Advertisement

Symptoms during the perimenopause: prevalence, severity, trajectory, and significance in women’s lives

      This article examines published evidence from longitudinal studies of the menopausal transition that address the following questions: (1) Which symptoms do women report during the perimenopause, and how prevalent are these symptoms as women traverse the menopausal transition? (2) How severe are symptoms and for how long do they persist? (3) To what do women attribute their symptoms, and do their attributions match findings from epidemiologic studies of community-based populations? (4) How significant are these symptoms in women’s lives? Data from published longitudinal studies were examined for evidence bearing on each of these questions. Only vasomotor symptoms, vaginal dryness, and sleep disturbance symptoms varied in prevalence significantly across menopausal transition stages and postmenopause in >1 population studied. A minority of women report severe symptoms. Given the limited follow-up data available, it is unclear how long symptoms persist after menopause. Women attribute their symptoms to a variety of biologic and psychosocial factors, and their attributions correspond well to those correlates identified in epidemiologic studies of community-based populations. The significance of symptoms for women’s lives remains uncertain. The impact of symptoms during the perimenopause on well-being, role performance, adaptation to demands of daily living, and quality of life warrants additional study. The appraisal of the consequences of perimenopausal symptoms by women from different ethnic groups will be enhanced significantly as a result of the Study of Women’s Health Across the Nation (SWAN) and other studies in progress.

      Keywords

      As women complete the transition to menopause, an estimated 85% report ≥1 symptom, such as hot flashes, depressed mood, or sleep disruption, that prompts nearly 10% of women to visit a healthcare provider.
      • McKinlay S.M.
      • Brambilla D.J.
      • Posner J.
      The normal menopause transition.
      In the post–Women’s Health Initiative Study (WHI) era, symptom management has become more complex owing to awareness of the risks associated with hormone therapy (HT).
      North American Menopause Society
      Recommendations for estrogen and progestogen use in peri- and postmenopausal women October 2004 position statement of The North American Menopause Society.
      Women use a range of symptom management options, including such self-care strategies as use of over-the-counter preparations; complementary and alternative therapies, such as herbal preparations; exercise programs and other lifestyle modifications; and taking prescription drugs.
      • McKinlay S.M.
      • Brambilla D.J.
      • Posner J.
      The normal menopause transition.
      • Bair Y.A.
      • Gold E.B.
      • Greendale G.A.
      • et al.
      Ethnic differences in use of complementary and alternative medicine at midlife longitudinal results from SWAN participants.
      Contact with health professionals during the perimenopause creates an opportunity for women to consider strategies for both symptom management and promotion of healthy aging. The paucity of data about women’s experiences of symptoms and their efforts at symptom management during the perimenopause, however, limits health professionals’ awareness of typical experiences of community-based populations of women as contrasted with the subset of women seeking healthcare. Moreover, clinicians do not have access to data about the meanings women assign to their experiences.
      The purpose of this article is to examine published evidence of the prevalence of menopause-related symptoms reported by participants in longitudinal studies of the menopausal transition to address the following questions: (1) Which symptoms do women report during the perimenopause, and how prevalent are these symptoms as women traverse the menopausal transition? (2) How severe are symptoms and for how long do they persist? (3) To what do women attribute their symptoms, and do their attributions match findings from epidemiologic studies of community-based populations? (4) How significant are these symptoms in women’s lives?

      Methods

      Data from published community-based longitudinal studies of the menopausal transition were reviewed for evidence bearing on each of the questions presented above.
      • McKinlay S.M.
      • Brambilla D.J.
      • Posner J.
      The normal menopause transition.
      North American Menopause Society
      Recommendations for estrogen and progestogen use in peri- and postmenopausal women October 2004 position statement of The North American Menopause Society.
      • Bair Y.A.
      • Gold E.B.
      • Greendale G.A.
      • et al.
      Ethnic differences in use of complementary and alternative medicine at midlife longitudinal results from SWAN participants.
      • Matthews K.A.
      • Wing R.R.
      • Kuller L.H.
      • et al.
      Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy women.
      • Kaufert P.A.
      • Gilbert P.
      • Tate R.
      The Manitoba Project a re-examination of the link between menopause and depression.
      • Holte A.
      Influences of natural menopause on health complaints a prospective study of healthy Norwegian women.
      • Woods N.F.
      • Mitchell E.S.
      Anticipating menopause observations from the Seattle Midlife Women’s Health Study.
      • Hunter M.
      The South-East England longitudinal study of the climacteric and postmenopause.
      • Dennerstein L.
      • Smith A.M.
      • Morse C.A.
      • et al.
      Menopausal symptoms in Australian women.
      • Freeman E.W.
      • Grisso J.A.
      • Berlin J.
      • et al.
      Symptom reports from a cohort of African American and white women in the late reproductive years.
      • Harlow B.L.
      • Cohen L.S.
      • Otto M.W.
      • et al.
      Prevalence and predictors of depressive symptoms in older premenopausal women the Harvard Study of Moods and Cycles.
      • Sowers M.
      • Crawford S.
      • Sternfeld B.
      • et al.
      SWAN A multicenter, multiethnic community-based cohort study of women and the MT.
      Where possible, the Staging Reproductive Aging Workshop (STRAW) criteria were used to approximate the stage of menopausal transition and to promote comparison of data specific to menopausal transition stages across multiple studies.
      • Soules M.R.
      • Sherman S.
      • Parrott E.
      • et al.
      Executive summary Stages of Reproductive Aging Workshop (STRAW).
      The STRAW stages are based on menstrual cycle patterns and include the following: (1) late reproductive stage, denoted by minor changes in cycle length, particularly decreasing length of the cycle; (2) early menopausal transition stage, indicated by increasing irregularity of menses without skipping periods (>7 days’ difference from the beginning of a given cycle to the next, experienced after previously regular cycles); (3) late menopausal transition stage, characterized by skipping periods (amenorrhea >60 days); and (4) postmenopause, spanning the time from a woman’s final menstrual period (FMP) to the end of her life. Classification of the menopausal transition stages for most studies was based on retrospective histories of menses, although some recent studies have incorporated daily diary recordings.
      • Woods N.F.
      • Mitchell E.S.
      Anticipating menopause observations from the Seattle Midlife Women’s Health Study.
      • Sowers M.
      • Crawford S.
      • Sternfeld B.
      • et al.
      SWAN A multicenter, multiethnic community-based cohort study of women and the MT.

      Findings from studies of community-based populations

      Prevalence of symptom reporting

      Women at midlife report hot flashes and sweats, depressed mood, sleep disturbances, sexual concerns or problems, cognitive symptoms, vaginal dryness, urinary incontinence, and somatic or bodily pain symptoms. Because women experience these symptoms at many other points in their lives (as do men, with the exception of the vaginal symptoms), none can be said to be specific to the perimenopause.

