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The Massachusetts Women's Health Study: an epidemiologic investigation of the menopause


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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 factors that affect this transition. Findings indicate that natural menopause appears to have no major impact on health or health behavior. The majority of women do not seek additional help concerning menopause, and their attitudes toward it are, overwhelmingly, positive or neutral. Physicians treating mid-aged women must be careful not to confuse "menopausal" symptoms with indicators of underlying disease or conditions unrelated to menopause.
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March/April 1995 45
The Massachusetts Womens Health Study:
An Epidemiologic Investigation of the Menopause
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
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
Contact Point in Relation to Peri and Postmenopause
PerimenopausePremenopause Menopause
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
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
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.
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).
at T2 (%)
Not Depressed at T1Depressed at T1
PrePre PrePeri PeriPeri Pre/PeriPost PostPost
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.
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JAMWA Vol.50, No.2
... Al parecer, algunas mujeres son especialmente sensibles a los cambios en los niveles de las hormonas reproductivas y no a concentraciones específicas. El trastorno disfórico premenstrual es una condición clínica que está confinada a la fase lútea del ciclo ovárico y cuyos síntomas son suficientemente severos como para generar malestar clínicamente significativo e interferir con el desempeño de las actividades de la vida cotidiana [46][47][48][49][50] . Las mujeres que refieren síntomas premenstruales tienen mayor probabilidad de experimentar depresión postparto y posiblemente mayores cambios afectivos en el período perimenopáusico [51][52][53][54] . ...
... La asociación entre síntomas psiquiátricos y menopausia es controvertida. Aunque algunos estudios no muestran incremento de la psicopatología en este período, en general, se ha descrito un aumento en la prevalencia de depresión y ansiedad 49,50 , los cuales parecen ser producto de la interrelación entre factores biológicos y psicosociales. Los factores biológicos incluyen la reducción de la producción ovárica de estradiol, cambios hipotalámicos relacionados con la edad, incremento en la proporción de estrona en comparación con el estradiol y descenso en la producción de andrógenos ováricos. ...
Full-text available
El comportamiento humano y las enfermedades mentales se ven estrechamente influenciados por el funcionamiento del sistema endocrino y el entendimiento de esta relación se ha podido construir a partir de estudio de la Neurociencia. Una gran cantidad de personas con trastornos neuroendocrinos presentan manifestaciones psiquiátricas y estas pueden incluso anteceder al diagnóstico del trastorno neuroendocrino. Estas manifestaciones disminuyen de cierta medida al instaurarse el manejo del trastorno, pero en algunas ocasiones, requieren manejo psicoterapéutico o farmacológico específico. Este artículo de revisión pretende informar y sensibilizar al lector sobre el porqué de esta frecuente asociación; ilustra las presentaciones clínicas más habituales y postula algunas estrategias terapéuticas. Los trastornos neuroendocrinos a tratar son: el hipotiroidismo, hipertiroidismo, hipoparatiroidismo, hiperparatiroidismo, síndrome de Cushing, enfermedad de Addison, hiperprolactinemia, trastorno dismórfico premenstrual, hiperandrogenismo de origen ovárico, e hipogonadismo. Es importante también enfatizar que el correcto manejo de estos pacientes requerirá de la participación de un grupo interdisciplinario.
... The transition from ovulatory menstrual cycles to the complete cessation of menstruation is known as the menopause transition and typically spans 5-6 years leading up to the last menstrual period (Avis and McKinlay, 1995;Oldenhave et al., 1993;Treloar, 1981). Perhaps the most well-established method of defining the menopause transition are the Stages of Reproductive Aging Workshop (STRAW+10) criteria, based on the appearance of menstrual cycle irregularity (Harlow et al., 2012) (Fig. 1). ...
