Peter Chedraui

Understanding weight gain at menopause

ABSTRACT Objective The aim of this review was to summarize the literature regarding the impact of the menopause transition on body weight and body composition. Methods We conducted a search of the literature using Medline (Ovid, 1946–present) and PubMed (1966–2012) for English-language studies that included the following search terms: ‘menopause’, ‘midlife’, ‘hormone therapy’ or ‘estrogen’ combined with ‘obesity’, ‘body weight’ or ‘body composition’. Results Whereas weight gain per se cannot be attributed to the menopause transition, the change in the hormonal milieu at menopause is associated with an increase in total body fat and an increase in abdominal fat. Weight excess at midlife is not only associated with a heightened risk of cardiovascular and metabolic disease, but also impacts adversely on health-related quality of life and sexual function. Animal and human studies indicate that this tendency towards central abdominal fat accumulation is ameliorated by estrogen therapy. Studies mostly indicate a reduction in overall fat mass with estrogen and estrogen–progestin therapy, improved insulin sensitivity and a lower rate of development of type 2 diabetes. Conclusion The hormonal changes across the perimenopause substantially contribute to increased abdominal obesity which leads to additional physical and psychological morbidity. There is strong evidence that estrogen therapy may partly prevent this menopause-related change in body composition and the associated metabolic sequelae. However, further studies are required to identify the women most likely to gain metabolic benefit from menopausal hormone therapy in order to develop evidence-based clinical recommendations.

Effects of the Mediterranean diet on longevity and age-related morbid conditions.

OBJECTIVES To delineate the influences of the Mediterranean diet (MD) on human mortality and age-related morbid conditions, principally the metabolic syndrome, hypertension, cardiovascular disease, excess body weight, cancer, poor bone mineralization and rheumatoid arthritis, and neurodegenerative disorders. METHOD Citations were selected from a PubMed search according to their clinical and experimental relevance. RESULTS AND CONCLUSIONS Individuals who adhere to the principles of the traditional MD tend to have a longer life-span. Both men and women who report eating foods closest to the MD are about 10-20% less likely to die over the course of a study of heart disease, cancer or any other cause. The longevity of Mediterranean people has been related to olive oil, and its several microcomponents of antioxidant potential, present in all MD variants. The prevalence of the metabolic syndrome may be reduced by a MD. The MD is significantly inversely associated with both systolic and diastolic blood pressure. It also has benefits in relation to the prevention of cardiovascular events, reduces the risk of mortality after myocardial infarction, and reduces peripheral arterial disease. The risk of obesity decreases with increasing adherence to the traditional MD. The MD also has a preventive effect on cancer, through its antiproliferative and pro-apoptotic effects, mostly due to the components of virgin olive oil and vegetables. There is some evidence of the benefits of the MD in relation to bone metabolism, rheumatoid arthritis, and neurodegenerative age-related diseases (cognitive deficit, Alzheimers disease, Parkinsons disease).

Assessment of sexuality among middle-aged women using the Female Sexual Function Index

Objective The purpose of the present investigation was to assess sexual function among middle-aged women and determine related risk factors (personal and partner) for sexual dysfunction. Methods In this cross-sectional study, women aged 40–59 years were requested to fill out the Female Sexual Function Index (FSFI) and a general demographic questionnaire containing personal and partner data. Results A total of 409 women with a mean age of 47 ± 5.3 years were surveyed. Of these, 42.1% were premenopausal, 24.4% perimenopausal and 33.5% postmenopausal. At the time of survey, 10.5% of women were hysterectomized, 1.5% used psychotropic drugs, and 9.8% were on hormone therapy (HT) for the menopause; 28.1% had less than 12 years of schooling and 80.4% had only one partner at the moment of survey. Among their male partners, 7.3% abused alcohol, 10.3% had erectile dysfunction, 11.2% premature ejaculation and 63.83% were faithful partners. Mean (± standard deviation) scores for the FSFI domains were: desire (3.7 ± 1.2), arousal (3.1 ± 2.5), lubrication (3.3 ± 2.6), orgasm (2.6 ± 2.3), satisfaction (4 ± 1.7), and pain/dyspareunia (3.2 ± 2.6). The mean total FSFI score was 20.1 ± 12.4 (median 24.7). In this series, the prevalence of female sexual dysfunction (FSFI score ≤26.55) was 55.7%, with women presenting difficulties across all domains of female sexual function but mostly in the dyspareunia and lubrication domains. Logistic regression analysis determined that female age (odds ratio (OR) 3.3, 95% confidence interval (CI) 1.6–6.8), p = 0.001), postmenopausal status (OR 2.8, 95% CI 1.3–6.1, p = 0.007), partners age (OR 2.0, 95% CI 1–4, p = 0.03), educational level (OR 2.7, 95% CI 1.5–5, p = 0.001), and the presence of erectile dysfunction (OR 3.8, 95% CI 1.3–10.9, p = 0.01) and premature ejaculation (OR 4.1, 95% CI 1.4–11.7, p = 0.0001) significantly increased the risk for female sexual dysfunction. Partner faithfulness (OR 0.2, 95% CI 0.1–0.4, p = 0.001) and menopausal HT use (OR 0.4, 95% CI 0.1–1, p = 0.04) decreased this risk. Conclusions In this series, male sexual health and demographic profile and female HT use were relevant determinants for sexual functioning among middle-aged women.

