Ben Schwartz is Associate Editor, Contemporary OB/GYN.

Ben Schwartz

Like some aspects of reproductive function, menopausal symptoms appear to exhibit seasonal variation, according to new research from 

The Journal of the North American Menopause Society

. The study assessed the impact of season and proximity to the fi nal men-strual period (FMP) on frequency of symptom reporting. 

The authors included 955 participants from the Study of Women’s Health Across the Nation, a cohort study that followed a multiethnic sample during the transition from premenopause to postmenopause over a 10-year period. 

Participants fi lled out men-strual calendars daily to capture days when spotting or bleeding occurred. Women answered questions about hormone therapy (HT) use and gyne-cological procedures that could aff ect their bleeding reports monthly and also completed a short survey about whether they had experienced symp-toms (hot fl ashes, night sweats, and trouble sleeping) in the past month.

FMP was defi ned as the fi rst day of the bleeding episode that was fol-lowed by at least 12 months of amenorrhea. Hot flashes, night sweats, and trouble sleeping were coded as a binary variable (yes/no) for each month of observation. HT use varied by time and was coded based on current use (yes/no) for each month of observation.

The authors found that 5 to 10 years before the FMP, approximately 20% of women reported hot flashes and night sweats. During that period, approximately 40% reported trouble sleeping. These numbers rose approximately 4 years before the FMP with a sharp jump in prevalence of hot flashes (~60%) and night sweats (~40) coincident with the FMP. 

the authors noted that a peak in hot flash reports was observed in July, while January had a trough in hot flash reports

. Women had 66% greater odds of a hot flash at their seasonal peak compared to their seasonal minimum in both the unadjusted model and the model adjusted for smoking, race, age at FMP, and body mass index. The corresponding odds for night sweats and sleep problems were 50% and 24%, respectively. 

The authors also noted that odds of reporting all three symptoms increased as women approached the FMP. The authors believe their findings indicate that menopausal symptoms exhibit seasonal variation based on summer and winter. They believe their findings indicate the need for physicians to recognize the summer months as a critical period for managing their patients’ symptoms.

Harlow SD, Elliott MR, Bondarenko I, Thurston RC, Jackson EA. Monthly variation of hot ﬂ ashes, night sweats, and trouble sleeping. Menopause. 2020;27(1):5-13. doi:10.1097/gme.0000000000001420

Articles

A peak in hot fl ash reports was observed in July, while January had a trough in hot fl ash reports.

Menopause symptoms through the seasons

Vulvovaginal candidiasis (VVC) is relatively common, and research from 

 indicates a woman’s risk could be increased by certain personal behaviors as well as the composition of her vaginal microbiota. 

 is the most common etiology for VCC and this study looked at what factors are associated with its molecular detection. 

The objective of the study was to better understand epidemiologic factors associated with molecular 

detection and to evaluate how the vaginal microbiota and relative abundance of individual bacterial taxa differ between women with and without 

For the cross-sectional study, vaginal swabs were self-collected by 394 non-pregnant, reproductive-age women. The participants submitted two swabs; one was used to characterize the composition and structure of the vaginal microbiota and the other was used the prepare a smear for Nugent Gram stain scoring.

 using polymerase chain reaction targeting 

 ITS1/2 region. Vaginal microbiota was characterized using 16S rRNA gene amplification sequencing of the V3 to V4 hypervariable regions and then clustered into community state types (CSTs).

Five primary CSTs were identified in this study; four dominated by 

Lactobacillus species (L. iners, L. crispatus, L. gasseri, L. jensenii)

, plus one lacking significant numbers of 

and characterized by higher proportions of strict and facultative anaerobic bacteria (termed CST IV). 

The authors used multiple logistic regression to identify risk factors associated with 

 in 21%of vaginal samples (83 of 394). Women in whom 

 was detected were more likely to report use of tampons, engage in receptive oral sex, and use of over-the-counter (OTC) antifungals to self-treat for vaginal infections before seeing a doctor for examination.

Neither self-reported diagnosis of VVC nor bacterial vaginosis in the prior 60 days were associated with 

Furthermore, detection was not associated with vaginal pH, re-porting any type of vaginal symptom in the past 60 days, age, history of pregnancy, use of hormonal contraception in the past 60 days, number of recent sexual partners, or other forms of sexual activity in the past 60 days.

-dominated CST had increased, but not statistically significant, oddsof 

 CST IV after cofactor adjustment of receptive oral sex and a history of self-treatment with OTC antifungals (adjusted odds ratio, 2.05%; 95% CI 0.97-4.37, n=323). 

However, using the same model, antifungal use and receptive oral sex were significantly associated with 

detection, with a dose-response trend for increasing frequency of oral sex and escalating odds of 

When assessing individual bacteria to determine if there were taxa that were most likely to be associated with 

Lactobacillus coleohominis, Prevotella oris

 being in higher relative abundance in women in whom 

The authors believe their findings indicate that 

-dominated vaginal microbiota may be associated with increased 

 detection. They also point to receptive oral sex as a risk factor for 

Moura APC, Ribeiro HSAA, Bernardo WM, et al. Accuracy of transvaginal sonography versus magnetic resonance imaging in the diagnosis of rectosigmoid endometriosis: Systematic review and meta-analysis. PLOS One. 2019;14(4):e0214842.

