeking behavior, were adminis-
tered in rotation, so that respondents
completed one of these three instruments
at each interview. Assignments were
rotated so that, after three interviews,
each woman had been administered each
of these three instruments once. Women
were randomly assigned to one of the
three possible orderings of instruments.
The group of women assigned to each
rotation did not differ in either educa-
tion or age. The same sequence was
used for interviews four through six.
Thus, during the course of the study,
each respondent completed each supple-
mental instrument twice, 27 months
apart. The quality of the data in this
study is reflected in the high response
rates and in the methodological studies
reported elsewhere.16-19
The Normal Menopausal Transitions
The prospective, longitudinal nature of
the research design allowed us to charac-
terize, for the first time, the transitions
from pre- to peri- to postmenopause.
While the standard epidemiological defi-
nition of natural menopause (12 con-
secutive months of amenorrhea, in the
absence of other cause such as pregnancy
or lactation) is well accepted,14,21 we have
little knowledge of the inception and
length of the perimenopause.
The perimenopause, a period of
menstrual change immediately prior to
menopause, was first identified by Tre-
loar.21 In the MWHS, this period was
defined, after reports from two consecu-
tive interviews, as either a change in
cycle regularity or periods of amenorrhea
of 11 months or less. Using data from
the baseline survey, logit analyses of age-
specific proportions of women who had
reached natural menopause resulted in
an estimated median age of final men-
strual period (FMP) of 51.3. An equiva-
lent logit analysis was performed on the
same data set to estimate the median age
at inception of perimenopause, using the
age-specific proportions that had reached
perimenopause; the median age was 47.5
years. The difference of 3.8 years between
median age at peri-and postmenopause
provides an estimate of median length of
the perimenopausal state.
Among factors thought to affect age at
natural menopause (education, cigarette
smoking, parity, HRT use, use of oral
contraception, income, and marital status)
only current cigarette smoking resulted
in a significant difference. A median dif-
ference of 1.8 years between current and
nonsmokers was extremely large and
consistent with other reports.18,22 The
lack of difference between nonsmokers
and quitters reported in this and other
studies22 is consistent with an immediate
toxic impact on ovarian function caused
by some as yet unidentified product of
smoking.23 It is also consistent with
other reports that smokers are more like-
ly to experience menstrual irregularity24
and difficulty conceiving.25,26 When the
effect of smoking is controlled in multi-
variate analysis, the apparent associations
with socioeconomic status, parity, and
obesity do not remain. These latter fac-
tors are highly correlated with smoking
behavior and/or each other.
Similar analyses of factors associated
with perimenopause were conducted for
the first time in this study. Nulliparous
women and smokers were likely to start
perimenopause earlier. Smokers and
women starting perimenopause at a later
age were more likely to have shorter peri-
ods of perimenopause. Nearly 10% of
the cohort either experienced less than
six months of menstrual irregularity or
ceased menstruating abruptly.
Symptoms and Health Care Behavior
While cross-sectional studies often report
the highest prevalence of hot flashes post-
menopause, longitudinal data on the age
and menopause status at which hot
flashes begin are sparse. McKinlay et al27
reported data from the MWHS on the
relationship of hot flashes to the meno-
pause transition. Figure 1 summarizes a
complex analysis of 1,178 women who
46 JAMWA Vol.50, No.2
Figure 1. Percent of women reporting hot flashes in previous two weeks by contact points
pre- and postmenopause (n=1,178); (From: McKinlay SM, et al: The normal menopause
transition. Am J Hum Biol 1992;4:37-46).
★
★
★
★
★
★
★★
★
★
★
-3 -2 -1 -3 -2 -1 0 1 2 3 4
0
10
20
30
40
50
Contact Point in Relation to Peri and Postmenopause
PerimenopausePremenopause Menopause
Defined
Postmenopause
Years Before and After Menopause
Percent of Women
were defined as strictly premenopausal at
the first follow-up. (Only premenopausal
women were included in the analysis,
since women who were perimenopausal
at the first follow-up could provide only
limited data on their premenopausal
condition.) At three contact points prior
to the inception of perimenopause, 10%
of the women reported hot flashes. This
rate increased with irregularity in menses.
