Lorraine Dennerstein

A prospective population-based study of menopausal symptoms☆

Objective To identify symptoms that change in prevalence and severity during midlife and evaluate their relationships to menopausal status, hormonal levels, and other factors. Methods In a longitudinal, population-based study of 438 Australian-born women observed for 7 years with an 89% retention rate, 172 advanced from premenopause to perimenopause or postmenopause. Annual measures included a 33-item symptom check list; psychosocial, lifestyle, and health-related factors; menstrual status; hormone usage; and blood levels of follicle-stimulating hormone and estradiol (E2). Results Increasing from early to late perimenopause were the number of women who reported five or more symptoms (+14%), hot flushes (+27%), night sweats (+17%) and vaginal dryness (+17%) (all P < .05). Breast soreness-tenderness decreased with the menopausal transition (−21%). Trouble sleeping increased by +6%. The major change in prevalence was from early to late perimenopause, except for insomnia, which showed a gradual increase. Those variables most related to onset of hot flushes were number of symptoms at early perimenopause (P < .05), having an unskilled or no occupation (P < .05), more than 10 pack-years of smoking (P < .01), and decreased E2 (P < .01). The onset of night sweats increased with the change in E2 (P < .05). The onset of vaginal dryness decreased with more years of education (P < .05). Trouble sleeping was predicted by prior lower well-being (P < .01), belief at baseline that women with many interests hardly notice menopause (P < .01), and hot flushes (P < .01). Conclusion Although middle-aged women are highly symptomatic, the symptoms that appear to be specifically related to hormonal changes of menopausal transition are vasomotor symptoms, vaginal dryness, and breast tenderness. Insomnia reflected bothersome hot flushes and psychosocial factors.

Hormones, mood, sexuality, and the menopausal transition

OBJECTIVE To determine the extent of changes in womens sexual functioning and well-being during the menopausal transition and the relationship to hormonal changes. DESIGN Prospective observational study. SETTING Population-based sample assessed at home. PATIENT(S) 438 Australian-born women 45-55 of years who were still menstruating at baseline. Of these, 226 were studied for effects of hormones on sexual functioning. MAIN OUTCOME MEASURE(S) Short Personal Experiences Questionnaire (SPEQ) and Affectometer 2 scores and annual blood sampling. RESULT(S) From the early to late menopausal transition, the percentage of women with SPEQ scores indicating sexual dysfunction increased from 42% to 88%. Mood scores did not change significantly. In the early menopausal transition, women with low total SPEQ scores had lower estradiol level but similar androgen levels to those with higher scores. Decreasing SPEQ scores correlated with decreasing estradiol level but not with androgen levels. Hormone levels were not related to mood scores. CONCLUSION(S) Female sexual functioning declines with the natural menopausal transition. This decline relates more to decreasing estradiol levels than to androgen levels.

Are changes in sexual functioning during midlife due to aging or menopause

OBJECTIVE To determine whether changes in womens sexual functioning during midlife are due to aging or menopause. DESIGN Prospective, observational study. SETTING Population-based sample assessed in own homes. PATIENT(S) Four hundred thirty-eight Australian-born women aged 45-55 years and still menstruating at baseline. One hundred ninety-seven were studied for effects of the natural menopausal transition. Control group A (n = 44) remained premenopausal or early perimenopausal for 7 years. Control group B (n = 42) remained postmenopausal over 5 years. INTERVENTION(S) Nil; questionnaires and blood sampling annually. MAIN OUTCOME MEASURE(S) Shortened version of the Personal Experiences Questionnaire. RESULT(S) By the late perimenopause, there was a significant decline in the factors we had derived of sexual responsivity and total score, and there was an increase in the partners problems factor. By the postmenopausal phase, there was a further decline in the factors sexual responsivity, frequency of sexual activities, libido, and in the total score, and a significant increase in vaginal dyspareunia and partners problems. Sexual responsivity significantly declined in both control groups. CONCLUSION(S) Sexual responsivity is adversely affected by both aging and the menopausal transition. Other domains of female sexual functioning were significantly adversely affected when the women became postmenopausal. The relationship with the partner and his ability to perform sexually is adversely affected by the menopausal transition.

Risk factors for female sexual dysfunction in the general population: exploring factors associated with low sexual function and sexual distress.