Impaired quality of life among middle aged women: a multicentre Latin American study.

BACKGROUND Several studies indicate that quality of life (QoL) is impaired in middle aged women. Assessment of QoL using a single validated tool in Latin American climacteric women has not been reported to date at large scale. OBJECTIVE The Menopause Rating Scale (MRS) was used to assess QoL among middle aged Latin American women and determine factors associated with severe menopausal symptoms (QoL impairment). METHODS In this cross-sectional study, 8373 healthy women aged 40-59 years, accompanying patients to healthcare centres in 18 cities of 12 Latin American countries, were asked to fill out the MRS and a questionnaire containing socio-demographic, female and partner data. RESULTS Mean age of the entire sample was 49.1+/-5.7 years (median 49), a 62.5% had 12 or less years of schooling, 48.8% were postmenopausal and 14.7% were on hormonal therapy (HT). Mean total MRS score (n=8373) was 11.3+/-8.5 (median 10); for the somatic subscale, 4.1+/-3.4; the psychological subscale, 4.6+/-3.8 and the urogenital subscale, 2.5+/-2.7. The prevalence of women presenting moderate to severe total MRS scorings was high (>50%) in all countries, Chile and Uruguay being the ones with the highest percentages (80.8% and 67.4%, respectively). Logistic regression determined that impaired QoL (severe total MRS score > or =17) was associated with the use of alternatives therapies for menopause (OR: 1.47, 95% CI [1.22-1.76], p=0.0001), the use of psychiatric drugs (OR: 1.57, 95% CI [1.29-1.90], p=0.0001), attending a psychiatrist (OR: 1.66, 95% CI [1.41-1.96], p=0.0001), being postmenopausal (OR: 1.48, 95% CI [1.29-1.69, p=0.0001]), having 49 years or more (OR: 1.24, 95% CI [1.08-1.42], p=0.001), living at high altitude (OR: 1.43, 95% CI [1.25-1.62, p=0.0001]) and having a partner with erectile dysfunction (OR: 1.69, 95% CI [1.47-1.94, p=0.0001]) or premature ejaculation (OR: 1.34, 95% CI [1.16-1.55, p=0.0001]). Lower risk for impaired QoL was related to living in a country with a lower income (OR: 0.77, 95% CI [0.68-0.88], p=0.0002), using HT (OR: 0.65, 95% CI [0.56-0.76], p=0.0001) and engaging in healthy habits (OR: 0.59, 95% CI [0.50-0.69], p=0.0001). CONCLUSION To the best of our knowledge this is the first and largest study assessing QoL in a Latin American climacteric series with a high prevalence of impairment related to individual female and male characteristics and the demography of the studied population.

Gender differences in cardiovascular disease: hormonal and biochemical influences.

Objective: Atherosclerosis is a complex process characterized by an increase in vascular wall thickness owing to the accumulation of cells and extracellular matrix between the endothelium and the smooth muscle cell wall. There is evidence that females are at lower risk of developing cardiovascular disease (CVD) as compared to males. This has led to an interest in examining the contribution of genetic background and sex hormones to the development of CVD. The objective of this review is to provide an overview of factors, including those related to gender, that influence CVD. Methods: Evidence analysis from PubMed and individual searches concerning biochemical and endocrine influences and gender differences, which affect the origin and development of CVD. Results: Although still controversial, evidence suggests that hormones including estradiol and androgens are responsible for subtle cardiovascular changes long before the development of overt atherosclerosis. Conclusion: Exposure to sex hormones throughout an individual’s lifespan modulates many endocrine factors involved in atherosclerosis.

