Myra Hunter

Relationships between psychological symptoms, somatic complaints and menopausal status

The importance of distinguishing climacteric symptoms from other psychological and somatic complaints has been repeatedly stressed, but as yet no detailed guidelines are available to assist the clinician in the day-to-day management of patients. Previous epidemiological surveys of climacteric symptoms have been criticised because of inadequate methodology. We have attempted to overcome most of these problems and to provide a more detailed analysis of the relationships between menopausal status and psychological and somatic symptoms. Eight hundred and fifty pre-, peri- and post-menopausal women, aged 45-65 yr, took part in a cross-sectional survey of general health, psychosocial factors and current symptomatology. They were a non-menopause clinic sample and were blind to the purpose of the study. Using a principal components analysis, the relationships between symptoms were examined. Certain psychological and somatic symptoms occurred together in specific clusters. Some of these symptom clusters, e.g., vasomotor symptoms and sexual difficulties, were best predicted solely by menopausal status, while others, such as psychological and somatic symptoms, were more clearly associated with psychosocial factors. On the basis of these results, guidelines for the assessment of climacteric and post-menopausal women can be suggested.

The South-East England longitudinal study of the climacteric and postmenopause

Fifty-six premenopausal women were drawn from a cross-sectional survey of 850 women living in South-East England. They were recontacted 3 years later when 36 met the criterion of being naturally peri- or postmenopausal. Somatic, vasomotor and emotional symptoms, as well as general health, use of medical services and beliefs about the menopause, were assessed on both occasions using the Womens Health Questionnaire (a symptom scale standardized for use with this age group). In general, the cross-sectional findings were confirmed--vasomotor symptoms, sleep problems and to a lesser extent depressed mood increased during the peri- and postmenopause. However, ratings of general health and use of medical services remained unchanged. A stepwise regression analysis was used to predict depressed mood and hot flushes in peri- and postmenopausal women. The results illustrate the importance of previously existing symptoms, stereotyped beliefs and social factors in explanations of climacteric symptoms.

The women's health questionnaire: A measure of mid-aged women's perceptions of their emotional and physical health

Abstract When assessing mood and general health of mid-aged women, the effects of hormonal changes (and resulting symptoms such as hot flushes) and changes associated with age (such as in sleep patterns) can confound the results. A questionnaire was specifically developed to measure subjective reports of emotional and physical well-being of women aged 45 to 65 years. The relationships between symptoms was explored using factor analysis and a range of subscales was derived. Depressed mood and anxiety formed separate scales, as did sleep problems, somatic symptoms, menstrual problems and sexual behaviour. Vasomotor symptoms (hot flushes and night sweats) made up an additional scale. The full scale, with scoring information and norms for two samples ((i) 682 women aged 45-65, and (ii) 55 women aged 23-38) is provided. Test-retest reliability was found to be high (range 0.69-0.96) and concurrent validity for the depressed mood scale was confirmed by comparison with the General Health Questionnaire (Goldberg, ...

Critical research gaps and translational priorities for the successful prevention and treatment of breast cancer

IntroductionBreast cancer remains a significant scientific, clinical and societal challenge. This gap analysis has reviewed and critically assessed enduring issues and new challenges emerging from recent research, and proposes strategies for translating solutions into practice.MethodsMore than 100 internationally recognised specialist breast cancer scientists, clinicians and healthcare professionals collaborated to address nine thematic areas: genetics, epigenetics and epidemiology; molecular pathology and cell biology; hormonal influences and endocrine therapy; imaging, detection and screening; current/novel therapies and biomarkers; drug resistance; metastasis, angiogenesis, circulating tumour cells, cancer ‘stem’ cells; risk and prevention; living with and managing breast cancer and its treatment. The groups developed summary papers through an iterative process which, following further appraisal from experts and patients, were melded into this summary account.ResultsThe 10 major gaps identified were: (1) understanding the functions and contextual interactions of genetic and epigenetic changes in normal breast development and during malignant transformation; (2) how to implement sustainable lifestyle changes (diet, exercise and weight) and chemopreventive strategies; (3) the need for tailored screening approaches including clinically actionable tests; (4) enhancing knowledge of molecular drivers behind breast cancer subtypes, progression and metastasis; (5) understanding the molecular mechanisms of tumour heterogeneity, dormancy, de novo or acquired resistance and how to target key nodes in these dynamic processes; (6) developing validated markers for chemosensitivity and radiosensitivity; (7) understanding the optimal duration, sequencing and rational combinations of treatment for improved personalised therapy; (8) validating multimodality imaging biomarkers for minimally invasive diagnosis and monitoring of responses in primary and metastatic disease; (9) developing interventions and support to improve the survivorship experience; (10) a continuing need for clinical material for translational research derived from normal breast, blood, primary, relapsed, metastatic and drug-resistant cancers with expert bioinformatics support to maximise its utility. The proposed infrastructural enablers include enhanced resources to support clinically relevant in vitro and in vivo tumour models; improved access to appropriate, fully annotated clinical samples; extended biomarker discovery, validation and standardisation; and facilitated cross-discipline working.ConclusionsWith resources to conduct further high-quality targeted research focusing on the gaps identified, increased knowledge translating into improved clinical care should be achievable within five years.