INTRODUCTION No previous population-based studies have used validated instruments to measure female sexual dysfunction (FSD) in Australian women across a broad age range. AIM To estimate prevalence and explore factors associated with the components of FSD. MAIN OUTCOME MEASURES Sexual Function Questionnaire measured low sexual function. Female Sexual Distress Scale measured sexual distress. Methods. Multivariate analysis of postal survey data from a random sample of 356 women aged 20-70 years. RESULTS Low desire was more likely to occur in women in relationships for 20-29 years (odds ratio 3.7, 95% confidence intervals 1.1-12.8) and less likely in women reporting greater satisfaction with their partner as a lover (0.3, 0.1-0.9) or who placed greater importance on sex (0.1, 0.03-0.3). Low genital arousal was more likely among women who were perimenopausal (4.4, 1.2-15.7), postmenopausal (5.3, 1.6-17.7), or depressed (2.5, 1.1-5.3), and was less likely in women taking hormone therapy (0.2, 0.04-0.7), more educated (0.5, 0.3-0.96), in their 30s (0.2, 0.1-0.7) or 40s (0.2, 0.1-0.7), or placed greater importance on sex (0.2, 0.05-0.5). Low orgasmic function was less likely in women who were in their 30s (0.3, 0.1-0.8) or who placed greater importance on sex (0.3, 0.1-0.7). Sexual distress was positively associated with depression (3.1, 1.2-7.8) and was inversely associated with better communication of sexual needs (0.2, 0.05-0.5). Results were adjusted for other covariates including age, psychological, socioeconomic, physiological, and relationship factors. CONCLUSIONS Relationship factors were more important to low desire than age or menopause, whereas physiological and psychological factors were more important to low genital arousal and low orgasmic function than relationship factors. Sexual distress was associated with both psychological and relationship factors.

What is the "true" prevalence of female sexual dysfunctions and does the way we assess these conditions have an impact?

INTRODUCTION A wide range of prevalence estimates of female sexual dysfunctions (FSD) have been reported. AIM Compare instruments used to assess FSD to determine if differences between instruments contribute to variation in reported prevalence. MAIN OUTCOME MEASURES Sexual Function Questionnaire combined with Female Sexual Distress Scale (SFQ-FSDS) was our gold standard, validated instrument for assessing FSD. Alternatives were SFQ alone and two sets of simple questions adapted from Laumann et al. 1994. Methods. A postal survey was administered to a random sample of 356 Australian women aged 20 to 70 years. RESULTS When assessed by SFQ-FSDS, prevalence estimates (95% confidence intervals) of hypoactive sexual desire disorder, sexual arousal disorder (lubrication), orgasmic disorder, and dyspareunia were 16% (12% to 20%), 7% (5% to 11%), 8% (6% to 12%), and 1% (0.5% to 3%), respectively. Prevalence estimates varied across alternative instruments for these disorders: 32% to 58%, 16% to 32%, 16% to 33%, and 3% to 23%, respectively. Compared with SFQ-FSDS alternative instruments produced higher estimates of desire, arousal and orgasm disorders and displayed a range of sensitivities (0.25 to 1.0), specificities (0.48 to 0.99), positive predictive values (0.01 to 0.56), and negative predictive values (0.95 to 1.0) across the disorders investigated. Kappa statistics comparing SFQ-FSDS and alternative instruments ranged from 0 to 0.71 but were predominantly 0.44 or less. Changing recall from previous month to 1 month or more in the previous year produced higher estimates for all disorders investigated. Including sexual distress produced lower estimates for desire, arousal, and orgasm disorders. CONCLUSIONS Prevalence estimates of FSD varied substantially across instruments. Relatively low positive predictive values and kappa statistics combined with a broad range of sensitivities and specificities indicated that different instruments identified different subgroups. Consequently, the instruments researchers choose when assessing FSD may affect prevalence estimates and risk factors they report.

ORIGINAL RESEARCH—EPIDEMIOLOGY: What can Prevalence Studies Tell Us about Female Sexual Difficulty and Dysfunction?

INTRODUCTION Many recent studies have investigated the prevalence of female sexual difficulty/dysfunction. AIM Investigate female sexual difficulty/dysfunction using data from prevalence studies. METHODS We reviewed published prevalence studies excluding those that had not included each category of sexual difficulty (desire, arousal, orgasm, and pain), were based on convenience sampling, or had a response rate <50% or a sample size <100. Main Outcome Measures. For each study we used the prevalence of any sexual difficulty as the denominator and calculated the proportion of women reporting each type of difficulty. For each category of sexual difficulty we used the prevalence of that difficulty lasting 1 month or more as the denominator and calculated the proportion of difficulties lasting several months or more and 6 months or more. RESULTS Only 11 of 1,248 studies identified met our inclusion criteria. These studies used different measures of sexual dysfunction, so generating a simple summary prevalence was not possible. However, we observed consistent patterns in the published data. Among women with any sexual difficulty, on average, 64% (range 16-75%) experienced desire difficulty, 35% (range 16- 48%) experienced orgasm difficulty, 31% (range 12-64%) experienced arousal difficulty, and 26% (range 7-58%) experienced sexual pain. Of the sexual difficulties that occurred for 1 month or more in the previous year, 62-89% persisted for at least several months and 25-28% persisted for 6 months or more. Two studies investigated distress. Only a proportion of women with sexual difficulty were distressed by it (21-67%). CONCLUSIONS Desire difficulty is the most common sexual difficulty experienced by women. While the majority of difficulties last for less than 6 months, up to a third persist for 6 months or more. Sexual difficulties do not always cause distress. Consequently, prevalence estimates will vary depending on the time frame specified by researchers and whether distress is included in these estimates.