      Hot flashes

      The prevalence of hot flashes among women who had not begun the menopausal transition (STRAW late reproductive stage) ranges from 6%
      • Matthews K.A.
      • Wing R.R.
      • Kuller L.H.
      • et al.
      Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy women.
      to 13%.
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      As women progress from the early to late menopausal transition stages (from noting changes in their cycle regularity to skipping menstrual periods), the prevalence of hot flashes increased (late reproductive, 4% to 46%; late menopausal transition, 33% to 63%).
      • McKinlay S.M.
      • Brambilla D.J.
      • Posner J.
      The normal menopause transition.
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      For women who had completed menopause (STRAW postmenopause, defined as ≥1 year with no menses), the prevalence rose as high as 79%
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      (Table 1
      • Matthews K.A.
      • Wing R.R.
      • Kuller L.H.
      • et al.
      Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy women.
      • Kaufert P.A.
      • Gilbert P.
      • Tate R.
      The Manitoba Project a re-examination of the link between menopause and depression.
      • Holte A.
      Influences of natural menopause on health complaints a prospective study of healthy Norwegian women.
      • Freeman E.W.
      • Grisso J.A.
      • Berlin J.
      • et al.
      Symptom reports from a cohort of African American and white women in the late reproductive years.
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      • Gold E.B.
      • Sternfeld B.
      • Kelsey J.L.
      • et al.
      Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age.
      • Kaufert P.
      • Syrotuik J.
      Symptom reporting at the menopause.
      • Gold E.
      • Block G.
      • Crawford S.
      • et al.
      Lifestyle and demographic factors in relation to vasomotor symptoms baseline results from the Study of Women’s Health Across the Nation.
      • Freeman E.
      • Sammel M.
      • Lin H.
      • Gracia C.R.
      • Kapoor S.
      • Ferdusi T.
      The role of anxiety and hormonal changes in menopausal hot flashes.
      • Lock M.
      Culture and the menopause.
      • Guthrie J.
      • Dennerstein L.
      • Hopper J.
      • et al.
      Hot flushes, menstrual status, and hormone levels in a population-based sample of midlife women.
      ).
      Table 1Prevalence of vasomotor symptoms from selected longitudinal studies
      STRAW MT Stage
      StudyStudy PopulationMeasuresLate ReproductiveEarly MTLate MTPostmenopause
      Healthy Women Study
      • Matthews K.A.
      • Wing R.R.
      • Kuller L.H.
      • et al.
      Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy women.
      460 women, aged 42–50 yr (19 black, 183 white), randomly selected from drivers’ licenses and census listsChecklist of 27 symptoms administered in follow-up clinical examination6%NANA43%
      Manitoba Project on Women and Their Health in the Middle Years
      • Kaufert P.A.
      • Gilbert P.
      • Tate R.
      The Manitoba Project a re-examination of the link between menopause and depression.
      • Kaufert P.
      • Syrotuik J.
      Symptom reporting at the menopause.
      469 women, aged 45–55 yr, selected from nonrandom mail survey, 145 with hysterectomyChecklist of symptoms
      • Lock M.
      Culture and the menopause.
      Hot flashes, 13.8%NA39.7%41.5%
      Night sweats, 10.6%NA27.6%22.2%
      Norwegian Menopause Project
      • Holte A.
      Influences of natural menopause on health complaints a prospective study of healthy Norwegian women.
      200 women, aged 45–55 yr (of 1,886 women studied in 1981), followed annually for 5 yrSymptoms reported in interview, as well as frequency and whether troubled by symptoms
      • Hot flashes,
      • Very troubled, 12%
      • NA
      • NA
      • 46%
      • NA
      • 67% (1 yr)
      • 61% (2 yr)
      • 18% (1 yr)
      • 12% (2 yr)
      Melbourne Women’s Midlife Health Project
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      453 women, aged 45–55 yr, from a population-based Australian sampleSymptoms over past 2 wk, frequency/day, and bother
      • Guthrie J.
      • Dennerstein L.
      • Hopper J.
      • et al.
      Hot flushes, menstrual status, and hormone levels in a population-based sample of midlife women.
      Hot flashes (>1/day), 13%NA37%
      Bothered, 6%NA26%
      172 women who had made a transition to perimenopause or postmenopause (in 2000)As aboveHot flashes, 10%15%42%42% (1 yr) 41% (2 yr)
      Sweats, 10%14%30%35% (1 yr)
      24% (2 yr)
      SWAN
      • Gold E.B.
      • Sternfeld B.
      • Kelsey J.L.
      • et al.
      Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age.
      • Gold E.
      • Block G.
      • Crawford S.
      • et al.
      Lifestyle and demographic factors in relation to vasomotor symptoms baseline results from the Study of Women’s Health Across the Nation.
      16,065 women, aged 40–55 yr, from multiracial/ethnic sample, 7 sites, community-based sampling strategies to include African American, Chinese American, Japanese American, Hispanic, and European American womenSelf-reported questionnaires, asked whether they had hot flashes/sweats over the past 2 wk19.4%36.9%56.8%48.8%
      Penn Ovarian Aging Study
      • Freeman E.W.
      • Grisso J.A.
      • Berlin J.
      • et al.
      Symptom reports from a cohort of African American and white women in the late reproductive years.
      • Freeman E.
      • Sammel M.
      • Lin H.
      • Gracia C.R.
      • Kapoor S.
      • Ferdusi T.
      The role of anxiety and hormonal changes in menopausal hot flashes.
      Women, aged 35–47 yr, randomly selected from community (African Americans = 219; European Americans = 217)Standardized menopause symptoms checklist regarding hot flashes over the past month/severityHot flashes (6 yr), 37%48%63%79%
      MT = menopausal transition; NA = estimate not available from published literature; STRAW = Staging Reproductive Aging Workshop; SWAN = Study of Women’s Health Across the Nation.
      The peak prevalence of hot flashes occurs during the late menopausal transition stage (labeled “late perimenopause” in several of the studies) and during the early postmenopause. Because many studies have not included follow-up beyond the first 1 or 2 years of postmenopause, it is difficult to discern when or whether hot flashes cease.