Hot flash reporting peaked at about 50%
at the contact just prior to inception of
menopause. By the fourth postmenopausal
contact (about four years after FMP), the
rate of hot flash reporting had declined
to 20%. These findings contradict the
widely held clinical impression that hot
flashes begin to increase after the final
menstrual period. McKinlay et al also
found that the rate of hot flash reporting
was related to the duration of the peri-
menopause. Women with a perimenopause
of less than six months (estimated at
10% of women) had much lower rates,
with a peak rate of about 30%.
Additional analyses examined frequency
of hot flash reporting, bothersomeness of
hot flashes, and physician consult for
those women who were premenopausal
at the beginning of the study and become
postmenopausal by the last interview, T6
(N=454). Analyses also looked at predic-
tors related to these outcomes. Predictors
included sociodemographics, reproduc-
tive history, health status, health care uti-
lization, life-style (smoking, alcohol con-
sumption, exercise), attitudes toward
menopause, depression, and stress. All
predictors were taken from the follow-up
immediately prior to the interview at
which a woman was first classified as
perimenopausal.
Results showed a wide distribution
of hot flash and night sweat reporting.
Almost one-quarter of the sample (23%)
of postmenopausal women did not report
hot flashes or night sweats at any of the
six interviews, 17% reported them at
only one interview, and only 7.5%
reported hot flashes or night sweats at
all six interviews. The variables related
to frequency of hot flash/night sweat
reporting were number of interviews at
which a woman was classified as peri-
menopausal (a surrogate for length of
perimenopause), psychological and
physical symptoms prior to menopause,
lower educational level, and smoking.
It is not surprising that women who
reported fewer general symptoms prior
to menopause and who had a shorter
perimenopause were less likely to report
menopausal symptoms. Women who
had more negative attitudes toward
menopause (eg, agreeing with the state-
ment that “women become depressed or
irritable during the menopause”) also had
a higher frequency of hot flash reporting.
The vast majority of women—almost
69%—did not report being bothered by
hot flashes or night sweats. Women who
had less frequent hot flashes were less
bothered by them, but we also found that
women who did not report psychological
symptoms prior to menopause, had a
college education, did not smoke, and
exercised were less bothered by symptoms.
Only 32% of women in this sample
reported ever seeing a physician about
menopause-related problems. The most
striking variables related to consulting a
physician were frequency of hot flashes
and night sweats and depression prior to
menopause. Women who were depressed
prior to menopause were almost twice as
likely to consult a physician during
menopause. This finding further empha-
sizes the bias found in patient-based
studies. Other variables related to con-
sulting a physician were education, having
a breast exam in the prior nine months,
bothersomeness of hot flashes/night
sweats, and number of perimenopausal
interviews.
Attitudes Toward Menopause
To underscore the normalcy of meno-
pause for the majority of women, popu-
lation-based studies have been reporting
low rates of regret or negative attitudes
toward menopause for two decades.28,29,30
Results from the MWHS showed that
women’s attitudes become more positive
after they experience menopause.31 Two
sets of questions on attitudes toward
menopause were asked. Respondents
were asked to best describe their feelings
toward menopause as relief, regret, mixed,
or no particular feelings at all. The sec-
ond question consisted of a series of six
statements about menopause that women
were asked to rate on a five-point scale
(strongly agree to strongly disagree).
At baseline (T0) the majority of women
reported feeling relief toward the cessation
of menses (42.2%), followed by neutral
feelings (35.5%). Some women reported
mixed feelings (19.6%), but very few
women reported feeling regret (2.7%).
Feelings toward the cessation of menses
were significantly related to menopause
status, with women who had had a surgi-
cal menopause most likely to report relief
and premenopausal women least likely
to report relief. Postmenopausal women
were generally most likely to report posi-
tive or neutral feelings. The percentage
of women reporting relief was very
similar to that found by McKinlay and
Jeffery28 (over two decades earlier in a
British study) and just slightly higher
than that found by Lock (34%) in a
Japanese sample.32 This finding, there-
fore, is remarkably stable over different
generations and cultures. The direction
March/April 1995 47
Percentage of Women Reporting each Feeling at T6According
to Feeling at T0 by Menopause Status at T6* (N= 2150)
Feeling T6
Feeling T0Status at T6N(100%) Regret Mixed Neutral Relief
Regret Pre 7 42.9 57.1 0.0 0.0
Peri 25 20.0 28.0 20.0 32.0
Post 26 23.1 30.8 15.6 25.0
Surgical 4 50.0 50.0 0.0 0.0
Mixed Pre 38 2.6 29.0 34.2 34.2
Peri 214 2.8 26.6 33.6 36.9
Post 222 3.2 27.0 33.7 36.5
Surgical 32 3.1 21.9 31.3 43.7
Neutral Pre 69 4.4 4.4 62.3 29.0
Peri 271 1.5 8.1 52.0 38.4
Post 354 0.3 4.5 54.3 36.6
Surgical 41 4.9 7.3 43.9 43.9
Relief Pre 46 2.2 6.5 26.1 65.2
Peri 291 1.0 4.8 15.8 78.3
Post 429 1.4 5.1 23.8 69.7
Surgical 81 0.0 2.5 14.8 67.7
*From Avis NE, McKinlay SM: A longitudinal analysis of women’s attitudes towards menopause: Results
from the Massachusetts Women’s Health Study. Maturitas 1991;13:65-79.
