Lynnette Leidy Sievert

The North American Menopause Society recommendations for clinical care of midlife women

In celebration of the 25th anniversary of The North American Menopause Society (NAMS), the Society has compiled a set of key points and clinical recommendations for the care of midlife women. NAMS has always been a premier source of information about menopause for both healthcare providers and midli

Nonhormonal management of menopause-Associated vasomotor symptoms: 2015 position statement of the North American Menopause Society

Objective:To update and expand The North American Menopause Societys evidence-based position on nonhormonal management of menopause-associated vasomotor symptoms (VMS), previously a portion of the position statement on the management of VMS. Methods:NAMS enlisted clinical and research experts in the field and a reference librarian to identify and review available evidence. Five different electronic search engines were used to cull relevant literature. Using the literature, experts created a document for final approval by the NAMS Board of Trustees. Results:Nonhormonal management of VMS is an important consideration when hormone therapy is not an option, either because of medical contraindications or a womans personal choice. Nonhormonal therapies include lifestyle changes, mind-body techniques, dietary management and supplements, prescription therapies, and others. The costs, time, and effort involved as well as adverse effects, lack of long-term studies, and potential interactions with medications all need to be carefully weighed against potential effectiveness during decision making. Conclusions:Clinicians need to be well informed about the level of evidence available for the wide array of nonhormonal management options currently available to midlife women to help prevent underuse of effective therapies or use of inappropriate or ineffective therapies. Recommended: Cognitive-behavioral therapy and, to a lesser extent, clinical hypnosis have been shown to be effective in reducing VMS. Paroxetine salt is the only nonhormonal medication approved by the US Food and Drug Administration for the management of VMS, although other selective serotonin reuptake/norepinephrine reuptake inhibitors, gabapentinoids, and clonidine show evidence of efficacy. Recommend with caution: Some therapies that may be beneficial for alleviating VMS are weight loss, mindfulness-based stress reduction, the S-equol derivatives of soy isoflavones, and stellate ganglion block, but additional studies of these therapies are warranted. Do not recommend at this time: There are negative, insufficient, or inconclusive data suggesting the following should not be recommended as proven therapies for managing VMS: cooling techniques, avoidance of triggers, exercise, yoga, paced respiration, relaxation, over-the-counter supplements and herbal therapies, acupuncture, calibration of neural oscillations, and chiropractic interventions. Incorporating the available evidence into clinical practice will help ensure that women receive evidence-based recommendations along with appropriate cautions for appropriate and timely management of VMS.

Hot flashes are associated with increased ambulatory systolic blood pressure.

Objective: To determine the association between ambulatory blood pressure (BP) and hot flash experience. Design: The participants in the study were 154 women (mean age = 46 years, range = 18-65 years), who were evaluated as part of a cross-sectional study on ethnicity, socioeconomic status, and diurnal BP patterns. Participants could be either normotensive or mildly hypertensive. Participants wore an ambulatory BP monitor for 24 hours and recorded their awake and sleep times. Hot flashes were assessed using an everyday complaint questionnaire that embeds symptoms associated with menopause into a list of everyday complaints. Results: Thirty-three percent of participants reported having had hot flashes during the 2 weeks before they completed the questionnaire. Compared with women who did not report hot flashes, mean awake and sleep systolic BP values were significantly higher (P < 0.004 and P = 0.007, respectively) in women who reported having had hot flashes. Hot flashes continued to independently predict average awake and sleep systolic BP (both P = 0.03) after controlling for age, race/ethnicity, body mass index, and menopausal status. Hot flashes were not associated with diastolic BP or nocturnal dipping of BP. Conclusions: Hot flashes are associated with increased awake and sleep systolic BP independent of menopausal status. Further investigation is warranted to elucidate the mechanisms by which hot flashes are associated with BP.