      Depressed mood

      Where reproductive stage measures are available, the prevalence of depressed mood symptoms (e.g., feeling sad or blue) ranged from 19% to 29%. For women in the early or late menopausal transition stages, prevalence estimates ranged from 28% to 29%; for those who had completed menopause, the prevalence of depressed mood symptoms ranged from 24.5% to 29% (late reproductive) to 23% to 28% (late MT) to 23% to 34% (postmenopause)
      • Matthews K.A.
      • Wing R.R.
      • Kuller L.H.
      • et al.
      Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy women.
      • Dennerstein L.
      • Guthrie J.R.
      • Clark M.
      • et al.
      A population-based study of depressed mood in middle-aged, Australian-born women.
      • Avis N.E.
      • Crawford S.
      • Stellato R.
      • et al.
      Longitudinal study of hormone levels and depression among women transitioning through menopause.
      • Avis N.E.
      • Brambilla D.
      • McKinlay S.M.
      • Vass K.
      A longitudinal analysis of the association between menopause and depression results from the Massachusetts Women’s Health Study.
      • McKinlay J.B.
      • McKinlay S.M.
      • Brambilla D.
      The relative contributions of endocrine changes and social circumstances to depression in mid-aged women.
      • Woods N.F.
      • Mariella A.
      • Mitchell E.
      Patterns of depressed mood across the MT approaches to studying patterns in longitudinal data.
      • Woods N.F.
      • Mitchell E.S.
      Patterns of depressed mood in midlife women observations from the Seattle Midlife Women’s Health Study.
      • Bromberger J.T.
      • Assmann S.F.
      • Avis N.E.
      • et al.
      Persistent mood symptoms in multiethnic community cohort of pre- and perimenopausal women.
      (Table 2
      • Matthews K.A.
      • Wing R.R.
      • Kuller L.H.
      • et al.
      Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy women.
      • Kaufert P.A.
      • Gilbert P.
      • Tate R.
      The Manitoba Project a re-examination of the link between menopause and depression.
      • Lock M.
      Culture and the menopause.
      • Avis N.E.
      • Crawford S.
      • Stellato R.
      • et al.
      Longitudinal study of hormone levels and depression among women transitioning through menopause.
      • Avis N.E.
      • Brambilla D.
      • McKinlay S.M.
      • Vass K.
      A longitudinal analysis of the association between menopause and depression results from the Massachusetts Women’s Health Study.
      • McKinlay J.B.
      • McKinlay S.M.
      • Brambilla D.
      The relative contributions of endocrine changes and social circumstances to depression in mid-aged women.
      • Busch C.
      • Zonderman A.
      • Costa P.
      MT and psychological distress in a nationally representative sample is menopause associated with psychological distress?.
      • Lock M.
      • Kaufert P.
      • Gilbert P.
      Cultural construction of the menopausal syndrome the Japanese case.
      • Bromberger J.
      • Harlow S.
      • Avis N.
      • et al.
      Racial/ethnic differences in the prevalence of depressive symptoms among middle-aged women the Study of Women’s Health Across the Nation (SWAN).
      • Bromberger J.
      • Meyer P.
      • Kravitz H.
      • et al.
      Psychologic distress and natural menopause a multiethnic community study.
      • Freeman E.W.
      • Sammel M.D.
      • Liu L.
      • et al.
      Hormones and menopausal status as predictors of depression in women in transition to menopause.
      ).
      Table 2Prevalence of depressed mood symptoms from selected longitudinal studies
      StudyStudy PopulationMeasuresSTRAW MT Stage
      Late ReproductiveEarly MTLate MTPostmenopause
      Massachusetts Women’s Health Study
      • Avis N.E.
      • Crawford S.
      • Stellato R.
      • et al.
      Longitudinal study of hormone levels and depression among women transitioning through menopause.
      • Avis N.E.
      • Brambilla D.
      • McKinlay S.M.
      • Vass K.
      A longitudinal analysis of the association between menopause and depression results from the Massachusetts Women’s Health Study.
      • McKinlay J.B.
      • McKinlay S.M.
      • Brambilla D.
      The relative contributions of endocrine changes and social circumstances to depression in mid-aged women.
      2,352 white women, aged 45–55 yr, randomly selected from from Massachusetts state census listsAsked if sad or blue/depressed over past 2 wk (symptom checklist)29.1%NA28.1%33.8%
      Healthy Women Study
      • Matthews K.A.
      • Wing R.R.
      • Kuller L.H.
      • et al.
      Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy women.
      460 women, aged 42–50 yr (19 black and 183 white), randomly selected from drivers’ licenses and census listsBeck Depression Inventory 4.5%NANA5.9%
      National Health Examination Follow-up Study
      • Busch C.
      • Zonderman A.
      • Costa P.
      MT and psychological distress in a nationally representative sample is menopause associated with psychological distress?.
      394 women, aged 40–58 yr, selected using stratified probability sample of adult, noninstitutionalized civilian populationCES-D measures repeated 10 yr apart; cut point, >1613%NA19%17%
      Manitoba Project on Women and Their Health in the Middle Years
      • Kaufert P.A.
      • Gilbert P.
      • Tate R.
      The Manitoba Project a re-examination of the link between menopause and depression.
      • Lock M.
      Culture and the menopause.
      • Lock M.
      • Kaufert P.
      • Gilbert P.
      Cultural construction of the menopausal syndrome the Japanese case.
      469 women, aged 45–55 yr, selected from nonrandom mail survey, 145 with hysterectomyQuestionnaire asking whether depressed or blue24.5%NA23.2%23.0%
      SWAN
      • Bromberger J.
      • Harlow S.
      • Avis N.
      • et al.
      Racial/ethnic differences in the prevalence of depressive symptoms among middle-aged women the Study of Women’s Health Across the Nation (SWAN).
      • Bromberger J.
      • Meyer P.
      • Kravitz H.
      • et al.
      Psychologic distress and natural menopause a multiethnic community study.
      3,015 of 3,302 women selected from 7 sitesPersistent mood symptoms included dysphoric mood, feeling blue or depressed, irritable or grouchy, tense or nervous, and frequent mood changes >6 days/wk8%–12%14.9%–18.4%NANA
      16,065 women, aged 40–55 yrPsychologic distress (feeling tense, depressed, and irritable in the previous week)20.9%NA28.9%22%
      Penn Ovarian Aging Study
      • Freeman E.W.
      • Sammel M.D.
      • Liu L.
      • et al.
      Hormones and menopausal status as predictors of depression in women in transition to menopause.
      Women, aged 35–47 yr, randomly selected from community (African Americans = 219, European Americans = 217)Interviews using CES-D conducted at baseline and 4 yr laterCES-D >16 12%–15%1.4%–7.8%13.1%–18.3%1%–13.8%
      Interviews to identify MDDMDD 10%–13%1%–4%<1%<1%
      CES-D = Center for Epidemiologic Studies Depression Scale; MDD = major depressive disorder; MT = menopausal transitron; NA = estimate not available from published literature; STRAW = Staging Reproductive Aging Workshop; SWAN = Study of Women’s Health Across the Nation.
      Several investigators have used the Center for Epidemiologic Studies Depression Scale (CES-D) to obtain estimates of depressed mood. Using a cut point of 16 to identify women with scores resembling those of patients with major depressive disorders, investigators estimated that the prevalence of depressed mood for women in the reproductive stage ranged from 11.6% to 15%.
      • Busch C.
      • Zonderman A.
      • Costa P.
      MT and psychological distress in a nationally representative sample is menopause associated with psychological distress?.
      • Freeman E.W.
      • Sammel M.D.
      • Liu L.
      • et al.
      Hormones and menopausal status as predictors of depression in women in transition to menopause.
      Estimates ranged from 1% to 19% for women in the early menopausal transition stage, from 13% to 18% for those who were in the late menopausal transition stage, and from 1% to 17% for those who were postmenopausal.
      • Kaufert P.A.
      • Gilbert P.
      • Tate R.
      The Manitoba Project a re-examination of the link between menopause and depression.
      • Avis N.E.
      • Brambilla D.
      • McKinlay S.M.
      • Vass K.
      A longitudinal analysis of the association between menopause and depression results from the Massachusetts Women’s Health Study.
      • Woods N.F.
      • Mitchell E.S.
      Patterns of depressed mood in midlife women observations from the Seattle Midlife Women’s Health Study.
      • Busch C.
      • Zonderman A.
      • Costa P.
      MT and psychological distress in a nationally representative sample is menopause associated with psychological distress?.
      • Freeman E.W.
      • Sammel M.D.
      • Liu L.
      • et al.
      Hormones and menopausal status as predictors of depression in women in transition to menopause.
      As a basis of comparison, 22.4% of women in the Harvard Study of Moods and Cycles had CES-D scores >16, with 8.6% having scores >24.
      • Harlow B.L.
      • Cohen L.S.
      • Otto M.W.
      • et al.
      Prevalence and predictors of depressive symptoms in older premenopausal women the Harvard Study of Moods and Cycles.
      In the Seattle Midlife Women’s Health Study, overall prevalence estimates of women with CES-D scores >16 ranged from 26% to 28%. Estimates from SWAN were that 24% of the total sample had scores >16.
      • Avis N.E.
      • Crawford S.
      • Stellato R.
      • et al.
      Longitudinal study of hormone levels and depression among women transitioning through menopause.
      • Bromberger J.T.
      • Assmann S.F.
      • Avis N.E.
      • et al.
      Persistent mood symptoms in multiethnic community cohort of pre- and perimenopausal women.
      Few studies have incorporated clinical diagnosis of depression using the Diagnostic and Statistical Manual of Mental Disorders–4th Edition (DSM-IV) criteria. The recent exceptions are the Penn Ovarian Aging Study,
      • Freeman E.W.
      • Sammel M.D.
      • Liu L.
      • et al.
      Hormones and menopausal status as predictors of depression in women in transition to menopause.
      in which women were interviewed to identify cases of major depressive disorder (MDD), and the Harvard Study of Moods and Cycles,
      • Harlow B.L.
      • Cohen L.S.
      • Otto M.W.
      • et al.
      Prevalence and predictors of depressive symptoms in older premenopausal women the Harvard Study of Moods and Cycles.
      in which women between the ages of 36 and 45 years were interviewed for evidence of DSM-IV criteria for past or current major depression. In the Penn Ovarian Aging Study, the prevalence of MDD was 10% to 13% of women classified as being in reproductive stages and 1% to 4% of those in the early menopausal transition.
      • Freeman E.W.
      • Sammel M.D.
      • Liu L.
      • et al.
      Hormones and menopausal status as predictors of depression in women in transition to menopause.
      Follow-up with this population can yield important findings on the progression/persistence of MDD. To date there is a single published report from a small-sample (n = 29) longitudinal study of initial onset of depression during the menopausal transition.
      • Schmidt P.
      • Haq N.
      • Rubinow D.
      A longitudinal evaluation of the relationship between reproductive status and mood in perimenopausal women.
      These findings are being replicated in the SWAN cohort.
      • Bromberger J.T.
      • Kravitz H.M.
      • Wei H.L.
      • et al.
      History of depression and women’s current health and functioning during midlife.
      Persistence of depressed mood from reproductive stages to postmenopause has received minimal attention. Bromberger and colleagues
      • Bromberger J.T.
      • Assmann S.F.
      • Avis N.E.
      • et al.
      Persistent mood symptoms in multiethnic community cohort of pre- and perimenopausal women.
      defined persistence of depressed mood as having dysphoric mood (feeling blue or depressed, irritable or grouchy, tense or nervous) and frequent mood changes for >6 days per week. In the SWAN population, cross-sectional estimates of persistent depressed mood ranged from 8% to 12% among women in the late reproductive stage and 14.9% to 18.4% for women in the early menopausal transition stage.
      • Kravitz J.
      • Ganz P.
      • Bromberger J.
      • et al.
      Sleep difficulty in women at midlife a community survey of sleep and the MT.
      Woods and Mitchell
      • Woods N.F.
      • Mitchell E.S.
      Patterns of depressed mood in midlife women observations from the Seattle Midlife Women’s Health Study.
      reported data on the persistence of high CES-D scores (>16) among women who were in the early menopausal stage or in a reproductive stage. Over a 1-year period they found that 60% of these women scored <16, but 13% scored >16 during both years.
      The Seattle Midlife Women’s Health Study investigators identified clusters of women based on their CES-D scores (level and trajectory) over a 10-year period.
      • Woods N.F.
      • Mariella A.
      • Mitchell E.
      Patterns of depressed mood across the MT approaches to studying patterns in longitudinal data.
      The most prevalent cluster included women who had nondepressed scores (4 to 7) and low-level scores (8 to 10). Other clusters included women with moderate-level scores (10 to 19) that remained constant, improved, or worsened over time and a cluster of women with high scores (most >24) that remained constant over time. There was no evidence of a relation between progression through the menopausal transition stages and CES-D scores in this cohort.
      • Woods N.F.
      • Mariella A.
      • Mitchell E.
      Patterns of depressed mood across the MT approaches to studying patterns in longitudinal data.