of attitude change for women who were
premenopausal at the beginning of the
study and later became postmenopausal
was overwhelmingly toward more posi-
tive attitudes. Thus the experience of
menopause led to more positive, rather
than negative attitudes, perhaps reflect-
ing a reduction in uncertainty as the
transition is experienced.
Women’s responses to the general
statements about menopause varied
according to their menopause status pri-
marily on the transmenopause state-
ments. In particular, women who had
had a surgical menopause viewed the
menopause most negatively. The responses
to statements about postmenopause dif-
fered less by menopause status. In general,
the pre- and postmenopausal women
reported the most favorable attitudes.
Avis et al31 also reported that negative
attitudes toward menopause prior to
experiencing menopause were related to
symptom reporting during menopause.
For example, only 37% of those who
agreed with the statement “women with
other interests don’t notice the meno-
pause” subsequently reported hot flashes,
while 56% who disagreed later reported
hot flashes. In general, fewer women
reported experiencing night sweats than
hot flashes, but there was also a relation-
ship between prior attitudes and subse-
quent reporting of night sweats. Only
19% of those who agreed with the state-
ment “menopause does not change
women” reported sweats, while 37%
who disagreed reported sweats. These
results confirm that expectations regard-
ing menopause can be related to symp-
tom reporting and are consistent with
other research on menopausal and men-
strual symptoms.33,34 In other words,
negative attitudes may become a self-
fulfilling prophecy.
Depression
A long-held notion that persists, despite
evidence to the contrary, is that meno-
pausal women are likely to become
depressed.28,35,36 This presumption pre-
vails among women in general,31 as well
as among clinicians.37,38 Much of the
research that gives rise to this perceived
relationship is derived from patient-based
populations.14 Some cross-sectional
research has shown more frequent
depressed mood among peri- or post-
menopausal women than among pre-
menopausal women,39-42 while other
studies have not.35,43,44 In the MWHS,
cross-sectional analyses of the relative
contributions of health and social cir-
cumstances and menopause to depres-
sion43 found that the variables most
associated with depression were lower
education, marital status (widowed,
divorced, separated women have higher
rates), physical health, and stress from
worry about others. Cross-sectional data,
however, can neither control for pre-
menopausal depression, nor characterize
the transition through menopause. Longi-
tudinal data are necessary to study women
as they proceed through menopause.
The MWHS provided the opportunity
to address the effect of change in meno-
pause status on depression (as measured
by self-reported depressive symptoms),
while controlling for prior depression.45
Depression was measured by the CES-D
scale, a well-established scale developed by
the Center for Epidemiological Studies46
and often used in epidemiological research.
The CES-D consists of 20 self-report
items concerning depressed mood. Scores
range from 0-60, with those scoring 16
and above generally classified as at high
risk for clinical depression.47 To study
the effects of change in menopause status,
a menopause transition variable was
created that took into account a woman’s
menopausal status at the two timepoints
(27 months apart) at which depression
was measured (referred to as T1and T2).
Women were classified into five cate-
gories: premenopausal at both T1and T2
(pre-pre, N=235), premenopausal at T1
and perimenopausal at T2(pre-peri,
N=291), perimenopausal at both T1
and T2(peri-peri, N=785), pre- or peri-
menopausal at T1and postmenopausal
at T2(pre/peri-post, N=652), and post-
menopausal at both T1and T2(post-
post, N=240).
