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IMS Menopause Live

Commentaries from the IMS on recently published scientific papers that may be of interest. The latest articles are available to Members only when logged in. Selected articles are open to public.

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Mood, menopause and hysterectomy

9 July, 2012:

In a recent study by Gibson and colleagues, depression and anxiety symptoms were assessed in 1970 women followed up annually since premenopause for up to 10 years in a sub-study of the SWAN (Study of Women's Health Across the Nation) cohort, with the objective of examining whether mood symptoms were influenced negatively by hysterectomy, with or without bilateral oophorectomy, relative to natural menopause [1]. Women were recruited in a community-based setting, which is one of SWAN's specifications together with its multiethnic commitment [2]. They were 42–52 years of age, premenopausal, had an intact uterus and at least one ovary at baseline, as well as one or more menstrual cycles in the 3 months before. Symptoms were measured with the 'Center for Epidemiological Studies Depression Index' along with the evaluation of four anxiety items. In line with multivariate analyses, piece-wise hierarchical growth models were used to relate natural menopause, hysterectomy with ovarian conservation, and hysterectomy with bilateral oophorectomy to trajectories of mood symptoms before and after the final menstrual period or surgery.

Around 90% of the women reached natural menopause by the tenth annual visit, whereas 5.2% (n = 101) reported hysterectomy with bilateral oophorectomy and 3.9% (n = 76) hysterectomy with ovarian conservation. Depressive symptoms declined before the final menstrual period or surgery (regardless of whether the ovaries were conserved) and continued to decline afterwards. There was no significant difference in the mean rate of change in depressive symptoms relative to natural menopause. Both depressive and anxiety symptoms generally improved over the course of the menopausal transition for all women.

Hormone therapy (HT) was concurrently associated with lower levels of depressive and anxiety symptoms, while antidepressant use increased anxiety scores. HT was used at some point of the study by the majority of participants and was particularly common among women with hysterectomy and oophorectomy; but exclusion of HT users, as stated by the authors, did not affect the trajectories of changes in depressive or anxiety symptoms.

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Testosterone concentrations in ovarian insufficiency: a review

25 June 2012

An important and to date not clearly resolved question in clinical reproductive medicine has been whether premature loss of ovarian function (e.g. primary ovarian insufficiency (POI) below the age of 40 years) and iatrogenic premature loss of ovarian function (as a result of surgery, gonadotoxic chemotherapy or pelvic irradiation) result in a significant decrease in circulating testosterone concentrations and hence might merit testosterone treatment. Many published studies have included small sample sizes and/or non-uniform control groups. Janse and colleagues [1] have undertaken a systematic review and meta-analysis of the literature and conclude that testosterone levels are lower, though the magnitude of the difference is relatively small. They reviewed 206 articles on POI and 1358 on iatrogenic menopause, of which nine and 17, respectively, were selected for final analysis. In both groups, there was evidence of a lower testosterone concentration than in controls. Weighted mean differences were -0.38 nmol/l (95% confidence interval (CI) -0.55 to -0.22) and -0.29 nmol/l (95% CI -0.39 to -0.18), respectively. The mean differences represented a range of 1–49% lower (average 25%) in POI and a range of 11% higher to 77% lower (average 22% lower) for iatrogenic menopause. A sensitivity analysis of the three highest-quality studies in each group did not change the data substantially. The significance of such relatively small differences and their clinical importance are unclear.

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The relationship of mammographic density and age

11 June 2012:

Chemoprevention of breast cancer has the potential of a bright future in menopausal medicine. However, before chemoprevention can be implemented effectively, better methods for the reliable prediction of breast cancer are needed. Three major strategies for early prediction or risk assessment of breast cancer have been established. Next to the algorithm of epidemiological factors, as given by the Gail criteria, rank the assessment of the endocrine environment, mainly the circulating sex steroids, and mammographic density of the breast. The latter has been shown to provide an independent prediction of the breast cancer risk, although the link between enhanced mammographic density and the cellular and molecular pathways leading to breast cancer has not yet been elucidated.


Checka and co-workers [1] now present a retrospective analysis of a large cohort of more than 7000 women, in which the relationship between mammographic density, as given by the BI-RADS density categories, and age is analyzed. BI-RADS is the acronym for Breast Imaging-Reporting and Data System and was defined and published by the American College of Radiology. The BI-RADS assessment system consists of seven categories, but only those ranking from 1 to 4 can be used for the prediction of breast cancer risk, as they classify mammographic density differences from negative to suspicious. The median age of the cohort was 57 years. There was a significant inverse relationship between age and breast density (p g biopsy.