      Sleep symptoms

      Estimates of sleep disturbances range from 31% for women in the reproductive stage to 45% for women who are 3 years postmenopausal.
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      SWAN found that 4,632 of >16,000 women reported difficulty sleeping.
      • Gold E.B.
      • Sternfeld B.
      • Kelsey J.L.
      • et al.
      Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age.
      The odds of reporting difficulty sleeping were greater for women who were in the early or late menopausal transition stages or who were postmenopausal compared with those in the reproductive stage. Unfortunately, data from ongoing longitudinal studies are not yet available (e.g., SWAN, Seattle Midlife Women’s Health Study, Penn Ovarian Aging Study) about the prevalence of sleep difficulty as women progress through the menopausal transition stages (Table 3).
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      • Kravitz J.
      • Ganz P.
      • Bromberger J.
      • et al.
      Sleep difficulty in women at midlife a community survey of sleep and the MT.
      Table 3Prevalence of sleep disturbance symptoms from selected longitudinal studies
      StudyStudy PopulationMeasuresSTRAW MT Stage
      Late ReproductiveEarly MTLate MTPostmenopause
      Melbourne Women’s Midlife Health Project
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      438 women observed for 7 yr; 172 women advanced from premenopause to perimenopause or to postmenopause33-item symptom checklist administered annually: subjects indicated whether they had trouble sleeping31%32%38%38% (1 yr)43% (2 yr)
      SWAN
      • Kravitz J.
      • Ganz P.
      • Bromberger J.
      • et al.
      Sleep difficulty in women at midlife a community survey of sleep and the MT.
      12,603 women, aged 40–55 yrSelf-reported questionnaire: subjects asked whether they had experienced difficulty sleeping in past 2 wk31.4%39.6%45.5%43.2%
      MT = menopausal transition; STRAW = Staging Reproductive Aging Workshop; SWAN = Study of Women’s Health Across the Nation.

      Sexual symptoms

      Data from the Massachusetts Women’s Health Study
      • Avis N.E.
      • Stellato R.
      • Crawford S.
      • Johannes C.
      • Longcope C.
      Is there an association between menopause status and sexual functioning?.
      revealed that menopausal status (being classified as in the menopausal transition or postmenopause) was related to experiencing lowered sexual desire, believing that interest in sexual activity declines with age, and that being postmenopausal was associated with decreased arousal when compared with women’s own experiences in their 40s. Postmenopausal women reported a lower degree of desire and less arousal than women who were in reproductive stages or in a menopausal transition stage. Low estradiol levels were associated with dyspareunia.
      • Avis N.E.
      • Stellato R.
      • Crawford S.
      • Johannes C.
      • Longcope C.
      Is there an association between menopause status and sexual functioning?.
      Melbourne Women’s Midlife Health Project (MWMHP) scores on the Shortened Personal Experiences Questionnaire (SPEQ) indicated that the prevalence of any type of sexual dysfunction rose from 42% to 88% as women became postmenopausal.
      • Dennerstein L.
      • Lehert P.
      Modeling mid-aged women’s sexual functioning a prospective, population-based study.
      • Dennerstein L.
      • Randolph J.
      • Taffe J.
      • Dudley E.
      • Burger H.
      Hormones, mood, sexuality, and the menopausal transition.
      There was a significant decrease in total SPEQ score, sexual interest, responsivity, and frequency of sex as well as a significant increase in dyspareunia and reports of partners’ problems in sexual performance as women moved through the menopausal transition.
      • Gold E.B.
      • Sternfeld B.
      • Kelsey J.L.
      • et al.
      Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age.
      • Dennerstein L.
      • Lehert P.
      Modeling mid-aged women’s sexual functioning a prospective, population-based study.
      Prior sexual functioning and decreasing estradiol levels, but not androgen levels, were associated with sexual dysfunction as measured on the SPEQ (Table 4).
      • Gold E.B.
      • Sternfeld B.
      • Kelsey J.L.
      • et al.
      Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age.
      • Dennerstein L.
      • Lehert P.
      Modeling mid-aged women’s sexual functioning a prospective, population-based study.
      • Dennerstein L.
      • Randolph J.
      • Taffe J.
      • Dudley E.
      • Burger H.
      Hormones, mood, sexuality, and the menopausal transition.
      When participants in the Penn Ovarian Aging Study described libido (i.e., interest in sex) in the past month, 27% reported decreased libido. Fluctuating testosterone levels—but not the testosterone, dehydroepiandrosterone sulfate (DHEAS), estradiol, or follicle-stimulating hormone (FSH) levels measured over the study period—were associated with reports of decreased libido.
      • Gracia C.
      • Sammel M.
      • Freeman E.
      • et al.
      Predictors of decreased libido in women during the late reproductive years.
      These findings suggest that fluctuation may be more important than the level of estrogens and androgens during the menopausal transition.
      Table 4Prevalence of sexual, cognitive, vaginal, urinary, and pain symptoms from selected longitudinal studies
      StudyStudy PopulationMeasuresSTRAW MT Stage
      Late ReproductiveEarly MTLate MTPostmenopause
      Melbourne Women’s Midlife Health Project
      • Dennerstein L.
      • Lehert P.
      Modeling mid-aged women’s sexual functioning a prospective, population-based study.
      • Dennerstein L.
      • Randolph J.
      • Taffe J.
      • Dudley E.
      • Burger H.
      Hormones, mood, sexuality, and the menopausal transition.
      172 women who had made a transition to perimenopause or postmenopause reported on symptomsSPEQ scores indicating sexual dysfunctionNA42%88%NA
      Vaginal dryness over past 2 wk, frequency and bothersomeness; prevalence of bothersome symptom 3% 4%21%25% (1 yr) 32% (2 yr)
      Urine control problems over the past 2 wk17%12%14%14%
      Aches or stiff joints over the past 2 wk41%47%53%53% (1 yr) 57% (2 yr)
      SWAN
      • Gold E.B.
      • Sternfeld B.
      • Kelsey J.L.
      • et al.
      Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age.
      16,065 women, aged 40–55 yr, participating in baseline surveyVaginal dryness over past 2 wk 7.1%12.9%18.2%21.2%
      Urine leakage over past 2 wk12.3%20.6%19.6%17.7%
      Stiffness/soreness over past 2 wk45.8%57.9%58.4%54.8%
      Forgetfulness over the past 2 wk measured on symptom checklist31.2%44%44.8%42.0%
      MT = menopausal transition; NA = not available from published literature; SPEQ = Shortened Personal Experiences Questionnaire; STRAW = Staging and Reproductive Aging Workshop; SWAN = Study of Women’s Health Across the Nation.

