Rossella E. Nappi

Course of Migraine During Pregnancy and Postpartum: A Prospective Study

The aim of this study was to investigate prospectively the course of migraine during pregnancy and postpartum. Of all the pregnant women consecutively attending an obstetrics and gynaecology department for a routine first-trimester antenatal check-up, 49 migraine sufferers - two were affected by migraine with aura (MA) and 47 by migraine without aura (MO) - who had experienced at least one attack during the 3 months preceding pregnancy were identified, enrolled in the study and given a headache diary. Subsequent examinations were performed at the end of the second and third trimesters and 1 month after delivery. Migraine was seen to improve in 46.8% of the 47 MO sufferers during the first trimester, in 83.0% during the second and in 87.2% during the third, while complete remission was attained by 10.6%, 53.2%, and 78.7% of the women, respectively. Migraine recurred during the first week after childbirth in 34.0% of the women and during the first month in 55.3%. Certain risk factors for lack of improvement of migraine during pregnancy were identified: the presence of menstrually related migraine before pregnancy was associated with a lack of headache improvement in the first and third trimesters, while second-trimester hyperemesis, and a pathological pregnancy course were associated with a lack of headache improvement in the second trimester. Breast feeding seemed to protect from migraine recurrence during postpartum.

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.

Characteristics of Menstrual and Nonmenstrual Attacks in Women with Menstrually Related Migraine Referred to Headache Centres

Aim of this study was to determine whether menstrual attacks differ from non-menstrual attacks (NMA) as regards clinical features or response to abortive treatment in women affected by menstrually related migraine (MRM) referred to tertiary care centres. Sixty-four women with MRM were enrolled in a 2-month diary study. Perimenstrual attacks were split into three groups – premenstrual (PMA), menstrual (MA) and late menstrual (LMA) – and compared to nonmenstrual ones. Perimenstrual attacks were significantly longer than NMA. No other migraine attack features were found to differ between the various phases of the cycle. Migraine work-related disability was significantly greater in PMA and MA than in NMA. Acute attack treatment was less effective in perimenstrual attacks. Pain-free at 2 h after dosage was achieved in 13.5% of MA (OR 0.41; 95% CI 0.22, 0.76) vs. 32.9% of NMA. We concluded that, in MRM, perimenstrual attacks are longer and less responsive to acute attack treatment than NMA.

Menopause and sexuality: Prevalence of symptoms and impact on quality of life

OBJECTIVE This article aims to summarise the available knowledge on the prevalence of sexual symptoms at the menopause and their impact on quality of life in elderly women. Sexual changes are analysed in the context of the menopause transition and beyond. METHODS The medical literature was searched (1990-2008) with regard to menopause and sexuality using several related terms. RESULTS The prevalence of sexual symptoms at the menopause differs across studies depending on several factors such as sample size, design, hormonal status and country. The most common sexual complaints are reduced sexual desire, vaginal dryness and dyspareunia, poor arousal and orgasm and impaired sexual satisfaction. Age and declining oestradiol levels have significant detrimental effects on sexual functioning, desire and responsiveness (arousal, sexual pleasure and orgasm) across the normal menopause transition, while reduced androgens levels played a role in hypoactive sexual desire disorder (HSDD), a symptom frequently diagnosed in surgically menopausal women. CONCLUSIONS Women attending menopause clinics are vulnerable to female sexual dysfunction (FSD) because of a complex interplay of individual factors variably affecting well-being. Surgically menopausal women may be more distressed by sexual symptoms. Giving women the opportunity to talk about sexual problems is a fundamental part of health care and may improve their quality of life.

Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey

Objective To assess knowledge of vaginal atrophy among women using the Vaginal Health: Insights, Views & Attitudes (VIVA) survey. Methods A structured online questionnaire was used to obtain information from 3520 postmenopausal women aged 55–65 years living in Great Britain, the United States, Canada, Sweden, Denmark, Finland, and Norway. Results In total, 45% of women reported experiencing vaginal symptoms. Only 4% of women attributed these symptoms to vaginal atrophy, and 63% failed to recognize vaginal atrophy as a chronic condition. Overall, 44% of respondents did not have a gynecologist, but this percentage varied between countries. Most women (75%) felt that vaginal atrophy had a negative impact on life, but this perception also showed country-specific differences. Most Finnish respondents (76%) were satisfied with the amount of information available about vaginal atrophy, compared with just 37–42% of women from other countries. Most women used over-the-counter products for vaginal atrophy symptoms, but specific means of treating the underlying cause were less well known. Almost half (46%) of all respondents lacked knowledge about local estrogen therapy, with women in Great Britain, the United States and Canada being most likely to lack knowledge of such treatment. Overall, 30% of women would consider taking local estrogen therapy, with vaginal tablets being the preferred option in all countries. Conclusion Postmenopausal women have a low understanding of vaginal atrophy. Medical practitioners should proactively raise this topic, help patients to understand that vaginal atrophy is a chronic condition, and discuss treatment options. Country-specific approaches may be required.