The menopause transition, which constitutes the five or so years surrounding the final menstrual period, has been established as a time of increased risk for depressive symptoms. While mounting research suggests that exposure to more extreme and fluctuating levels of estradiol (E2) plays a role, it remains unclear which specific trigger is most strongly implicated in the development of depressive mood: acute E2 withdrawal or extreme increases in E2. The current review summarizes the literature supporting the role of each, considering research pertaining to perimenopausal depression as well as other reproductive mood disorders in which ovarian hormone change is believed to play a key role, namely premenstrual dysphoric disorder and postpartum depression. Taking together the available research pertaining to the various reproductive mood disorders, we propose that women may exhibit one of four E2 sensitivity profiles, each of which may have important implications for the expected timing and severity of depressive mood during the menopause transition: the E2-increase sensitive profile, developing depressive mood in response to elevations in E2, the E2-decrease sensitive profile, for whom E2 withdrawal triggers negative mood, the E2-change sensitive profile, characterised by mood sensitivity to E2 change in either direction, and the E2 insensitive profile for whom changes in E2 have negligible psychological effects. The evidence supporting the existence of such profiles are summarized, potential biological mechanisms are briefly highlighted, and implications for future research are discussed.
... Early investigations examining this potential liability for menopausal women to experience psychological disturbances primarily relied on cross-sectional designs with varying methodologies. Women were recruited from a myriad of heterogeneous settings, including community-based samples and specialized menopause clinics, making generalization challenging (Avis & McKinlay, 1995;Harlow, Wise, Otto, Soares, & Cohen, 2003;Kaufert, Gilbert, & Tate, 1992). All in all, the early research landscape was plagued with mixed and inconsistent reports (Soares, 2007). ...
Schizophrenia is a mental disorder that affects how a person reacts with the surrounding world. Patients with schizophrenia have a lower quality of life. The long-term cost for supporting patients with schizophrenia is far greater than that of many other mental disorders. The cost of supporting schizophrenia patients is about 1%–3% of the national health care cost in most of the developed nations. This cost is almost up to 20% of the direct expenses of all types of mental health cost. Case studies are detailed qualitative investigation where a single or few participants are investigated. Case studies can explain social phenomena, that is, events happening in the society that relate to everyday living problem. Data in case studies can be gathered by documentation, interview, archival records, direct observation, participant observation, and physical artifact. Interview is a well-established technique for data collection in case study. There are various case studies on managing different symptoms and quality of life associated with schizophrenia patients. In the current study, the eligibility criteria for the selection of case studies are their effectiveness in addressing issues related to the management of schizophrenia. This chapter reviews prior case studies of the management of schizophrenia and explains why case studies are important for understanding and treating schizophrenia.
... Menopause is defined as 'the permanent cessation of menstruation for one year resulting from loss of ovarian follicular activity' [1]. Natural menopause is not a singular event but a transition lasting for an average period of 3.8 years [11]. This phase of ageing process during which a woman passes from reproductive to non-reproductive stage is known as climacteric. ...
Background: This study aimed to determine the prevalence of depression in perimenopausal and postmenopausal women in a semi-rural area in a city in Turkey and to evaluate perceived social support and quality of life by examining some of the variables thought to be related. Methods: The study was conducted on 827 perimenopausal and postmenopausal women aged 40-60 years. The questionnaire included sociodemographic characteristics, some variables associated with depression, questions from the Beck Depression Inventory, Multidimensional Scale of Perceived Social Support, and European Health Impact Scale - Quality of Life-8 (EUROHIS-QOL-8) scale. Results: The prevalence of depression was 23.1% (n = 191) in the study. The prevalence of depression was found to be higher in single/widowed/separated individuals (odds ratio (OR): 2.539; 95% CI: 1.593-4.047) and at poor income levels (1.980; 1.000-3.021). The frequency of depression was found to be lower in those who gave birth once or twice (0.470; 0.294-0.752), those with a high level of social support (0.959; 0.948-0.971), and those with a high level of QOL (0.836; 0.794-0.879). There was a moderate negative correlation between the depression scale and QOL scale scores (r = -0.405, P = 0.001). A weak negative correlation was found between depression and social support scores (r = -0.383, P = 0.001). Conclusion: Women are more vulnerable to depression in premenopausal and postmenopausal periods. Being single/widowed, having a poor income level, having low social support, and low QOL are important risk factors which increase the frequency of depression.