      Cognitive symptoms

      Although cognitive symptoms are prevalent (e.g., problems remembering names), few women rate their symptoms as serious.
      • Mitchell E.S.
      • Woods N.F.
      Midlife women’s attributions about perceived memory changes observations from the Seattle Midlife Women’s Health Study.
      When women were asked about their attributions, they linked their memory problems to increased role burden and stress, getting older, physical health problems, menstrual cycle changes, hormone changes, inadequate concentration and emotional changes, but few mentioned menopause.
      • Woods N.F.
      • Mitchell E.S.
      • Adams C.
      Memory functioning among midlife women observations from the Seattle Midlife Women’s Health Study.
      Only SWAN has examined changes in cognition in various stages of the menopausal transition: experiences of forgetfulness were reported by 31% of participants in the reproductive stage, 44% in the early menopausal transition stage, 44.8% in the late menopausal transition stage, and 42% in postmenopause.
      • Gold E.B.
      • Sternfeld B.
      • Kelsey J.L.
      • et al.
      Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age.
      A cross-sectional analysis of data from the MMWHP indicated that memory did not vary with any variables that measured estrogen exposures, including menopausal transition stage, time from the FMP, use of HT, or serum estradiol concentration.
      • Henderson V.W.
      • Guthrie J.R.
      • Dudley E.C.
      • et al.
      Estrogen exposures and memory at midlife a population-based study of women.
      The single longitudinal analysis of cognitive assessments to measure working memory and perceptual speed indicated that the measures improved for women in the late reproductive and early menopausal transition stages over a 2-year period. Significant decreases in Symbol Digit Modalities Test scores were evidenced only for postmenopausal women, a pattern consistent with expected changes related to aging.
      • Meyer P.M.
      • Powell L.H.
      • Wilson R.S.
      • et al.
      A population-based longitudinal study of cognitive functioning in the MT.

      Vaginal symptoms

      Vaginal dryness was common as women proceeded through the menopausal transition. In the MWMHP, symptoms of vaginal dryness were reported as bothersome by 3% of women in the reproductive stage, 4% of women in the early menopausal transition, 21% of women in the late menopausal transition, and 47% of women who are 3 years postmenopausal.
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      In the SWAN cohort, 1,629 of >16,000 women providing baseline data reported vaginal dryness. Menopausal status (progression through the transition), was associated with vaginal dryness as was age.
      • Gold E.B.
      • Sternfeld B.
      • Kelsey J.L.
      • et al.
      Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age.
      This symptom is also related to the reports of sexual dysfunction and is included in some measures (e.g., in the SPEQ) as an indicator of sexual dysfunction.

      Urinary symptoms

      In the MWMHP, the prevalence of urinary symptoms was reported as 17% in women in the late reproductive stage, 12% in women in the early menopausal transition, 14% in women in the late menopausal transition, and 14% in women who were postmenopausal.
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      Participants in SWAN (n = 2,135 of >16,000) reported leaking urine over the past 2 weeks. Menopausal transition stage and age were correlated.
      • Gold E.B.
      • Sternfeld B.
      • Kelsey J.L.
      • et al.
      Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age.
      In a more complete assessment of symptoms of incontinence, frequency, and severity completed at the beginning of the longitudinal phase of SWAN, 57% of women reported incontinence, with 15% rating it as moderate and 10% as severe. Being in a menopausal transition stage versus in a late reproductive stage and being older were both associated with symptoms of incontinence.
      • Sampselle C.M.
      • Harlow D.S.
      • Skurnick J.
      • et al.
      Urinary incontinence predictors and life impact in ethnically diverse perimenopausal women.

      Somatic symptoms

      The MWMHP is the only source of prevalence estimates of aches or stiff joints for women in the various menopausal transition stages, with prevalence increasing from 41% in the late reproductive stage to 47% in early menopausal transition, to 53% in late menopausal transition, and to 57% at 2 years postmenopause.
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      SWAN participants (n = 6,620 of >16,000) reported stiffness and soreness.
      • Gold E.B.
      • Sternfeld B.
      • Kelsey J.L.
      • et al.
      Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age.
      Both increasing age and progression through the menopausal transition stages were associated with these symptoms.
      • Gold E.B.
      • Sternfeld B.
      • Kelsey J.L.
      • et al.
      Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age.

      Severity and persistence of symptoms

      A minority of women report severe symptoms.
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      In the Norwegian Menopause Project, 67% of participants reported any hot flashes during the menopausal transition, 58% reported an increase in frequency from the reproductive stage to postmenopause, and 54% reported an increase in distress related to hot flashes.
      • Holte A.
      Influences of natural menopause on health complaints a prospective study of healthy Norwegian women.
      In the MWMHP, 39% of participants reported frequency and bothersomeness of hot flashes, with 29% of women in the menopausal transition stages and 37% of postmenopausal women reporting that hot flashes occurred several times per day.
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      In the Penn Ovarian Aging Study, 26% of women reported their hot flashes were moderate to severe, with 15% experiencing hot flashes on >15 days per month and 9% reporting having hot flashes daily.
      • Freeman E.W.
      • Grisso J.A.
      • Berlin J.
      • et al.
      Symptom reports from a cohort of African American and white women in the late reproductive years.
      Studies with trajectory data indicate that symptoms such as hot flashes peak in severity during the later part of the menopausal transition, when women are skipping menstrual periods.
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      • Avis N.E.
      • McKinlay S.M.
      Health care utilization among mid-aged women.
      • Avis N.E.
      • Crawford S.L.
      • McKinlay S.M.
      Psychosocial, behavioral, and health factors related to menopause symptomatology.

      Woods NF, Mitchell E, Percival D, et al. Patterns of hot flash severity across the perimenopause: observations from the Seattle Midlife Women’s Health Study. Presented at: meeting of the Society of Menstrual Cycle Research; June 6, 2005; Boulder, CO.

      It is unclear whether and when symptoms abate after menopause owing to limited follow-up. To date the longest reported follow-up of a cohort has been the MWMHP, which has reports based on 8 years of follow-up data.
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.

      Women’s attributions about symptoms and correlates in community-based population studies

      Although there are only a few reports about women’s attributions of their symptoms, the women’s view of factors associated with their symptoms (ranging from hot flashes and sweats to aches and stiffness) correspond closely to findings from epidemiologic studies of community-based populations. Women attribute their symptoms to factors such as aging, menopausal hormone changes, family history, role overload, stress, health changes, emotional changes, attitudes and expectations, lack of information, and uncertainty about menopause.
      • Woods N.F.
      • Mitchell E.S.
      Anticipating menopause observations from the Seattle Midlife Women’s Health Study.
      Epidemiologic studies link similar symptoms to factors including age; endocrine changes (estradiol, FSH, DHEAS, testosterone, androstenedione); stressors such as economic strain and parenting strain; stressful life circumstances such as abuse; health behaviors such as smoking, alcohol intake, exercise, and nutrient intake; personal characteristics such as optimism; concurrent and past health conditions, including prior episodes of depression or premenstrual symptoms; and physical indicators such as body mass index.
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      • Gold E.B.
      • Sternfeld B.
      • Kelsey J.L.
      • et al.
      Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age.
      • Mitchell E.S.
      • Woods N.F.
      Midlife women’s attributions about perceived memory changes observations from the Seattle Midlife Women’s Health Study.
      • Avis N.E.
      • Crawford S.L.
      • McKinlay S.M.
      Psychosocial, behavioral, and health factors related to menopause symptomatology.
      Despite the wide range of factors associated with a wide array of symptoms, focus has remained on the role of endogenous endocrine factors such as estrogen.
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      • Avis N.E.
      • Crawford S.
      • Stellato R.
      • et al.
      Longitudinal study of hormone levels and depression among women transitioning through menopause.