Bone mass and long-term monophasic oral contraceptive treatment in young women

A prospective study has been designed to investigate bone metabolism in young women taking an oral monophasic contraceptive formulation (ethinylestradiol 20 micrograms + desogestrel 0.150 mg) over 5 years. Healthy women (n = 200) between 19 and 22 years of age were divided into two groups. Group A received oral contraception, Group B did not receive any treatment. All the subjects underwent a bone mass density (BMD) evaluation at spinal level L2-L4 with Dexa (Norland XR-26) and a measurement of the serum alkaline phosphatase levels and urinary excretion of OH-proline at baseline and every 12 months over 5 years. Our results demonstrated that Group A did not show any significant BMD change after 5 years of oral contraceptive treatment, while Group B demonstrated a significant increase (p < 0.01) in the bone mass content at the end of the time of observation (+7.8% after 5 years). No significant changes were found in serum alkaline phosphatase levels and in urinary excretion of OH-proline at the end of the study in comparison with basal levels in both groups. Our data suggested that long-term treatment with an oral monophasic contraceptive formulation (ethinylestradiol 20 micrograms + desogestrel 0.150 mg) did not modify the BMD but prevented the occurrence of the physiologic peak of bone mass in young women.

Characteristics of headache at menopause: A clinico-epidemiologic study

The prevalence and characteristics of primary headaches in a large sample of postmenopausal women were investigated. Seventy-six out of 556 women (13.7%) were affected by headache of either the migraine or tension type. In 82% of cases onset had preceded the menopause. The postmenopausal course of headaches with a premenopausal onset differed according to type of headache and type of menopause. Indeed, while migraine improved in almost two-thirds of cases, tension-type headache worsened or did not change in 70% of cases. However, in women who had undergone surgical ovariectomy, the natural course of migraine was worse than in those who had a physiological menopause (P = 0.003). Among the symptoms covered by the Kuppermann Index, only anxiety and insomnia were correlated with headache. The favourable course of migraine in the postmenopausal period can be attributed primarily to the absence of variations in sex hormone levels although psychological factors also seem to play a fundamental role.

Menstrual cycle-related changes in plasma oxytocin are relevant to normal sexual function in healthy women

Circulating levels of the neuro-hypophysial nonapeptide oxytocin increase during sexual arousal and orgasm in both men and women. A few studies have evaluated the effect of the menstrual cycle on plasma oxytocin in normally cycling, sexually active, healthy fertile women using or not using contraceptive pills. In 20 ovulating women and 10 women taking an oral contraceptive (group 1 and group 2, respectively), sexual function, hormonal profile, and plasma oxytocin (OT) were evaluated throughout the menstrual cycle. In group 1, plasma OT was significantly lower during the luteal phase in comparison with both the follicular and ovulatory phases. Plasma oxytocin was significantly correlated with the lubrication domain of the Female Sexual Function Index (FSFI) during the luteal phase and showed a trend towards statistical significance during the follicular phase. In group 2, plasma OT did not show any significant fluctuation throughout the menstrual cycle, even though a significant correlation was evident with both the arousal and the lubrication domain of the FSFI during the assumption of the contraceptive pill. These findings suggest that plasma OT fluctuates throughout the menstrual cycle in normally cycling healthy fertile women with adequate sexual activity but not taking any oral contraceptive pill. Moreover, plasma OT levels significantly relates to the genital lubrication in both women taking and not taking oral contraceptive pill apparently confirming its role in peripheral activation of sexual function.

Memory Functioning at Menopause: Impact of Age in Ovariectomized Women

Estrogens are known to act selectively on some components of memory, exerting beneficial effects on cognitive performances. However, there are few data on the long-term effect of the lack of estrogen in postmenopausal women. Therefore, we investigated attentive and verbal memory performances in physiological and surgical menopause, drawing attention to the impact of age at menopause, and we compared a well-known aging and estrogen-dependent index, the entity of bone mass loss to memory functioning. No significant differences were found in the mean scores of attentive and psychomotor performances between physiological and surgical menopause, whereas a lower number of recalled words (recency effect = PS2) was found in surgical menopause (p < 0.001) in comparison to physiological menopause. In addition, both the age at the time of ovariectomy (r = 0.47; p = 0.014) and the years since surgery (r = –0.64; p = 0.000) correlated to short-term verbal memory performance (PS2) with better scores when surgery occurred later in women’s lives. Surgical menopause is able to affect short-term verbal memory more than physiological menopause and seems to represent a critical negative event within the female brain, in particular when it occurs prematurely.

Women's voices in the menopause: Results from an international survey on vaginal atrophy

OBJECTIVES To consider issues relating to vaginal atrophy via an international survey. METHODS Using a structured questionnaire, interviews were performed on 4246 women aged 55-65 years living in Sweden, Finland, the United Kingdom, the United States and Canada. RESULTS Overall, 98% of survey respondents were postmenopausal. Thirty-nine percent of the postmenopausal women had experienced vaginal atrophy, with the prevalence varying between countries, from 34% in Canada to 43% in Finland and the United States. Attitudes towards symptoms also varied between countries. Symptoms were described as moderate or severe by less than half of women from Finland and Sweden, compared with nearly two-thirds of women from the United States. However, vaginal atrophy was deemed to impact on quality of life by a higher proportion of women in Finland and Sweden (≥60%) than in the United Kingdom, the United States and Canada (≤50%). Overall, 77% of respondents believed women were uncomfortable discussing vaginal atrophy and 42% did not know that local treatment was available. The proportions of women unaware of the availability of local treatment were higher in the United States, the United Kingdom and Canada (51%, 50% and 48%, respectively), and very low in Finland (10%). Whilst 63% of women who had experienced vaginal atrophy had never been prescribed treatment for the condition, 67% of those who had been treated reported positive effects. CONCLUSION The survey results illustrate differing needs of menopausal women in different countries. Country-specific approaches may be required to improve the uptake of treatment for vaginal atrophy.