It is well known that females are more vulnerable than males to stress-related psychiatric disorders, particularly during perimenopausal and postmenopausal periods. Hormone replacement therapy (HRT) has been widely used for the management of postmenopausal depression. However, HRT could be associated with severe adverse effects, including increased risk for coronary heart disease, breast cancer and endometrial cancer. Thus, there is a pressing demand for novel therapeutic options for postmenopausal depression without sacrificing uterine health. Simvastatin (SIM) was proven to have neuroprotective activities besides its hypocholesterolemic effect, the former can be attributed to its, antioxidant, anti-apoptotic and anti-inflammatory activities. Moreover, many reports highlighted that SIM has estrogenic activity and was able to induce the expression of estrogen receptors in rats. The present study showed that SIM (20 mg/kg, p.o.) markedly attenuated depressive-like behavior in ovariectomized (OVX) rats. Moreover, SIM prohibited hippocampal microglial activation, abrogated P2X7 receptor, TLR2 and TLR4 expression, inhibited NLRP3 inflammasome activation, with subsequent reduction in the levels of pro-inflammatory mediators; IL-1β and IL-18. Furthermore, a marked elevation in hippocampal expression of ERα and ERβ was noted in SIM-treated animals, without any significant effect on uterine relative weight or ERα expression. Taken together, SIM could provide a safer alternative for HRT for the management of postmenopausal depression, without any hyperplastic effect on the uterus.
Full-text available
Women worldwide are two to three times more likely to suffer from depression in their lifetime than are men. Female risk for depressive symptoms is particularly high during the reproductive years between menarche and menopause. The term “Reproductive Mood Disorders” refers to depressive disorders triggered by hormonal fluctuations during reproductive transitions including the perimenarchal phase, the pre-menstrual phase, pregnancy, the peripartum period and the perimenopausal transition. Here we focus on reproductive mood disorders manifesting in adult life. We propose a research agenda that draws together several reproductive mood disorders and investigates which genetic, endocrinological, neural, and psychosocial factors can explain depressive symptoms during phases of hormonal transitions in women. Based on current research it is assumed that some women experience an increased sensitivity to not only fluctuations in reproductive steroids (estrogen and progesterone), but also stress-related steroids. We integrate both dynamics into the concept of “steroid hormone sensitivity,” expanding on the concept of “reproductive hormone sensitivity.” We suggest that a differential response of the stress steroid system including corticosteroids, neurosteroids, like allopregnanolone and the GABA-A Receptor complex, as well as a differential (epi)genetic risk in serotonergic and GABAergic signaling, are moderators or mediators between changes in the reproductive steroid system and the physiological, affective, and cognitive outcomes manifesting in reproductive mood disorders. We point to the lack of research on the role of psychosocial factors in increasing a woman's stress level and at some point also the sensitivity of her stress steroid system within the etiology of Reproductive Mood Disorders. Drawing together the evidence on various reproductive mood disorders we seek to present a basis for the development of more effective pharmacological, social, and psychological treatment interventions and prevention strategies for women susceptible to these disorders. This could pave the way for new research as well as medical and psychological teaching and practice- such as a new type of Practice for Gynecological Psychoneuroendocrinology- with the aim of working on and ultimately offering more integrative forms of support not yet available to women suffering from depression during hormonal transitions. In medical history women have been left alone with this integrative challenge.
Menopause represents a vulnerable time in a woman’s life for a number of reasons, but in particular, for her skeletal health. Estrogen deficiency associated with menopause increases bone remodeling leading to an imbalance favoring bone resorption over bone formation. Cross-sectional studies demonstrated lower bone mineral density (BMD) among perimenopausal and postmenopausal women compared to premenopausal women. Early longitudinal studies suggested that bone loss may begin before the final menstrual period (FMP), especially at trabecular-rich sites. In the Study of Women’s Health Across the Nation, the cumulative (5 years before FMP to 5 years after the FMP) 10-year lumbar spine (LS) BMD loss was 10.6%; 7.38% was lost during the menopausal transition (MT). Cumulative femoral neck (FN) BMD loss was 9.1%; 5.8% was lost during the transition. Trabecular bone score, a surrogate of bone microarchitecture that predicts fracture independent of BMD, declined by 6.3% over the MT. Estimated bone strength using composite strength indices and markers of hip geometry also declined over the MT, although the magnitude was less than observed for areal BMD. Low LS BMD, high N-telopeptide levels, low estradiol and 25 hydroxyvitamin D and positive fracture history are the important risk factors for fractures across MT. Faster increases in bone turnover during the MT predict future fractures independent of BMD and may help to identify women in need of short-term antiresorptive therapy to reduce their risk of fracture and preserve their skeleton.