Do Japanese American women really have fewer hot flashes than European Americans? The Hilo Women's Health Study

Objective: Many studies have found a significantly lower frequency of reported hot flashes (HFs) in Japanese and Japanese American (JA) populations, leading to speculation about possible dietary, genetic, or cultural differences. These studies have relied on subjective reports of HFs. Accordingly, the purpose of this study was to compare both reported and objective HFs measured by sternal and nuchal skin conductance among JA and European American (EA) women. Methods: Two surveys of HF frequencies were carried out among women of either EA or JA ethnicity; aged 45 to 55 years; living in Hilo, Hawaii; and not using exogenous hormones. The first was a postal questionnaire (n = 325); the second was carried out during a clinical study of HFs (n = 134). Women in the second group underwent 24-hour ambulatory and 3-hour laboratory monitoring for objective HFs measured through skin conductance at sternal and nuchal sites. Subjective HFs were recorded on the monitor or in a diary. Results: JAs were significantly less likely to report having had HFs in the previous 2 weeks compared with EAs (postal sample: JAs, 30.9%; EAs, 43.9%; &khgr;2 = 6.9, P < 0.01; monitored sample: JAs, 26.1%; EAs, 46.6%; &khgr;2 = 5.3, P < 0.05). JAs were also significantly less likely to report experiencing other symptoms (15 of 30 in the postal sample; 6 of 30 in the monitored sample) than EAs. However, JAs did not significantly differ in likelihood of reporting subjective HFs during the 24-hour ambulatory period (JAs, 51.1%; EAs, 55.8%; &khgr;2 = 0.3, NS), nor in percentage of individuals displaying one or more objective HFs as measured by the skin conductance monitor (JAs, 77.8%; EAs, 72.1%; &khgr;2 = 0.5, NS). JAs also did not have a significantly fewer number of objective HFs (t = 0.2, NS) nor of subjective HFs (t = 0.8, NS) during the monitoring period, and these results were unchanged when analyses controlled for menopause status and body mass index. Conclusions: The common finding of fewer reported HFs in people of Japanese ancestry may be a consequence of reporting bias: JAs report fewer symptoms of many conditions compared with people from other ethnic groups. This is probably due to cultural conceptions of what is appropriate to report.

Age at menopause in Puebla, Mexico

Comparisons of age at menopause are made difficult by the different methodologies applied across populations. This study extended an opportunity to apply different methodologies to the same data to draw some preliminary conclusions about age at menopause in Puebla, Mexico. Among 755 women aged 28 to 70 interviewed in the capital city of Puebla, Mexico, 447 (59.6%) were naturally or surgically postmenopausal. Mean recalled age at natural menopause in Puebla (46.7 years) appears to be similar to mean recalled age at menopause in Mexico City (46.5 years), suggesting that age at menopause is similar in urban Mexican populations. However, median age at menopause computed by probit analysis was later in the city of Puebla (49.6 years) compared to the median age computed by the same method in the capital city of León, Guanajuato, Mexico (48.2 years). Median age at menopause computed by Kaplan-Meier survival analysis suggests that age at menopause in Puebla (50.0 years) is older still, and close to that of the United States (51.1 years). The differences in median ages at menopause in Puebla are solely due to methodological choices and highlight the difficulty inherent in making inferences across studies of age at menopause between biological and/or cultural groups. Factors associated with age at menopause offer another avenue for comparing and understanding variation in this basic biological process. In Puebla, smoking, low levels of education, and nulliparity are associated with an earlier age at menopause.

Vasomotor symptoms among Japanese-American and European-American women living in Hilo, Hawaii