      Significance of symptoms in women’s lives

      Data from the MWMHP indicate little relation between symptoms (hot flashes, night sweats, vaginal dryness) and well-being.
      • Dennerstein L.
      • Lehert P.
      • Guthrie J.
      The effects of the menopausal transition and biopsychosocial factors on well-being.
      Instead, well-being during the perimenopause was influenced by past well-being, changes in marital status, work satisfaction, daily hassles, and stressful life events. Moreover, in the MWMHP cohort, well-being improved as women entered the late menopausal transition stage. Data from studies of negative mood do indicate, however, that severe vasomotor symptoms affect sleep and mood and imply that these symptoms may interfere with women’s well-being.
      • Avis N.E.
      • Crawford S.
      • Stellato R.
      • et al.
      Longitudinal study of hormone levels and depression among women transitioning through menopause.
      The appraisal of the consequences of perimenopausal symptoms by women from different ethnic groups will be enhanced significantly as a result of the SWAN findings.
      • Sampselle C.M.
      • Harris V.
      • Harlow S.D.
      • et al.
      Midlife development and menopause in African American and Caucasian women.
      • Villaruel A.M.
      • Harlow S.D.
      • Lopez M.
      • Sowers M.
      El cambio de vida conceptualizations of menopause and midlife among urban Latina women.
      • Kagawa-Singer M.
      • Kim S.
      • Wu K.
      • et al.
      Comparison of menopause and midlife transition between Japanese American and European American women.
      • Adler S.R.
      • Fosket J.R.
      • Kagawa-Singer M.
      • et al.
      Conceptualizing menopause and midlife Chinese American and Chinese women in the US.
      • Avis N.E.
      • McKinlay S.M.
      A longitudinal analysis of women’s attitudes toward the menopause results from the Massachusetts Women’s Health Study.

      State of the science, clinical implications, and future directions for research

      The STRAW recommendations for staging the menopausal transition have prompted investigators to differentiate women’s experiences across the reproductive aging stages. The late menopausal transition and early postmenopausal stages appear to be intervals of vulnerability in which the prevalence of symptoms is higher than during other reproductive aging stages. This pattern has been observed in >1 study for hot flashes and sweats, vaginal dryness, and sleep disturbances. Depressed mood may increase in prevalence during the menopausal transition stages for a subset of women, but data about its persistence are limited.
      • Avis N.E.
      • Brambilla D.
      • McKinlay S.M.
      • Vass K.
      A longitudinal analysis of the association between menopause and depression results from the Massachusetts Women’s Health Study.
      • McKinlay J.B.
      • McKinlay S.M.
      • Brambilla D.
      The relative contributions of endocrine changes and social circumstances to depression in mid-aged women.
      • Woods N.F.
      • Mariella A.
      • Mitchell E.
      Patterns of depressed mood across the MT approaches to studying patterns in longitudinal data.
      • Woods N.F.
      • Mitchell E.S.
      Patterns of depressed mood in midlife women observations from the Seattle Midlife Women’s Health Study.
      • Bromberger J.T.
      • Assmann S.F.
      • Avis N.E.
      • et al.
      Persistent mood symptoms in multiethnic community cohort of pre- and perimenopausal women.
      Difficulty sleeping seems to increase in a linear fashion over the menopausal transition and postmenopause, suggesting an association with increasing age as well as with prevalence of hot flashes and social factors.
      • Dennerstein L.
      • Dudley E.
      • Hopper J.
      • et al.
      A prospective population-based study of menopausal symptoms.
      To date there is no evidence of cognitive symptoms, urinary incontinence, somatic/pain symptoms, or depressed mood peaking in any of the stages.
      Understanding the various trajectories of symptoms in women (intraindividual analyses), coupled with between-groups analysis to reveal the joint effects of population and individual factors, remains to be accomplished. Most studies initiated in the 1990s have measured symptoms prospectively using standardized symptom checklists.
      • McKinlay S.M.
      • Brambilla D.J.
      • Posner J.
      The normal menopause transition.
      North American Menopause Society
      Recommendations for estrogen and progestogen use in peri- and postmenopausal women October 2004 position statement of The North American Menopause Society.
      • Bair Y.A.
      • Gold E.B.
      • Greendale G.A.
      • et al.
      Ethnic differences in use of complementary and alternative medicine at midlife longitudinal results from SWAN participants.
      • Matthews K.A.
      • Wing R.R.
      • Kuller L.H.
      • et al.
      Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy women.
      • Kaufert P.A.
      • Gilbert P.
      • Tate R.
      The Manitoba Project a re-examination of the link between menopause and depression.
      • Holte A.
      Influences of natural menopause on health complaints a prospective study of healthy Norwegian women.
      • Woods N.F.
      • Mitchell E.S.
      Anticipating menopause observations from the Seattle Midlife Women’s Health Study.
      • Hunter M.
      The South-East England longitudinal study of the climacteric and postmenopause.
      • Dennerstein L.
      • Smith A.M.
      • Morse C.A.
      • et al.
      Menopausal symptoms in Australian women.
      • Freeman E.W.
      • Grisso J.A.
      • Berlin J.
      • et al.
      Symptom reports from a cohort of African American and white women in the late reproductive years.
      • Harlow B.L.
      • Cohen L.S.
      • Otto M.W.
      • et al.
      Prevalence and predictors of depressive symptoms in older premenopausal women the Harvard Study of Moods and Cycles.
      • Sowers M.
      • Crawford S.
      • Sternfeld B.
      • et al.
      SWAN A multicenter, multiethnic community-based cohort study of women and the MT.
      Many have incorporated severity ratings, providing verbal descriptors that women can choose to indicate whether their symptoms are barely noticeable or extremely bothersome.
      • Woods N.F.
      • Mitchell E.S.
      Anticipating menopause observations from the Seattle Midlife Women’s Health Study.
      • Dennerstein L.
      • Smith A.M.
      • Morse C.A.
      • et al.
      Menopausal symptoms in Australian women.
      Few have measured the frequency of symptoms. Little is known about whether and when each of the symptoms considered in this review will cease. Attempts to relate symptoms to hypothesized causal factors have included measures precisely timed to allow understanding of antecedent-consequent relationships: measures of endocrine levels have been timed to a specific day of the menstrual cycle and related to symptoms measured at the same time or shortly thereafter.
      • Woods N.F.
      • Mitchell E.S.
      Anticipating menopause observations from the Seattle Midlife Women’s Health Study.
      • Sowers M.
      • Crawford S.
      • Sternfeld B.
      • et al.
      SWAN A multicenter, multiethnic community-based cohort study of women and the MT.