Women's knowledge and beliefs regarding breast cancer

Approximately 20–30% of women delay for 12 weeks or more from self-discovery of a breast symptom to presentation to a health care provider, and such delay intervals are associated with poorer survival. Understanding the factors that influence patient delay is important for the development of an effective, targeted health intervention programme to shorten patient delay. The aim of the study was to elicit knowledge and beliefs about breast cancer among a sample of the general female population, and examine age and socio-economic variations in responses. Participants were randomly selected through the Postal Address File, and data were collected through the Office of National Statistics. Geographically distributed throughout the UK, 996 women participated in a short structured interview to elicit their knowledge of breast cancer risk, breast cancer symptoms, and their perceptions of the management and outcomes associated with breast cancer. Women had limited knowledge of their relative risk of developing breast cancer, of associated risk factors and of the diversity of potential breast cancer-related symptoms. Older women were particularly poor at identifying symptoms of breast cancer, risk factors associated with breast cancer and their personal risk of developing the disease. Poorer knowledge of symptoms and risks among older women may help to explain the strong association between older age and delay in help-seeking. If these findings are confirmed they suggest that any intervention programme should target older women in particular, given that advancing age is a risk factor for both developing breast cancer and for subsequent delayed presentation.

MEMORY FOR PAIN

&NA; Memory for head pain was assessed by means of the McGill Pain Questionnaire (MPQ). Sixteen neurosurgical patients were divided into two groups in order to examine the decay of memory over time; one group recalled pain after 5 days and the other recalled pain after one day and then again, after 5 days. Contrary to expectations, the recall of pain was surprisingly accurate. The memory for pain showed little decay over time. The small subgroup of patients who made specific errors when recalling their pain comprised women who had high levels of pain and affect at the initial assessment. Overall, the findings provide some welcome reassurance about the accuracy and reliability of pain reports from memory.

Psychological and somatic experience of the menopause: a prospective study [corrected].

&NA; This study investigates the nature of psychological and somatic symptoms experienced during the menopause and attempts to predict individual differences using a prospective design. Thirty‐six women, who were premenopausal during an initial investigation, became peri‐ or postmenopausal three years later. The Womens Health Questionnaire, developed specifically for this population, was used to assess general health, beliefs, psychosocial factors, and current symptoms. As expected, vasomotor symptoms were more prevalent in peri‐ and postmenopausal women. However, significant but small increases in depressed mood were also evident. The results of a stepwise regression analysis indicated that past depression together with cognitive and social factors accounted for 51 per cent of the variance in depressed mood reported by menopausal women. The clinical and theoretical implications are discussed.

Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial

Summary Background Hot flushes and night sweats (HFNS) affect 65–85% of women after breast cancer treatment; they are distressing, causing sleep problems and decreased quality of life. Hormone replacement therapy is often either undesirable or contraindicated. Safe, effective non-hormonal treatments are needed. We investigated whether cognitive behavioural therapy (CBT) can help breast cancer survivors to effectively manage HFNS. Methods In this randomised controlled trial, we recruited women from breast clinics in London, UK, who had problematic HFNS (minimum ten problematic episodes a week) after breast-cancer treatment. Participants were randomly allocated to receive either usual care or usual care plus group CBT (1:1). Randomisation was done in blocks of 12–20 participants, stratifying by age (younger than 50 years, 50 years or older), and was done with a computer-generated sequence. The trial statistician and researchers collecting outcome measures were masked to group allocation. Group CBT comprised one 90 min session a week for 6 weeks, and included psycho-education, paced breathing, and cognitive and behavioural strategies to manage HFNS. Assessments were done at baseline, 9 weeks, and 26 weeks after randomisation. The primary outcome was the adjusted mean difference in HFNS problem rating (1–10) between CBT and usual care groups at 9 weeks after randomisation. Analysis of the primary endpoint was done by modified intention to treat. The trial is registered, ISRCTN13771934, and was closed March 15, 2011. Findings Between May 5, 2009, and Aug 27, 2010, 96 women were randomly allocated to group CBT (n=47) or usual care (n=49). Group CBT significantly reduced HFNS problem rating at 9 weeks after randomisation compared with usual care (mean difference −1·67, 95% CI −2·43 to −0·91; p<0·0001) and improvements were maintained at 26 weeks (mean difference −1·76, −2·54 to −0·99; p<0·0001). We recorded no CBT-related adverse events. Interpretation Group CBT seems to be a safe and effective treatment for women who have problematic HFNS after breast cancer treatment with additional benefits to mood, sleep, and quality of life. The treatment could be incorporated into breast cancer survivorship programmes and delivered by trained breast cancer nurses. Funding Cancer Research UK.