Objective: The Hilo Womens Health Survey was designed and administered to gather baseline data on womens health in Hilo, HI. This randomized, cross-sectional study allowed for a focus on ethnic differences in symptom reporting. The results presented here focus on hot flash and night sweat experience among Japanese-American and European-American women. Design: Survey packets were mailed to street addresses associated with parcel numbers pulled randomly from Hilo tax maps. Of the 6,401 survey packets delivered to households, 1,824 questionnaires were completed and returned. The results reported here are based on 869 women aged 40 to 60, of whom 249 described themselves to be 100% Japanese and 203 described themselves to be 100% European-American. Logistic regression analyses were used to examine whether the relationship between ethnicity and vasomotor symptoms persisted after controlling for other variables. Results: European-American participants were more likely to have ever experienced a hot flash as compared with Japanese-American participants (72% vs 53%, P < 0.01). During the 2 weeks before the survey, European-American participants were more likely to have experienced hot flashes (P < 0.05) and night sweats (P < 0.01). In logistic regression analyses, after controlling for age, body mass index, menopause status, level of education, financial comfort, smoking habits, alcohol intake, exercise, use of hormone therapy, and soy intake, European-American women were still significantly more likely to have experienced hot flashes (odds ratio = 1.858) and night sweats (odds ratio = 2.672). Conclusions: The results, based on self-reporting of menopausal symptoms, indicate that Japanese-American women report fewer hot flashes and night sweats than European-American women. Japanese-American women reported a higher intake of soy, but soy intake was not associated with fewer vasomotor symptoms.