Well-being, symptoms and the menopausal transition

OBJECTIVES This paper reviews the knowledge accumulated from published population studies of health and ill-health experiences during the menopausal transition. RESULTS Well-being: mid-aged women are more likely to report positive moods than negative moods. Well-being is not associated with menopausal status but is associated with current health status, psychosocial and lifestyle variables. SYMPTOMS SYMPTOMS vary greatly across cultures, with North American and European samples reporting higher rates of symptoms than Asian women. The most symptomatic women in the North American samples and Australian studies are those whose menstrual cycles have changed. Vasomotor symptoms increase through the menopausal transition. Other variables such as socio-demographic, health status, stress, premenstrual complaints, attitudes to ageing and menopause, and health behaviors are associated with the occurrence of symptoms. Psychological complaints: There is no increase in the incidence of major depression with the menopause. Negative moods are not associated with the natural menopausal transition. Factors associated with negative moods include surgical menopause, prior depression, health status, menstrual problems, social and family stressors and negative attitudes to menopause. Sexuality: Several studies suggest a decline in sexual functioning associated with menopausal status rather than ageing. Social factors and health status factors are also associated with sexual outcomes. RECOMMENDATIONS Future research should bring together biomedical and sociological aspects. Positive aspects of health should be assessed as well as troubling symptoms. Longitudinal studies are needed with measures of hormonal change. Promoting positive attitudes to ageing and menopause, health lifestyles and stress reduction can be used as community interventions and as part of individual care.

The menopausal transition: a 9-year prospective population-based study. The Melbourne Women's Midlife Health Project

Objectives To describe the natural history of the menopause in Australian-born women. To determine the hormonal changes relating to the menopausal transition (MT) and how these affect quality of life, bone mineral density, body composition, cardiovascular disease (CVD) risk and memory. Design A 9-year prospective, observational study of a population-based sample of 438 Australian-born women aged 45–55 years at baseline. By the 9th year, the retention rate was 88%. Interviews, blood sampling, menstrual calendars, quality of life and physical measures were taken annually, and bone mineral density was measured bi-annually. Results The late MT coincides with changes in estradiol, follicle stimulating hormone, and free testosterone index, decreases in bone density and mastalgia, and increases in central adiposity, vasomotor symptoms, insomnia and vaginal dryness. Levels of total testosterone and dehydroepiandrosterone sulfate are unchanged by the MT. An increase in CVD risk was associated with increases in weight and free testosterone index and a decrease in estradiol. Depressed mood is increased by symptoms and by stressors occurring in the MT. Sexual functioning significantly deteriorates with the MT and aging, but relational factors have major effects. Menstrual cycles became more variable and longer closer to the final menstrual period. Conclusions As hormonal changes during the MT directly or indirectly adversely affect quality of life, body composition and CVD risk, maintenance of health parameters in the premenopausal years is crucial for a healthy postmenopause.

Progesterone and the premenstrual syndrome: a double blind crossover trial

A double blind, randomised, crossover trial of oral micronised progesterone (two months) and placebo (two months) was conducted to determine whether progesterone alleviated premenstrual complaints. Twenty three women were interviewed premenstrually before treatment and in each month of treatment. They completed Mooss menstrual distress questionnaire, Beck et als depression inventory, Spielberger et als state anxiety inventory, the mood adjective checklist, and a daily symptom record. Analyses of data found an overall beneficial effect of being treated for all variables except restlessness, positive moods, and interest in sex. Maximum improvement occurred in the first month of treatment with progesterone. Nevertheless, an appreciably beneficial effect of progesterone over placebo for mood and some physical symptoms was identifiable after both one and two months of treatment. Further studies are needed to determine the optimum duration of treatment.

Sexuality and the menopause

Sexual problems are often reported to clinicians by women in the midlife years. Yet few of the epidemiological studies of women in midlife have investigated the relationship of the menopause to sexual functioning. This paper reports the results of a cross-sectional telephone survey of 2001 randomly selected Australian-born women aged between 45 and 55 years. The major outcome variables were questions relating to changes in sexual interest over the prior 12 months, reasons for any changes, occurrence of sexual intercourse, and of unusual pain on intercourse. Logistic regression was used to identify explanatory variables for change in sexual interest. The majority of women (62%) reported no change in sexual interest, although 31% reported a decrease. Decline in sexual interest was significantly and adversely associated with natural menopause (p < 0.01) rather than age, decreased well-being (p < 0.001), decreasing employment (p < 0.01) and symptomatology (vasomotor p < 0.05, cardiopulmonary p < 0.001 and skeletal p < 0.01). Eleven to twelve years of education was associated with a lowered risk of decreased sexual functioning (p < 0.01). Heterogeneous results were reported by users of hormone replacement therapies. Longitudinal studies of large and representative samples are needed to determine the etiology of adverse sexual changes with the menopause and the role of hormone replacement therapies.