Sexual dysfunction in middle-aged women: a multicenter Latin American study using the Female Sexual Function Index

Objective: The purpose of this study was to assess the prevalence of sexual dysfunction (SD) and associated risk factors among middle-aged Latin American women using one validated instrument. Methods: The Female Sexual Function Index (FSFI) was applied to 7,243 healthy women aged 40 to 59 years who were users of 19 healthcare systems from 11 Latin American countries. An itemized questionnaire containing personal and partner sociodemographic data was also filled out. Results: Mean ± SD age of surveyed women was 49.0 ± 5.7 years, with 11.6 years of schooling on average. There were 55.1% of women who were married, 46.8% who were postmenopausal, 14.1% who used hormonal therapy (HT), and 25.6% who were sexually inactive. Among those who were active (n = 5,391), the mean ± SD total FSFI score was 25.2 ± 5.9 and 56.8% of them presented SD (FSFI total score ≤26.55), with a prevalence varying from 21.0% to 98.5% depending on the center. Centers were grouped in terciles (according to mean ± SD prevalence). The tercile with higher SD prevalence (86.4%) compared with that with lower SD prevalence (32.2%) had significantly older women (49.5 ± 5.3 vs 48.0 ± 5.6 y) with a higher rate of vaginal dryness (60.4% vs 40.8%) and older partners (53.0 ± 6.9 vs 50.2 ± 7.5 y). Similarly, there was a significantly higher rate of married (68.5% vs 63.1%), postmenopausal (49.7% vs 39.3%), and HT-using women (23% vs 9.2%). There were no differences in regard to their health perception, history of oophorectomy, rape, and partner SD rate (27% vs 26.2%). The total FSFI score was significantly lower in the tercile with higher SD prevalence (22.0 ± 5.0 vs 27.5 ± 5.4). Logistic regression analysis was used to determine the odds ratios (95% CIs) for the main risk factors associated with SD among those who were sexually active: bad lubrication, 3.86 (3.37-4.43); use of alternative menopausal therapies, 2.13 (1.60-2.84); partner SD, 1.89 (1.63-2.20); older women (>48 y), 1.84 (1.61-2.09); bladder problems, 1.47 (1.28-1.69); HT use, 1.39 (1.15-1.68); negative perception of female health status, 1.31 (1.05-1.64); and being married, 1.22 (1.07-1.40). Protective factors were higher educational level (women), partner faithfulness, and access to private healthcare. Conclusions: The prevalence of SD in this middle-aged Latin American series was found to be high, varying widely in different populations. A decrease in vaginal lubrication was the most important associated risk factor. Differences in the prevalence of risk factors among the studied groups, several of which are modifiable, could explain the variation of SD prevalence observed in this study.

The US National Cholesterol Education Programme Adult Treatment Panel III (NCEP ATP III): prevalence of the metabolic syndrome in postmenopausal Latin American women.

Background Metabolic syndrome (METS) is a strong predictor of cardiovascular risk. Since the prevalence of METS increases after menopause, gynecological routine consultation offers an excellent screening opportunity. Objectives To assess the prevalence of METS in Latin American postmenopausal women and factors modifying its risk; as well as to assess the role of simple routine care measurements in the diagnosis of the METS. Methods A total of 3965 postmenopausal women, aged 45–64 years, seeking health care at 12 gynecological centers in major Latin American cities were included in this cross-sectional study. The US National Cholesterol Education Programme Adult Treatment Panel III (NCEP ATP III) guidelines were applied to assess METS. This was present if three or more of the following conditions were present: waist circumference ≥ 88 cm; blood pressure ≥ 130/85 mmHg; fasting plasma triglycerides ≥ 150 mg/dl; high density lipoprotein (HDL) cholesterol < 50 mg/dl; glucose ≥ 110 mg/dl or subjects were receiving treatment for their condition. Results The prevalences of having at least two, three, four or five components were 62.5, 35.1, 13.5 and 3.2%, respectively. The prevalence increased from 28.1% in those aged 40–44 years to 42.9% in those aged 60–64 years. The risk of METS detection (multivariate analysis) increased with age (odds ratio (OR) 1.22, 95% confidence interval (CI) 1.03–1.43), time elapsed since menopause (OR 1.18, 95% CI 1.00–1.38), smoking cigarettes (OR 1.40, 95% CI 1.19–1.65), obesity (OR 13.01, 95% CI 10.93–15.49) and hypertension (OR 9.30, 95% CI 7.91–10.94). In contrast, hormone therapy reduces this risk (OR 0.59, 95% CI 0.51–0.70). Conclusion There is a high prevalence of the metabolic syndrome in postmenopausal Latin American women seeking gynecologic health care. Age, years since menopause, obesity and hypertension are strong predictors of this condition.