      Conceptual framework for studying perimenopausal symptoms

      Research on symptoms during the perimenopause can be strengthened by use of a conceptual framework that bridges emphasis on the genetic, molecular, and physiologic factors hypothesized to cause symptoms as well as the social and cultural context in which women experience them. A proposed conceptual framework builds on earlier work addressing symptom perception, evaluation, and response (Figure 1). Symptoms such as hot flashes are sensations that people perceive that differ from the ordinary. Perception and evaluation of symptoms precede response to symptoms. Symptom perception refers to noticing symptoms, their frequency, and their intensity, whereas symptom evaluation refers to judgments individuals make about symptoms, such as the degree of seriousness, treatability, causes, and consequences in their lives.
      • Mechanic D.
      The concept of illness behavior.
      People use culturally based explanatory models—a set of professional, lay, or idiosyncratic categories—to ascribe meaning to their symptoms.
      • Chrisman N.
      • Kleinman A.
      Popular health care, social networks, and cultural meanings the orientation of medical anthropology.
      Responses to symptoms may include feelings, thoughts, or behaviors, such as self-care efforts (e.g., changing dietary intake, using herbal or over-the-counter preparations), seeking help or advice from one’s social network, seeking help from a health professional that may include a prescribed medication, or choosing to do nothing about the symptoms. The processes of symptom perception, evaluation, and response occur within a social context that shapes the meanings individuals ascribe to their symptoms as well as to their responses.
      • Mechanic D.
      The concept of illness behavior.
      • Chrisman N.
      • Kleinman A.
      Popular health care, social networks, and cultural meanings the orientation of medical anthropology.
      Such a framework will enhance the efforts of clinicians and researchers to understand the experiences of women from various ethnic groups, such as those reflected in SWAN, and will contribute important insights on symptom management for women in the menopausal transition.
      • Sampselle C.M.
      • Harris V.
      • Harlow S.D.
      • et al.
      Midlife development and menopause in African American and Caucasian women.
      • Villaruel A.M.
      • Harlow S.D.
      • Lopez M.
      • Sowers M.
      El cambio de vida conceptualizations of menopause and midlife among urban Latina women.
      • Kagawa-Singer M.
      • Kim S.
      • Wu K.
      • et al.
      Comparison of menopause and midlife transition between Japanese American and European American women.
      • Adler S.R.
      • Fosket J.R.
      • Kagawa-Singer M.
      • et al.
      Conceptualizing menopause and midlife Chinese American and Chinese women in the US.
      • Avis N.E.
      • McKinlay S.M.
      A longitudinal analysis of women’s attitudes toward the menopause results from the Massachusetts Women’s Health Study.
      Figure thumbnail gr1
      Figure 1Conceptual model for understanding perimenopausal symptoms. (A) Symptom perception, symptom evaluation, and symptom responses are components of the process by which symptoms influence responses and are, in turn, influenced by explanatory models. (B) Symptom perception, evaluation, and responses are influenced by sociocultural context and personal characteristics.

      Summary: perimenopausal symptoms

      The prevalence of hot flashes, night sweats, vaginal dryness, and sleep disruption increases beginning with the late menopausal transition stage and persists postmenopause. Nearly 40% of women are bothered by hot flashes during the late menopausal transition and postmenopausal stages. Sleep problems seem to increase in a linear fashion across the menopausal transition and postmenopausal stages. Vaginal dryness becomes more prevalent during the postmenopause than during the late reproductive and early and late menopausal transition stages, as do other sexual symptoms. It is unclear whether problems with depressed mood, urinary control, cognitive functioning, and joint and muscle aches and pains vary across the menopausal transition stages. Severity of symptoms (hot flashes, night sweats, vaginal dryness, and sleep problems) increases during the late menopausal transition stage and postmenopause, but owing to the availability of limited follow-up data, it is unclear how long symptoms persist postmenopause. Women attribute their symptoms to a variety of factors, including hormone changes, aging, role overload, stress, health changes, and emotional changes; epidemiologic studies link symptoms to aging, endocrine, genetic, psychosocial, cultural, behavioral, and health history factors.

      Clinical implications

      Although there is growing evidence about the relation of symptoms to endocrine levels, factors other than endocrine changes should be considered in diagnostic workups and symptom management plans. Not everything that women experience during the menopausal transition can be attributed to menopause. Menopause-related health consultations provide an opportunity to promote healthy aging.

      Future research directions

      Greater attention needs to be focused on the longitudinal analyses of the data from the cohorts studied to identify within-woman patterns of symptoms over time, from the late reproductive stage through the postmenopause. In particular, longitudinal analyses of individual symptom clusters (e.g., vasomotor, sleep disturbances, depressed mood, sexuality), their trajectories, and their interrelation over time are needed. These analyses should be correlated to endocrine measures where available. Identification of women who have high levels of many symptom clusters should be pursued to determine whether there are important clinical correlates. Symptom clusters that are associated with high human and financial cost (e.g., depressed mood, incontinence, and somatic pain) should receive special attention.
      Increased emphasis on understanding the ethnic populations that have been studied and the meaning of symptoms within their cultures is needed as a basis for symptom management. Data are missing from menopause research about American Indian women, many Hispanic groups, Filipina American women, and Southeast Asian American women. Little attention has been focused on the early postmenopause, particularly the 5 years immediately after the FMP. SWAN will have the largest database of postmenopausal symptoms and biomarkers and, along with other cohort studies, it will provide a rich resource for understanding persistence of hot flashes, sleep disturbances, depressed mood, sexual symptoms, and the link between the menopausal transition and healthy aging. Models that include social as well as biologic and behavioral correlates of perimenopausal symptoms are essential to achieve a full understanding of the mechanisms responsible for symptoms and to guide symptom management efforts. Longitudinal studies of women’s experiences of symptoms, symptom evaluation, and responses to symptoms are needed to fully understand women’s symptom management strategies. Evaluation of effects of symptoms (e.g., vasomotor and sleep disturbances, dysphoric mood) on well-being, role performance, and adaptation to demands of daily living are essential to fully understand the impact of perimenopausal symptoms in women’s lives. These effects should be weighed against the effects of midlife events. It is not yet possible to depict the sequence of occurrence of these symptoms, but efforts to do so may help discern the time course of symptoms (e.g., whether hot flashes precede sleep disruption or vice versa).

