By: Dr. Geoffrey Modest
A subgroup assessment of the Study of Women’s Health Across the Nation (SWAN), a multiracial/multiethnic observational study from 7 US communities, assessed the duration of frequent menopausal vasomotor symptoms (VMS), defined as occurring at least 6 days over prior 2 weeks, and the duration of frequent VMS after the final menstrual period (see doi:10.1001/jamainternmed.2014.8063).
Details:
–analysis of 1449 women with frequent VMS, from Feb 1996 through Apr 2013. all with natural menopause. an array of psychosocial variables were recorded, including attitudes toward menopause, symptom sensitivity (assessment of heightened attention to bodily sensations), anxiety, perceived stress, depressive symptoms, and social support
–mean age at first VMS report was 50. only about 35% had symptoms starting post-menopause, 10% premenopausal and rest were perimenopausal. BMI <25 in 35%, BMI 25-30 in 27% , BMI >30 in 37% .
–median total VMS duration was 7.4 years
–of the 881 women with known final menstrual period (FMP), the median persistence of frequent VMS was 4.5 years after FMP
–those women who were premenopausal or early perimenopausal with frequent VMS had the longest duration of frequent VMS (11.8 years) and those with known FMP had the longest persistence of frequent VMS (9.4 years)
–women who were post-menopausal at onset of frequent VMS had the shortest VMS duration (median 3.4 years)
–African-American women reported the longest total VMS duration (10.1 years). Japanese/Chinese with shortest (4.8/5.4 yrs). nonHispanic White=6.5 yrs. Hispanic=8.9 yrs
–also, those who were younger at onset of frequent VMS, had lower educational level, greater perceived stress and symptom sensitivity, and higher depressive symptoms and anxiety at start of VMS had longer duration VMS
–overall, the strongest relationships with VMS duration and with persistence of symptoms in those with known FMP were: whether they were premenopausal or menopausal at onset of VMS and their age at onset of VMS (the hazard ratio being >10.9 if symptoms began age 42-45).
Menopausal vasomotor symptoms (e.g. hot flashes, night sweats) are really common, about 80% of women have them and most rate them as moderate to severe and affect their quality of life. Although the ACOG bulletin (Am College of Ob and Gyn) has until recently maintained that hot flashes lasted from 6 months to 2 years, this is the second report I’ve seen in the past couple of years which seriously challenge this (the Penn Ovarian Aging Study, found a median of 10.2 years of moderate-to-severe hot flashes postmenopausally. see Freeman E. Obstetrics & Gynecology. 2011; 117:1095-1104). Overall in the current study, the symptoms on average lasted 7.4 years, but even in the lowest-risk groups, 20% had symptoms at 13 years out. So, as those of us in primary care have known for decades, VMS frequently lasts much much longer than ACOG has historically noted, and that this has profound implications in terms of what what we as clinicians should consider within normal limits (i.e. when we should be concerned about underlying pathology), what women should expect, and, if medical treatment is needed, how long that treatment might last (i.e., it seems that short-term estrogen replacement has minimal adverse events, especially if administered by transdermal route which bypasses first-pass hepatic metabolism and thereby does not induce high levels of clotting factors. but now we are acknowledging that treatment may actually be required for far longer, raising big questions about development of breast cancer, for example, if estrogens, the most potent medication, is used).