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Simple ovarian cysts in postmenopausal women: scope of conservative management

21 May 2012:


The prevalence of simple ovarian cysts in postmenopausal women may range from 3% to 15%. Simple cysts are usually followed conservatively, but concern about progression to malignancy may lead to surgical exploration, which in most cases would likely be for benign conditions. A recent retrospective study from the USA [1] evaluated 619 patients with 743 simple ovarian cysts; 305 patients (49.27%) were lost in follow-up. Therefore, 314 patients (50.73%) with 378 cysts were followed further by ultrasound study. In all, 175 (46.30%) of the 378 cysts that could be followed further had spontaneous resolution and 166 cysts (43.91%) persisted unchanged over the follow-up period. Thirty cysts (7.94%) turned into complex cysts and four cysts (1.06%) significantly increased in size. One cyst significantly decreased in size, although it did not resolve. Only one patient developed papillary serous carcinoma (high grade) of the ovary. This occurred 3 years after her last ultrasound for simple cyst surveillance. Thus, simple ovarian cysts during the menopause can be followed conservatively because their risk for malignant transformation is low. The majority of these cysts either resolve spontaneously or persist unaltered on follow-up.

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Physical activity across adulthood maintains physical capability in midlife

14 May 2012:

Cooper and colleagues [1] have recently reported that cumulative leisure-time physical activity across adulthood may affect physical performance and strength in midlife. In all, 1189 men and 1253 women from the UK Medical Research Council National Survey of Health and Development, born in March 1946, participated in the study. Self-reported leisure-time physical activity at ages 36, 43 and 53 years was assessed and compared to grip strength, standing balance and chair rise times at age 53 years. It was found that more women than men were inactive at ages 36 and 43, whereas activity levels between genders at age 53 did not differ. However, men were stronger and had better physical performance at age 53 than women. Men appeared to have been of a higher educational level and occupational class. More women were never-smokers than men. Health status at age 53 between women and men did not differ. Independent positive effects of physical activity at all ages on chair rise performance and at ages 43 and 53 on standing balance performance were found, whereas physical activity at age 53 was associated only in men with grip strength. This study confirmed the cumulative benefits of physical activity in both men and women across adulthood for physical performance in midlife.

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SSRIs for hot flushes and insomnia

30 April 2012:

The selective serotonin reuptake inhibitor (SSRI) and serotonin norepinephrine reuptake inhibitor (SNRI) antidepressants are used off-label to treat menopausal hot flushes. One of their most common side-effects is insomnia and, therefore, investigation of this mode of therapy in postmenopausal women with vasomotor symptoms and related sleep disturbances is of importance. The aim of a recent randomized, blinded, multicenter, placebo-controlled study was to determine the effect of escitalopram, a widely used SSRI, on insomnia symptoms and subjective sleep quality in healthy perimenopausal and postmenopausal women with hot flushes [1].

The study included 205 women (95 African-American, 102 white, eight other) who received escitalopram (10–20 mg/day) or placebo for a duration of 8 weeks. Insomnia symptoms (Insomnia Severity Index, ISI) and subjective sleep quality (Pittsburgh Sleep Quality Index, PSQI) at weeks 4 and 8 were the pre-specified secondary outcomes. A total of 199 women (97%) provided ISI data and 194 (95%) women provided PSQI data at follow-up. At baseline, the mean hot flush frequency was 9.8 per day (standard deviation (SD) 5.60), the mean ISI was 11.4 (SD 6.3), and the mean PSQI was 8.0 (SD 3.7). Treatment with escitalopram reduced the ISI at week 8 (mean difference -2.00; 95% confidence interval (CI) -3.43 to -0.57; p < 0.001, overall treatment effect), with mean differences of -4.73 (95% CI -5.72 to -3.75) in the escitalopram group and -2.73 (95% CI -3.78 to -1.69) in the placebo group. The reduction in PSQI was greater in the escitalopram group than in the placebo group at week 8 (mean difference -1.31; 95% CI -2.14 to -0.49; p < 0.001, overall treatment effect). Clinical improvement in insomnia symptoms and subjective sleep quality (≥ 50% decreases in ISI and PSQI from baseline) was observed more frequently in the escitalopram group than in the placebo group (ISI: 50.0% vs. 35.4%, p = 0.04; PSQI: 29.6% vs. 19.2%, p = 0.09). The investigators' conclusions were that. among healthy perimenopausal and postmenopausal women with hot flushes, escitalopram at 10–20 mg/day compared with placebo reduced insomnia symptoms and improved subjective sleep quality at 8 weeks of follow-up.

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