Across all statuses, 9.6% of the women
(N=203) were classified as depressed at
T1and 8.8% (N=190) at T2. To exam-
ine how change in menopause status was
associated with depression, we used the
menopause transition variable. In a logis-
tic regression of T2depression on T1
depression, menopause transition, and
HRT, prior depression was clearly the
variable most predictive of subsequent
depression (P<0.0001) with an odds
ratio (OR) of 9.6. There was also a sig-
nificant effect of menopausal transition
(P < 0.03). A likelihood ratio test with 4
df was employed to test for differences
among the five menopause transition
groups with respect to depression before
examination of departures of individual
transition groups from the reference
group. Analyses revealed that the signifi-
cant effect was primarily due to the peri-
peri group, which differed significantly
from the pre-pre group (OR = 2.05) and
the post-post group (OR = 2.70) when
the latter was used as the comparison
group, suggesting that the rate of
increased depression is transitory. The
interaction between prior depression and
menopausal transition was not signifi-
cant. Neither the main effect of hormone
therapy nor its interaction with prior
depression or menopause transition were
significant in this model.
The rate of depression according to
transition pattern and premenopausal
depression is graphically shown in Figure
2. This figure clearly shows that across
all menopause statuses, those women
48 JAMWA Vol.50, No.2
Figure 2. Percentage of women classified as depressed at T2, by depression status at T1and
menopausal transition (From: Avis NE, et al; A longitudinal analysis of the association between
menopause and depression: Results from the Massachusetts Women’s Health Study. Annals of
Epidemiology 1994;4:214-220; © 1994 Wiley, Reprinted by permission of John Wiley & Sons).
0
25
50
Depressed
at T2 (%)
;
;;;
;;
Not Depressed at T1Depressed at T1
Pre➔Pre Pre➔Peri
;
;
Peri➔Peri Pre/Peri➔Post Post➔Post
who were classified as depressed at T1
had higher rates of depression at T2. For
women who were not depressed at T1,
the rate of depression at T2increases
slightly as women move from pre-pre to
pre-peri and is highest for women who
have remained perimenopausal for at
least 27 months. The rate of depression
begins to decrease as women move from
peri- to postmenopause and is lowest for
those women who have been post-
menopausal for at least 27 months.
While these results show that new onset
of depression is moderately associated
with the perimenopause status, they also
show that this depression is transitory; as
women become postmenopausal, their
rates of depression decline.
Further analyses of these data suggested
that this increased rate of depression
among the peri-peri women could be
attributed to symptoms associated with
menopause (ie, hot flashes, night sweats,
menstrual problems). Over all menopause
transition categories, those women who
reported experiencing hot flashes, night
sweats, and/or menstrual problems con-
sistently showed higher rates of depression.
Summary and Conclusions
The Massachusetts Women’s Health Study
is one of the largest and most compre-
hensive studies of mid-aged women and
menopause. Results of this community-
based study present a profile of menopause
experiences in mid-aged women that is
dramatically different from the impres-
sion gained in a physician’s office.
In a remarkable book on menopause
published in 1897,48 a physician noted
that: 1) the menopause lacks scientific
attention; 2) there is apparently no
menopause in animals and symptoms
vary widely across ethnic groups; 3) there
is evidence of predisposing factors in
women who have severe menopausal
symptoms; and 4) in industrialized soci-
eties, “highly bred,” “civilized” women
and “those with many troubles and ills”
appeared to be the primary sufferers.
These astute clinical observations have
been largely ratified by recent population-
based research, nearly a century later.
Physicians treating middle-aged
women must be sure to take careful his-
tories, asking about potentially stressful
aspects of their lives that may affect their
health. We have learned from both the
MWHS and other studies49-51 that the
stressful impact of other life events on
women’s health may be considerable.
The relative contribution of menopause
as an additional stressor in this context is
negligible. What appear to be “meno-
pausal” symptoms may often be indica-
tors of other underlying disease or condi-
tions quite unrelated to menopause itself.
The detrimental impact of smoking on
menopause is well documented and there
is growing evidence of menstrual distur-
bance and decreased fertility resulting
from this habit in younger women.
When this is combined with the known
high risk of smoking for heart disease in
women, the need to discourage cigarette
smoking— particularly in older women—
assumes new importance and should be
integrated into clinical practice.
Apart from the highly selective charac-
teristics of women expressing “meno-
pausal” complaints, the findings reviewed
here have important implications for
medical research. First, data from patient-
based studies cannot be generalized to all
women. Second, women with some form
of surgical menopause must be studied
separately from those with a natural
menopause, and observations from these
two groups cannot be directly combined.