      References

        • McKinlay S.M.
        • Brambilla D.J.
        • Posner J.
        The normal menopause transition.
        Maturitas. 1992; 14: 103-115
        • North American Menopause Society
        Recommendations for estrogen and progestogen use in peri- and postmenopausal women.
        Menopause. 2004; 11: 589-600
        • Bair Y.A.
        • Gold E.B.
        • Greendale G.A.
        • et al.
        Ethnic differences in use of complementary and alternative medicine at midlife.
        Am J Public Health. 2002; 92: 1832-1840
        • Matthews K.A.
        • Wing R.R.
        • Kuller L.H.
        • et al.
        Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy women.
        J Consult Clin Psychol. 1990; 58: 345-351
        • Kaufert P.A.
        • Gilbert P.
        • Tate R.
        The Manitoba Project.
        Maturitas. 1992; 14: 143-155
        • Holte A.
        Influences of natural menopause on health complaints.
        Maturitas. 1992; 14: 127-141
        • Woods N.F.
        • Mitchell E.S.
        Anticipating menopause.
        Menopause. 1999; 6: 167-173
        • Hunter M.
        The South-East England longitudinal study of the climacteric and postmenopause.
        Maturitas. 1992; 14: 117-126
        • Dennerstein L.
        • Smith A.M.
        • Morse C.A.
        • et al.
        Menopausal symptoms in Australian women.
        Med J Aust. 1993; 159: 232-236
        • Freeman E.W.
        • Grisso J.A.
        • Berlin J.
        • et al.
        Symptom reports from a cohort of African American and white women in the late reproductive years.
        Menopause. 2001; 8: 33-42
        • Harlow B.L.
        • Cohen L.S.
        • Otto M.W.
        • et al.
        Prevalence and predictors of depressive symptoms in older premenopausal women.
        Arch Gen Psychiatry. 1999; 56: 418-424
        • Sowers M.
        • Crawford S.
        • Sternfeld B.
        • et al.
        SWAN.
        in: Lobo R. Kelsey J. Marcus R. Menopause Biology and Pathobiology. Academic Press, San Diego, CA2000: 175-188
        • Soules M.R.
        • Sherman S.
        • Parrott E.
        • et al.
        Executive summary.
        Fertil Steril. 2001; 76: 874-878
        • Dennerstein L.
        • Dudley E.
        • Hopper J.
        • et al.
        A prospective population-based study of menopausal symptoms.
        Obstet Gynecol. 2000; 96: 351-358
        • Gold E.B.
        • Sternfeld B.
        • Kelsey J.L.
        • et al.
        Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40–55 years of age.
        Am J Epidemiol. 2000; 152: 463-473
        • Kaufert P.
        • Syrotuik J.
        Symptom reporting at the menopause.
        Soc Sci Med. 1981; 151: 173-184
        • Gold E.
        • Block G.
        • Crawford S.
        • et al.
        Lifestyle and demographic factors in relation to vasomotor symptoms.
        Am J Epidemiol. 2004; 159: 1189-1199
        • Freeman E.
        • Sammel M.
        • Lin H.
        • Gracia C.R.
        • Kapoor S.
        • Ferdusi T.
        The role of anxiety and hormonal changes in menopausal hot flashes.
        Menopause. 2005; 12: 258-266
        • Lock M.
        Culture and the menopause.
        in: Aso T. Yanaihara T. Fujimoto S. The Menopause at the Millennium: The Proceedings of the 9th International Menopause Society World Congress on the Menopause: Yokohama, Japan, October 17–21, 1999. Parthenon, New York2000: 29-35
        • Guthrie J.
        • Dennerstein L.
        • Hopper J.
        • et al.
        Hot flushes, menstrual status, and hormone levels in a population-based sample of midlife women.
        Obstet Gynecol. 1996; 88: 437-442
        • Dennerstein L.
        • Guthrie J.R.
        • Clark M.
        • et al.
        A population-based study of depressed mood in middle-aged, Australian-born women.
        Menopause. 2004; 11: 563-568
        • Avis N.E.
        • Crawford S.
        • Stellato R.
        • et al.
        Longitudinal study of hormone levels and depression among women transitioning through menopause.
        Climacteric. 2001; 4: 243-249
        • Avis N.E.
        • Brambilla D.
        • McKinlay S.M.
        • Vass K.
        A longitudinal analysis of the association between menopause and depression.
        Ann Epidemiol. 1994; 4: 214-220
        • McKinlay J.B.
        • McKinlay S.M.
        • Brambilla D.
        The relative contributions of endocrine changes and social circumstances to depression in mid-aged women.
        J Health Social Behav. 1987; 28: 345-363
        • Woods N.F.
        • Mariella A.
        • Mitchell E.
        Patterns of depressed mood across the MT.
        Acta Obstet Gynecol Scand. 2002; 81: 623-632
        • Woods N.F.
        • Mitchell E.S.
        Patterns of depressed mood in midlife women.
        Res Nurs Health. 1996; 19: 111-123
        • Bromberger J.T.
        • Assmann S.F.
        • Avis N.E.
        • et al.
        Persistent mood symptoms in multiethnic community cohort of pre- and perimenopausal women.
        Am J Epidemiol. 2003; 158: 347-356
        • Busch C.
        • Zonderman A.
        • Costa P.
        MT and psychological distress in a nationally representative sample.
        J Aging Health. 1994; : 6209-6228
        • Lock M.
        • Kaufert P.
        • Gilbert P.
        Cultural construction of the menopausal syndrome.
        Maturitas. 1988; 10: 317-332
        • Bromberger J.
        • Harlow S.
        • Avis N.
        • et al.
        Racial/ethnic differences in the prevalence of depressive symptoms among middle-aged women.
        Am J Public Health. 2004; 94: 1378-1385
        • Bromberger J.
        • Meyer P.
        • Kravitz H.
        • et al.
        Psychologic distress and natural menopause.
        Am J Public Health. 2001; 92: 1435-1442
        • Freeman E.W.
        • Sammel M.D.
        • Liu L.
        • et al.
        Hormones and menopausal status as predictors of depression in women in transition to menopause.
        Arch Gen Psychiatry. 2004; 61: 62-70
        • Schmidt P.
        • Haq N.
        • Rubinow D.
        A longitudinal evaluation of the relationship between reproductive status and mood in perimenopausal women.
        Am J Psychiatry. 2004; 161;: 2238-2244
        • Bromberger J.T.
        • Kravitz H.M.
        • Wei H.L.
        • et al.
        History of depression and women’s current health and functioning during midlife.
        Gen Hosp Psychiatry. 2005; 27: 200-208
        • Kravitz J.
        • Ganz P.
        • Bromberger J.
        • et al.
        Sleep difficulty in women at midlife.
        Menopause. 2003; 10: 19-28
        • Avis N.E.
        • Stellato R.
        • Crawford S.
        • Johannes C.
        • Longcope C.
        Is there an association between menopause status and sexual functioning?.
        Menopause. 2000; 7: 297-309
        • Dennerstein L.
        • Lehert P.
        Modeling mid-aged women’s sexual functioning.
        J Sex Marital Ther. 2004; 30: 173-183
        • Dennerstein L.
        • Randolph J.
        • Taffe J.
        • Dudley E.
        • Burger H.
        Hormones, mood, sexuality, and the menopausal transition.
        Fertil Steril. 2002; 779: S42-S48
        • Gracia C.
        • Sammel M.
        • Freeman E.
        • et al.
        Predictors of decreased libido in women during the late reproductive years.
        Menopause. 2004; 11: 144-150
        • Mitchell E.S.
        • Woods N.F.
        Midlife women’s attributions about perceived memory changes.
        J Womens Health Gend Based Med. 2001; 10: 351-362
        • Woods N.F.
        • Mitchell E.S.
        • Adams C.
        Memory functioning among midlife women.
        Menopause. 2000; 7: 257-265
        • Henderson V.W.
        • Guthrie J.R.
        • Dudley E.C.
        • et al.
        Estrogen exposures and memory at midlife.
        Neurology. 2003; 60: 1369-1371
        • Meyer P.M.
        • Powell L.H.
        • Wilson R.S.
        • et al.
        A population-based longitudinal study of cognitive functioning in the MT.
        Neurology. 2003; 61: 801-806
        • Sampselle C.M.
        • Harlow D.S.
        • Skurnick J.
        • et al.
        Urinary incontinence predictors and life impact in ethnically diverse perimenopausal women.
        Obstet Gynecol. 2002; 100: 1230-1238
        • Avis N.E.
        • McKinlay S.M.
        Health care utilization among mid-aged women.
        Ann N Y Acad Sci. 1990; 592: 228-238
        • Avis N.E.
        • Crawford S.L.
        • McKinlay S.M.
        Psychosocial, behavioral, and health factors related to menopause symptomatology.
        Womens Health. 1997; 3: 103-120
      1. Woods NF, Mitchell E, Percival D, et al. Patterns of hot flash severity across the perimenopause: observations from the Seattle Midlife Women’s Health Study. Presented at: meeting of the Society of Menstrual Cycle Research; June 6, 2005; Boulder, CO.

        • Dennerstein L.
        • Lehert P.
        • Guthrie J.
        The effects of the menopausal transition and biopsychosocial factors on well-being.
        Arch Women Ment Health. 2002; 5: 15-22
        • Sampselle C.M.
        • Harris V.
        • Harlow S.D.
        • et al.
        Midlife development and menopause in African American and Caucasian women.
        Health Care Women Int. 2003; 23: 351-363
        • Villaruel A.M.
        • Harlow S.D.
        • Lopez M.
        • Sowers M.
        El cambio de vida.
        Res Theory Nurs Pract. 2002; 16: 91-102
        • Kagawa-Singer M.
        • Kim S.
        • Wu K.
        • et al.
        Comparison of menopause and midlife transition between Japanese American and European American women.
        Med Anthropol Q. 2002; 16: 64-91
        • Adler S.R.
        • Fosket J.R.
        • Kagawa-Singer M.
        • et al.
        Conceptualizing menopause and midlife.
        Maturitas. 2000; 35: 11-23
        • Avis N.E.
        • McKinlay S.M.
        A longitudinal analysis of women’s attitudes toward the menopause.
        Maturitas. 1991; 13: 65-79
        • Mechanic D.
        The concept of illness behavior.
        J Chron Dis. 1962; 15: 189-194
        • Chrisman N.
        • Kleinman A.
        Popular health care, social networks, and cultural meanings.
        in: Mechanic D. Handbook of Health Care and Health Professions. Free Press, New York1983: 569-590