Conference Paper
This paper presents analyses from a comprehensive prospective cohort study of mid-aged women [the Massachusetts Women's Health Study (MWHS)], with numbers sufficient to provide stable estimates of parameters in the normal menopause transition. Three questions are addressed: what are the natural menopause transitions and when do they occur; what factors affect the transitions; and what signs and/or symptoms accompany the transitions? The data were obtained primarily from 5 years of follow-up of 2,570 women in Massachusetts who were aged 44-55 years as of January 1, 1982. Prospective study of the cohort consisted of six telephone contacts (T1-T6) at 9 month intervals with excellent retention. A subset of the full cohort was defined that consisted of women who were premenopausal (rather than perimenopausal) at baseline (T0) (n = 1,178). Confirming prior reports, the age at natural menopause occurred at 51.3 years with a highly significant median difference (1.8 years) between current smokers and non-smokers. The new analyses reported here on median age at inception of perimenopause (47.5 years) and factors affecting it are consistent with findings for age at last menstrual period. Smokers tend to have not only an earlier but also a shorter perimenopause. The length of the perimenopausal transition, estimated at about 3.5 years, has not been previously reported. The relationship between menopause transitions and symptom reporting appears to be transitory, with reporting rates showing an increase in the perimenopause and a compensatory decrease in postmenopause. The implications of combined hormone replacement therapy for future research on menopause in industrial societies is discussed in relation to these findings.
THE MENOPAUSE is the absence of menstruation due to physiologic cessation of ovarian activity. It normally occurs between the ages of 40 to 50 years and any cessation of menstruation previous to that must be suspected of having pathologic etiology or to be due to pregnancy. In so far as is known at present, the only actual symptoms resulting from this physiologic ovarian inactivity are amenorrhoea and vasomotor instability characterized by hot flushes. Therefore, we must assume that the multitudinous other symptoms from which women suffer at this stage of life are subjective and due to something beside physiologic cessation of ovarian activity. In any consideration of the treatment of the menopause it must be remembered that these secondary symptoms are frequently the complaint for which the patient demands treatment. Therefore the theoretical purpose of menopausal therapy—i.e., the substitution of ovarian function by therapy with estrogens, is frequently either unnecessary or inadequate.
The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.
Discusses the sex ratio for coronary heart disease (CHD), which has increased over time initially because of a greater increase in CHD mortality rates during the 1960's in men compared with women and a somewhat greater decline in CHD mortality in women compared with men since the late 1960's. Nevertheless, CHD remains the major cause of morbidity and mortality among postmenopausal women and is related to behavioral risk factors. Diet, cigarette smoking, and blood pressure are the major risk factors for CHD and stroke. The role of psychological symptoms or behavioral patterns with disease onset of changes in CHD risk factors in postmenopausal women is unclear. It is concluded that if hormone and behavioral changes during menopause could be related to obesity, diet, exercise, smoking, and alcohol, then a more scientifically founded prevention program could be developed for the major causes of both morbidity and mortality in postmenopausal women. (66 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Thirty-five physicians in family practice or gynecology, 43 practicing nurses, and 35 menopausal or postmenopausal women rated the frequency, severity, and causality of 15 menopausal symptoms commonly reported in the literature. Subjects also rated their degree of preference for four possible menopause treatments (counseling, estrogen therapy, mood-altering medication, and no treatment) and answered an open-ended question asking them what they saw as the major factor in determining whether a woman would experience difficulty at menopause. The results overall suggest that medical persons see menopausal symptoms as more pathological than women who have experienced or are experiencing menopause and that physicians, relative to menopausal women, adhere to a more psychogenic model in which psychological causality and symptoms are given greater emphasis than menopausal women give them.