The surgical group is younger, of poorer
health, and/or uses medical care more
frequently. Reports that do not acknowl-
edge these caveats should be reviewed
with some caution.
References
1. Pike MC, Pentti K, Welsh CW: The Epidemiol-
ogy of Breast Cancer As It Relates to Menarche,
Pregnancy and Menopause. Branbury report No.
8: Hormones and Breast Cancer. Cold Spring
Harbor, NY: Cold Spring Harbor Press; 1981.
2. Kuller LH, Meilahn EN, Costello EJ, et al:
Relationship of menopause to cardiovascular
disease. Behavioral Medicine Update 1984;
5:35-47.
3. Richelson LS, Wahner HW, Melton CJ, et al:
Relative contributions of aging and estrogen
deficiency to postmenopausal bone loss. N Engl
J Med 1984;311:1273-1275.
4. Brown JRWC, Brown MEC: Psychiatric disor-
ders associated with the menopause, in Beard J
(ed): The Menopause. Lancaster: MTP Press;
1976.
5. Buxton CL: Medical therapy during the meno-
pause. J Clin Endocrinol Metab 1944;4:591.
6. Hunt R, Vessey M, McPherson R, Coleman M:
Long-term surveillance of mortality and cancer
incidence in women receiving hormone replace-
ment therapy. Br J Obstet Gynaecol 1987;
94:620-635.
7. Bergkvist L, Adami H-O, Persson I, et al: Risk
of breast cancer after estrogen and estrogen-
progestin replacement. N Engl J Med 1989;
321:293-297.
8. Avis NE, Crawford S, McKinlay SM: Psychoso-
cial, behavioral, and health factors related to
menopause symptomology. Paper presented at
the American Psychological Conference on Psy-
chosocial and Behavioral Factors in Women’s
Health: Creating an Agenda for the 21st Cen-
tury, Washington, DC, 1994.
9. Brown JRWC, Brown MEA: Psychiatric disor-
ders associated with the menopause, in Beard
RJ (ed): The Menopause: A Guide to Current
Research and Practice. Baltimore, Md: Univer-
sity Park Press; 1976
10.Rose L: What is menopause? in Rose L (ed):
The Menopause Book. New York, NY:
Hawthorne Books; 1977:1-17.
11.Weideger P: Menstruation and Menopause. New
York, NY: Delta; 1977.
12.Avis NE, McKinlay SM: Health care utilization
among mid-aged women. Ann NY Acad Sci
1990;592:228-238.
13.McKinlay SM, McKinlay JB: Selected studies
of the menopause—A methodological critique.
J Biosoc Sci 1973;5:533-555.
14.Kaufert P: Women and their health in the
middle years: A Manitoba project. Soc Sci Med
1984;46:89-107.
15.McKinlay JB, McKinlay SM, Brambilla DJ:
Health status and utilization behavior associated
with menopause. Am J Epidemiol 1987a;
125:110-121.
16.Brambilla DJ, McKinlay SM, McKinlay JB:
Item nonresponse and response bias in mixed
mod surveys. Paper presented at the Public
Health Conference on Records and Statistics,
Washington, DC, 1987.
17.Brambilla DJ, McKinlay SM: A comparison of
responses to mailed questionnaires and tele-
phone interviews in a mixed mode health sur-
vey. Am J Epidemiol 1987;126:962-997
18.Brambilla DJ, McKinlay SM: A prospective
study of factors affecting age at menopause. J
Clin Epidemiol 1989;42:1031-1039.
19.Brambilla DJ, Bifano NL, McKinlay SM,
Clapp R: The validity of self-reported cancer
incidence in a prosepctive study, in Proceedings
of the Fifth Conference on Health Survey
Research Methods. Department of Health and
Human Services publication No. (PHS) 89-
3447, 1990.
20.World Health Organization Scientific Group:
Research on Menopause. WHO Technical Ser-
vice Report Series 670. Geneva: World Health
Organization; 1981.
21.Treloar AE: Menarche, menopause and inter-
vening fecundability. Hum Biol 1974;46:89-107.
22.McKinlay SM, Bifano NL, McKinlay JB:
Smoking and age at menopause. Ann Intern
Med 1985;103:350-356.
23.Mattison DR: The mechanisms of action of
reproductive toxins. Am J Ind Med 1983;4:65-79.