Determinants of hot flashes and night sweats

Primary Objective: The purpose of this study was to identify determinants of hot flashes and night sweats, two vasomotor symptoms associated with the hormonal changes of the menopause transition. Methods: Participants were 293 women, aged 45 to 55, randomly selected from automated demographic and membership records of a health maintenance organization in the northeast USA. Letters were mailed to eligible women, followed by face-to-face interviews. Results: Hot flashes during the month before interview were reported by 57% of the participants, although only 9% of the entire sample reported hot flashes to be “bothersome”. Night sweats were reported by 36% of all participants, with 6% reporting night sweats to be “bothersome”. Fifty-four percent of women reporting hot flashes also reported night sweats. In logistic regression analyses that controlled for menopause status and use of hormone therapy (HT), daily alcohol consumption significantly increased the risk of hot flashes, night sweats, and bothersome night sweats. Higher education and an excellent self-rating of health decreased the risk of night sweats, but not hot flashes. Smoking increased the risk of bothersome hot flashes, but not bothersome night sweats. Conclusions: In logistic regression analyses, alcohol consumption was a significant predictor of vasomotor symptoms. A slightly different set of variables were associated with hot flashes compared to night sweats. Résumé. Objectif premier: Cette étude a pour objet d’identifier les déterminants des bouffées de chaleur et des sudations nocturnes, deux symptômes vasomoteurs associés aux changements hormonaux de la transition ménopausique. Méthodes: Les participants sont 293 femmes choisies au hasard à partir d’enregistrements automatiques de données démographiques des membres d’une organisation de surveillance de la santé du nord ouest des USA. Des lettres ont été adressées aux femmes retenues, suivies d’entretiens face à face. Résultats: 57% des participantes on fait état de la survenue de bouffées de chaleur dans le mois qui a précédé l’entretien, mais seulement 9% ont mentionné en avoir été incommodées. 36% ont connu des sudations nocturnes, dont 6% ont été incommodées. 54% des femmes ayant fait état de bouffées de chaleur ont également connu des sudations nocturnes. Les analyses de régression logistique qui stabilisent l’effet du statut de la ménopause et du traitement hormonal (TH) indiquent que la consommation quotidienne d’alcool accroît les risques de bouffées de chaleur, de sueurs nocturnes et de sudation nocturne incommodante. Une plus grande éducation et un excellent auto contrôle de la santé diminuent les risques de sudations nocturnes, mais non de bouffées de chaleur. Conclusion: Les analyses de régression logistique montrent que la consommation d’alcool est un excellent prédicateur des symptômes vasomoteurs. Les bouffées de chaleurs sont associées à un groupe de variables légèrement différent de celui des sueurs nocturnes. Zusammenfassung. Studienziel: Sinn dieser Studie war es, Determinanten für Hitzwallungen und Nachtschweiß zu identifizieren, zwei vasomotorische Symptome, die mit den hormonellen Veränderungen des menopausalen Überganges einhergehen. Methoden: Teilnehmerinnen waren 293 Frauen von 45 bis 55 Jahren, die nach Zufallskriterien aus elektronischen demographischen und Mitglieder-Verzeichnissen einer Gesundheitsorganisation im Nordosten der USA gezogen worden waren. Briefe wurden an auffindbare Frauen verschickt, gefolgt von persönlichen Interviews. Ergebnisse: Hitzewallungen in den Monaten vor dem Interview wurden von 57% der Teilnehmerinnen angegeben, aber nur 9% der gesamten Stichprobe berichteten, dass ihnen die Hitzewallungen unangenehm seien. Nachtschweiß wurde von 36% aller Teilnehmerinnen angegeben, von denen 6% berichteten, dass ihnen das nächtliche Schwitzen unangenehm sei. 54% der Frauen, die über Hitzewallungen berichteten, gaben auch an, unter Nachtschweiß zu leiden. Unter Zugrundelegung desselben menopausalen Status und derselben begleitender Hormonbehandlung zeigte sich in logistischen Regressionsanalysen, dass täglicher Alkoholkonsum das Risiko von Hitzewallung, Nachtsschweiß und das Unwohlsein bei Nachtschweiß signifikant erhöhte. Höhere Bildung und eine besonders gute Selbsteinschätzung der eigenen Gesundheit senkten das Risiko von Nachtschweiß, nicht aber das von Hitzewallungen. Rauchen erhöhte das Risiko von Unwohlsein bei Hitzewallungen, nicht aber das Unwohlsein bei Nachtschweiß. Zusammenfassung: In logistischen Regressionsanalysen erwies sich Alkoholkonsum als signifikantes Vorhersagekriterium für vasomotorische Symptome. Verglichen mit Nachtschweiß war ein leicht veränderter Satz von Variablen mit Hitzewallungen verknüpft. Resumen. Objetivo principal: el propósito de este estudio fue identificar los determinantes de los sofocos y sudores nocturnos, dos síntomas vasomotores asociados con los cambios hormonales de la transición menopáusica. Métodos: las participantes fueron 293 mujeres, de 45 a 55 años de edad, seleccionadas aleatoriamente a partir de registros automatizados demográficos y de afiliación a una organización para el mantenimiento de la salud, en el nordeste de EE.UU. Se enviaron cartas circulares a las mujeres potencialmente elegibles, que fueron seguidas de entrevistas personales. Resultados: el 57% de las participantes dijeron haber tenido sofocos durante el mes anterior a la entrevista, aunque sólo el 9% de toda la muestra indicó que los sofocos habían sido “molestos”. Los sudores nocturnos fueron reportados por el 36% de las participantes, el 6% de las cuales señaló que los sudores nocturnos eran “molestos”. El cincuenta y cuatro por ciento de las mujeres que experimentaron sofocos también dijeron haber tenido sudores nocturnos. En los análisis de regresión logística que controlaban el status de menopausia y el uso de terapia hormonal (HT), se comprobó que el consumo diario de alcohol incrementaba el riesgo de padecer sofocos, sudores nocturnos y sudores nocturnos molestos. Un nivel educativo alto y una excelente valoración de la propia salud disminuían el riesgo de padecer sudores nocturnos, pero no de sofocos. El consumo de tabaco incrementaba el riesgo de sufrir sofocos molestos, pero no de sudores nocturnos molestos. Conclusiones: en los análisis de regresión logística, el consumo de alcohol fue un predictor significativo de los síntomas vasomotores. El conjunto de variables asociadas con los sofocos era ligeramente diferente al de las variables asociadas con los sudores nocturnos.

Methods used in cross-cultural comparisons of somatic symptoms and their determinants