Efficacy of Cognitive Behavioral Therapy and Physical Exercise in Alleviating Treatment-Induced Menopausal Symptoms in Patients With Breast Cancer: Results of a Randomized, Controlled, Multicenter Trial

PURPOSE The purpose of our study was to evaluate the effect of cognitive behavioral therapy (CBT), physical exercise (PE), and of these two interventions combined (CBT/PE) on menopausal symptoms (primary outcome), body image, sexual functioning, psychological well-being, and health-related quality of life (secondary outcomes) in patients with breast cancer experiencing treatment-induced menopause. PATIENTS AND METHODS Patients with breast cancer reporting treatment-induced menopausal symptoms (N=422) were randomly assigned to CBT (n=109), PE (n=104), CBT/PE (n=106), or to a waiting list control group (n=103). Self-report questionnaires were completed at baseline, 12 weeks, and 6 months. Multilevel procedures were used to compare the intervention groups with the control group over time. RESULTS Compared with the control group, the intervention groups had a significant decrease in levels of endocrine symptoms (Functional Assessment of Cancer Therapy-Endocrine Symptoms; P<.001; effect size, 0.31-0.52) and urinary symptoms (Bristol Female Lower Urinary Tract Symptoms Questionnaire; P=.002; effect size, 0.29-0.33), and they showed an improvement in physical functioning (36-Item Short Form Health Survey physical functioning subscale; P=.002; effect size, 0.37-0.46). The groups that included CBT also showed a significant decrease in the perceived burden of hot flashes and night sweats (problem rating scale of the Hot Flush Rating Scale; P<.001; effect size, 0.39-0.56) and an increase in sexual activity (Sexual Activity Questionnaire habit subscale; P=.027; effect size, 0.65). Most of these effects were observed at both the 12-week and 6-month follow-ups. CONCLUSION CBT and PE can have salutary effects on endocrine symptoms and, to a lesser degree, on sexuality and physical functioning of patients with breast cancer experiencing treatment-induced menopause. Future work is needed to improve the design and the planning of these interventions to improve program adherence.

3 Predictors of menopausal symptoms: psychosocial aspects

Summary The most relevant factors influencing a womans quality of life during the menopausal transition appear to be her previous emotional and physical health, her social situation, her experience of stressful life events (particularly bereavements and separations), as well as her beliefs about the menopause. Specific predictors of vasomotor symptoms include surgical menopause and possibly current cigarette smoking. The role of stress, past menstrual problems and reports of hot flushes earlier in life as predictors requires further study. There are considerable cultural differences in the reporting of vasomotor symptoms which may be explained by the meaning ascribed to them and the value of older women in societies, as well as possible dietary, lifestyle and genetic differences. Those who seek medical help for menopausal problems tend to report more physical and psychological problems in general. They are more likely to be under stress and to hold particular beliefs about the menopause. These personal and social issues need to be addressed in their own right and should not be automatically attributed to the menopause. Clinical psychologists and counsellors, ideally working as part of the team, can help women and couples to clarify the nature of the problems and to help them to explore solutions. In contrast to childbirth, preparation for the menopause has been neglected in the development of services, as well as in research ( Notelovitz , 1988; Hunter, 1990c ). The studies reviewed here do suggest some pointers for health promotion; these are being evaluated in a current study by Hunter and Liao and can be summarized as follows: 1. Providing balanced information about the menopause, to women and their families. 2. Discussion of attitudes towards the menopause, with reassurance of overly pessimistic beliefs. 3. Health promotion sessions focusing upon diet, exercise and smoking (factors which are associated with general health and the development of osteoporosis). 4. Stress management sessions. 5. Group discussion of personal, health and social issues met by women during midlife.