24.Hammond EC: Smoking in relation to physical
complaints. Arch Environ Health 1961;3:28-46.
25.Baird DD, Wilcox AJ: Cigarette smoking asso-
ciated with delayed conception. JAMA 1985;
253:2979-2983
26.Olsen J, Rachootin P, Schlodt AV, Damsbo N:
Tobacco use: Alcohol consumption and infertil-
ity. Int J Epidemiol 1983;2:179-184.
27.McKinlay SM, Brambilla DJ, Posner JG: The
normal menopause transition. Am J Hum Biol
1992:4:37-46.
28.McKinlay SM, Jefferys M: The menopausal
syndrome. Br J Prev Soc Med 1974;28:108-115
29.Neugarten BL, Wood V. Kraines RJ:
Menopausal symptoms in women of various
ages. Psychosom Med 1965;27:266-273.
30. Leiblum SR, Swartzman LC: Women’s attitudes
toward the menopause: An update. Maturitas
1986:8:47-56
31.Avis NE, McKinlay SM: A longitudinal analysis
of women’s attitudes towards menopause:
Results from the Massachusetts Women’s
Health Study. Maturitas 1991:13:65-79.
32.Lock M: Ambiguities of aging: Japanese experi-
ence and perceptions of menopause. Cult Med
March/April 1995 49
Psychiatry 1986:10:23-46.
33.Matthews K: Myths and realities of the meno-
pause. Psychosom Med 1992:54:1-9.
34.Brooks-Gunn J, Ruble DN: The development
of menstrual-related beliefs and behaviors dur-
ing early adolescence. Child Dev 1983:53:1567-
1577.
35.Kaufert PA, Gilbert P, Hassard T: Researching
the symptoms of menopause: An exercise in
methodology. Maturitas 1988:10:117-131.
36.Winokur G: Depression in the menopause. Am
J Psychiatry 1973:130:92-93.
37.Cowan G, Warren LW, Young JL: Medical
perceptions of menopausal symptoms. Psycholo-
gy of Women Quarterly 1985:9:3-14.
38.Roberts H: The Patient Patients: Women and
their Doctors. London: Pandora Press; 1985.
39.Hunter MS, Battersby R, Whitehead M: Rela-
tionships between psychological symptoms,
somatic complaints and menopausal status.
Maturitas 1986:8:217-228.
40.Jaszmann L, van Lith ND, Zaat JCA: The peri-
menopausal symptoms: The statistical analysis
of a survey—part A. Medical Gynecology Society
1969:4:286-277.
41.Bungay GT, Vessay MP, McPherson CK:
Study of symptoms in middle life with special
reference to menopause. Br Med J 1980:
19:181-183.
42.Ballinger CB: Psychiatric morbidity and the
menopause screening of general population
sample. Br Med J 1975:3:344-346.
43.McKinlay JB, McKinlay SM, Brambilla DJ:
The relative contributions of endocrine changes
and social circumstances to depression in mid-
aged women. J Health Soc Behav 1987b:28:345-
363.
44.Mathews KA, Kuller LH, Meilahn EN, et al:
Influences of natural menopause on psychologi-
cal characteristics and symptoms of middle-aged
healthy women. J Consult Clin Psychol 1990;
58:345-351.
45.Avis NE, Brambilla DJ, McKinlay SM, Vass K:
A longitudinal analysis of the association
between menopause and depression: Results
from the Massachusetts Women’s Health
Study. Annals of Epidemiology 1994:4:214-220.
46.Radloff L: The CES-D scale: A self reported
depression scale for research in the general pop-
ulation. Applied Psychological Measurement
1977:137:385-401.
47.Myers JK, Weissman M: Use of a self-report
system scale to detect depression in a communi-
ty sample. Am J Psychiatry 1980:137:1081-1084.
48.Currier AF: The Menopause. New York, NY:
D. Appleton; 1897.
49.McKinlay SM, McKinlay JB: The impact of
menopause and social factors on health, in
Hammond C, Haseltine F, Schiff I (eds):
Menopause: Evaluation, Treatment and Health
Concerns. New York, NY: Alan Liss; 1988.
50.Anesheusel C: Marital and employment role-
strain, social support and depression among
adult women., in Stress, Social Support and
Women. Washington, Hemisphere Publishing;
1986:99-114.
51.Verbrugge L: Multiple roles and physical health
of women and men. J Health Soc Behav
1983:24:16-30.
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