A large multinational study of vasomotor symptom prevalence, duration, and impact on quality of life in middle-aged women

Objective: The aim of this study was to determine vasomotor symptom (VMS) prevalence, duration, and impact on quality of life in middle-aged women using a validated menopausal tool. Methods: The Menopause Rating Scale (MRS) and an itemized questionnaire containing personal sociodemographic data were used to examine 8,373 women aged 40 to 59 years from 22 healthcare centers in 12 Latin American countries. Results: Less than half (48.8%) of all women studied were postmenopausal, 14.7% used hormone therapy (HT), 54.5% presented VMS of any degree, and 9.6% presented severe/bothersome symptoms. The rate of VMS (any degree) significantly increased from one menopausal stage to the next. HT users presented more VMS (any degree) than did nonusers (58.6% vs 53.8%, P = 0.001). When surgical postmenopausal women were compared, non-HT users displayed a higher prevalence of severe VMS (16.1% vs 9.0%, P = 0.0001). The presence of VMS of any degree was related to a more impaired quality of life (higher total MRS score; odds ratio, 4.7; 95% CI, 4.1-5.3). This effect was even higher among women presenting severe VMS. Logistic regression analysis determined that the presence of severe psychological/urogenital symptoms (MRS), lower educational level, natural perimenopause-postmenopause status, nulliparity, surgical menopause, and living at high altitude were significant risk factors for severe VMS. HT use was related to a lower risk. A second regression model determined that surgical menopause, intense psychological/urogenital symptoms, and a history of psychiatric consultation were factors related to severe VMS persisting into the late postmenopausal stage (5 or more years). Conclusions: In this Latin American middle-aged series, VMS prevalence was high, persisting into the late postmenopausal phase in a high rate and severely impairing quality of life. HT use was related to a lower risk of severe VMS.

Factors associated with inadequate prenatal care in Ecuadorian women

Although inadequate prenatal care has been associated with adverse perinatal outcomes, reports on the factors associated with poor prenatal care in developing Latin American countries are scarce.

The metabolic syndrome among postmenopausal women in Ecuador

Background. The prevalence of the metabolic syndrome increases with age and after the onset of menopause, and may explain in part the apparent acceleration of cardiovascular disease in postmenopausal women. Objective. To determine the prevalence of metabolic syndrome and related risk determinants among postmenopausal women in Ecuador. Methods. Postmenopausal women ≥40 years of age, non-users of hormone therapy and with an intact uterus, were asked to participate in a metabolic syndrome screening and educational program at the Institute of Biomedicine of the Universidad Católica of Guayaquil, Ecuador. Sociodemographic data, waist circumference and blood pressure measurements were recorded, and a fasting blood sample obtained for serum glucose and lipid profile determinations. Woman were counseled and managed according to the results. Metabolic syndrome was defined in accordance with the criteria of the Third Adult Treatment Panel (ATP III). Results. Three hundred and twenty-five postmenopausal women entered the program. Mean (±standard deviation) age was 55.9 ± 8.1 years, 53.5% of them were aged ≥54 years (median). The prevalence of metabolic syndrome, according to ATP III criteria, was 41.5%. Using the same criteria, 38.8%, 16.6%, 56.9% and 54.2% of the women presented with hypertension, diabetes, hypertriglyceridemia and abdominal obesity, respectively. More than 40% of women determined to have hypertension or diabetes lacked knowing so. Logistic regression analysis determined that age increased the risk of presenting hypertension and diabetes (odds ratio (95% confidence interval): 2.0 (1.2–3.2) and 1.6 (0.9–3.0), respectively, p < 0.05), entities which in turn duplicated the risk of having high triglyceride levels. Sedentary women with <5 years since menopause onset were at higher risk of having abdominal obesity, which was directly related to diabetes and hypertension. Conclusions. In this postmenopausal Ecuadorian population the prevalence of the metabolic syndrome was high and its determinant factors related to age, time since menopause onset and sedentary habits. Because of the implications for cardiovascular risk, counseling programs directed toward high-risk populations should be encouraged.