The initial findings of this study indicate that menopause is regarded as a natural life-cycle transition in Japan in which the biological marker of cessation of menstruation is not considered to be of great importance. Symptom reporting among all respondents is generally low regardless of menopausal status, and symptoms such as shoulder stiffness and headaches, which are reported frequently, are not linked specifically to menopausal status (even though individual informants may perceive them to be so). Symptoms of hot flashes and sudden perspiration are higher among peri- and post-menopausal women, but their prevalence appears to be much lower than research findings from other areas to date. Reports by Japanese gynecologists emphasize that menopausal women are liable to present with numerous non-specific somatic complaints. This may well be an accurate representation of a clinical population, but the findings of this present study indicate that such a picture is by no means representative of the average middle-aged female population in Japan. While occupational differences do not contribute to variation in reported symptomatology (with the exception of lumbago and shoulder stiffness), there are nevertheless considerable differences in the subjective meaning of menopause, many of which can be accounted for by class and occupational differences. Presentation of these differences awaits a future publication, but there is one topic which is of concern to the majority of the respondents from each of the sub-samples. The present generation of women entering their 50's are the first where the majority must face later middle age in a nuclear family, along with their husbands, although both they and their husbands have been socialized for the more distant male/female relationships of an extended family. Japanese women cannot look forward, as they did in the past, to the power and comforts derived from running an extended family; on the contrary many can expect a late middle age of looking after bed-ridden parents or parents-in-law, and a lonely, isolated and often poverty-stricken old age (Steslicke 1984), since many pension programs are by no means adequate. Some of their fears about aging are expressed in their views on menopause, but these fears do not appear to be manifested at all prominently as either psychological or somatic representations. When asked to compare their lives with that of their own mothers, stories of incredible hardships from pre- and immediately post-war Japan are vividly portrayed.(ABSTRACT TRUNCATED AT 250 WORDS)
A survey of 539 women from the general population indicated a high prevalence of minor psychiatric illness in women aged 40-55 years. There was evidence of an increase in psychiatric morbidity occurring before the menopause and lasting until about one year after menstrual periods had ended. Vasomotor symptoms increased dramatically when periods stopped and persisted up to five years after the menopause. Both these features seemed to have a clear relation to the menopause but not the same relation. The findings suggested that further investigation of the relation between perimenopausal hormonal changes and psychiatric morbidity should be directed towards premenopausal women. Environmental factors, particularly in relation to children, seemed to be associated with increased psychiatric morbidity at this time of life.
Menopause is a reproductive milestone in a woman's life around which many different myths have developed. We reviewed three sets of myths that middle-aged premenopausal women hold and evaluated those myths according to scientific data from our own work and that of others. First, middle-aged women expect to experience depression, irritability, and vasomotor symptoms during the menopause. It appears that the vast majority of postmenopausal women do not experience depression, but do experience vasomotor symptoms that are uncomfortable and may have secondary effects on psychological well being, especially during the perimenopause. Second, middle-aged women believe that holding negative expectations about the menopause affects the quality of the menopausal experience. Indeed, that appears to be the case, perhaps because myths can function as self-fulfilling prophecy. The third myth is that there are no important changes that occur during the menopause. That is incorrect. Estrogen deficiency during the menopause sets the stage for substantial changes in risk for CHD, which becomes clinically apparent later in life. We discussed how estrogen deficiency may influence both lipids and lipoprotein levels and the magnitude of neuroendocrine and cardiovascular respond to mental stress. That latter pathway is of particular interest because middle-aged women may be exposed more often to interpersonal stress and may respond more emotionally to it, relative to men, suggesting a potential interactive effect of the decline in reproductive hormones and co-occurring social and psychological changes during the menopausal period. This discussion of the myths and realities of the menopause has deliberately not been exhaustive.(ABSTRACT TRUNCATED AT 250 WORDS)