Methodological differences among studies of vasomotor symptoms limit rigorous comparison or systematic review. Vasomotor symptoms generally include hot flushes and night sweats although other associated symptoms exist. Prevalence rates vary between and within populations, but different studies collect data on frequency, bothersomeness, and/or severity using different outcome measures and scales, making comparisons difficult. We reviewed only cross-cultural studies of menopausal symptoms that explicitly examined symptoms in general populations of women in different countries or different ethnic groups in the same country. This resulted in the inclusion of nine studies: Australian/Japanese Midlife Womens Health Study (AJMWHS), Decisions At Menopause Study (DAMeS), Four Major Ethnic Groups (FMEG), Hilo Womens Health Survey (HWHS), Mid-Aged Health in Women from the Indian Subcontinent (MAHWIS), Penn Ovarian Aging Study (POAS), Study of Womens Health Across the Nation (SWAN), Womens Health in Midlife National Study (WHiMNS), and Womens International Study of Health and Sexuality (WISHeS). These studies highlight the methodological challenges involved in conducting multi-population studies, particularly when languages differ, but also highlight the importance of performing multivariate and factor analyses. Significant cultural differences in one or more vasomotor symptoms were observed in 8 of 9 studies, and symptoms were influenced by the following determinants: menopausal status, hormones (and variance), age (or actually, the square of age, age(2)), BMI, depression, anxiety, poor physical health, perceived stress, lifestyle factors (hormone therapy use, smoking and exposure to passive smoke), and acculturation (in immigrant populations). Recommendations are made to improve methodological rigor and facilitate comparisons in future cross-cultural menopause studies.

Attitudes Toward Menopause in Relation to Symptom Experience in Puebla, Mexico

ABSTRACT Objective: To examine how attitudes toward menopause were associated with symptom frequencies after controlling for menopause status and level of education. Methods: Women aged 28–70 (n = 755) were interviewed from May, 1999 through August, 2000 in the city of Puebla, Mexico. Over 90% of the sample were aged 40–60. Participants were asked to select from a set of dichotomies to describe “how a woman feels during menopause.” Symptom frequencies were assessed by a checklist of everyday complaints experienced during the two weeks before interview. Symptom presence or absence was examined in relation to attitudes while controlling for menopause status and level of education using binary logistic regression analyses. Results: The majority of respondents said that a menopausal woman feels “insecure” and “unattractive” yet “complete,” “necessary,” and “successful.” Pre-menopausal women and respondents who had undergone a hysterectomy were more likely to express negative attitudes. Post-menopausal women and women with fewer years of education were significantly more likely to report symptoms such as hot flashes, joint aches, and nervous tension. A range of negative attitudes were associated with nervous tension, feeling blue, and head aches; however, only a few negative attitudes were significantly predictive of estrogen-related symptoms (e.g., hot flashes). Conclusions: There is a high value placed on both external appearance and familial responsibility among menopausal women in Puebla, Mexico, and negative characterizations of menopause reflect these values. Negative attitudes were associated with more frequently reported symptoms compared with positive attitudes. The challenge remains to separate factors related to the hormonal changes of menopause from those not associated with hormonal changes to better understand symptom experience.

Patterns of occurrence and concordance between subjective and objective hot flashes among Muslim and Hindu women in Sylhet, Bangladesh

This study examined the pattern of occurrence and the rate of concordance between objective hot flashes measured by sternal skin conductance and the subjective experience of “gorom vap laga” (feeling steaming hot) among Muslim and Hindu women living in Sylhet, Bangladesh. Participants were aged 40–55, not pregnant or lactating, not using hormone therapy, and with no history of hysterectomy. Thirty women wore an ambulatory hot flash monitor for 8 h on average, from mid‐morning to early evening. True positive, false negative, and false positive measures of hot flashes were examined in relation to demographic, reproductive, and lifestyle variables. On body diagrams, women were most likely to indicate hot flashes on the top of their head (64%) and upper chest (68%). The greatest number of objective hot flashes occurred during the hour of 17:00, perhaps due to the heat of the day, and the clothing and activity associated with prayer. Muslim participants demonstrated more objective hot flashes per woman than Hindu participants (1.5 vs. 0.1, P < 0.05), and Muslims had more false positive measures (86%) compared with Hindu participants (0%, P = 0.06). Among all women who reported subjective hot flashes (n = 19), the proportion of true positive scores was 19%. Overall, the frequency of objective hot flashes was low compared with reports from studies in the United States. The pattern of sweating assessed by body diagrams was not associated with variation in hot flash experience. Am. J. Hum. Biol., 2008.