Candida albicans is the most common etiology for VCC and this study looked at what factors are associated with its molecular detection. 

Risk factors for candidiasis

 shows that these laws are not associated with an increased understanding of the clinical implications of breast density.

The study assessed the association of residing in a state with a DBN law and a woman’s awareness and knowledge about breast density through survey responses. The survey also looked at breast cancer anxiety. 

The internet survey was conducted in 2018 with participants in KnowledgePanel®, an online research panel. Participants were English-speaking women between ages 40 and 59 without a personal history of breast cancer who had received at least one screening mammogram (N = 1928; survey completion rate 68.2%). 

The four main measures of the survey were: 1) reported history of increased breast density; 2) knowledge of the increased risk of breast cancer from dense breasts; 3) knowledge of the masking effect of dense breasts on mammography and 4) breast cancer anxiety.

 knew that increased breast density was associated with higher risk of breast cancer.

Based on weighted analysis, 41.3% of women reported a history of increased breast density. A much higher proportion of survey participants who lived in states with DBN reported having increased breast density compared with women who reported living in states with no law (43.6% vs 32.7%, 

In multivariable regression, women residing in a DBN state were more likely to report increased breast density (OR 1.70, 95% CI 1.34-2.17), as were older women, women with a high school education or higher, and with public or private insurance (compared with no insurance).

Black and Hispanic women were less likely than white women to report having increased breast density. Only 23.0% of women overall know that increased breast density was associated with a higher risk of breast cancer and 68.0% of women understood that dense breasts decreased the sensitivity of mammography. 

However, the authors found no difference between women from DBN and non-DBN states for these outcomes, or for breast cancer-related anxiety.

Based on their findings, the authors suggest that state DBN laws are not associated with increased understanding of the clinical implications of breast density. 

Furthermore, they found that women with lower education may be less likely to benefit from DBN laws. 

Ultimately, the authors believe that the clinical implications of a dense breast finding are “complex and personalized and require a conversation between a woman and her provider.”

Kyanko KA, Hoag J, Busch SH, et al. Dense breast notification laws, education, and women’s awareness and knowledge of breast density: A nationally representative survey. 

. August 2020. doi:10.1007/s11606-019-05590-7

Currently, 38 states and the District of Columbia have enacted dense breast notification (DBN) laws mandating that mammogram results include language informing women of risks related to dense breasts. 

Breast density laws and patient knowledge

While hormone therapy (HT) is an acceptable treatment for these symptoms, it is a limited option because of increased health risks, which makes identifying modifiable lifestyle factors, like diet, more important.

 and aimed to address the relationship between climacteric symptoms and their subscales and total intakes of FV, and also their specific subtypes such as green, yellow, cruciferous, and other vegetables, plus citrus, berry and other fruit separately. 

The study recruited 393 postmenopausal women aged 40 to 76 who attended the municipality health centers associated with Tehran University of Medical Sciences between September 2016 and January 2017. Participants were included in the study if they had been postmenopausal for ≥ 1 year. 

Women were excluded if they had a BMI ≥ 40 kg/m2, smoked, had a medical history or presence of particular comorbidities (cancer, diabetes, stroke, multiple sclerosis, dementia, hyper or hypothyroidism), or had received HT for the past 6 months. Demographic and socioeconomic data were collected via face-to-face interview.

Participants were given a menopause rating scale (MRS) questionnaire with 11 items consisting of somatic, psychological, and urogenital symptoms to evaluate their menopausal symptoms. Responses ranged from 0 (no symptom) to 4 (very severe). 

The total MRS score (TMRSS) was the sum of the somatic score (SS), psychological score (PS), and urogenital score (US). Dietary intake was assessed through an in-person interview using a validated semiquantitative 147-item Food Frequency Questionnaire (FFQ) and consisted of food items with a standard serving size commonly consumed by Iranian people.

After adjusting for confounding variables, the authors discovered an inverse relationship between total FV and TMRSS (OR 0.23, 95% CI 0.06 – 0.81) and SS (OR 0.30, 95% CI 0.11-0.82). The authors also found that consumption of total fruits was significantly related to lower SS (OR 0.27, 95% CI 0.10-0.71). 

Only intake of citrus fruits was inversely associated with TMRSS (OR 0.23, 95% CI 0.07-0.71) and SS (OR 0.28, 95% CI 0.11-0.70).

Intakes of total FV (Or 2.46, 95% CI 1.37-4.41), total vegetables (OR 2.54, 95% CI 1.10-5.88), green leafy vegetables (OR 3.59, 95% CI 1.47-8.75), dark yellow vegetables (OR 2.28, 95% CI 1.00-5.18), other vegetables (OR 5.23, 95% CI 1.17-15.39) and citrus fruits were linked to higher US (OR 4.35, 95% CI 1.77-10.77).

Based on their findings, the authors believe that health care providers may want to consider developing nutritional plans for their postmenopausal patients who suffer from menopausal symptoms. 

Increased total amount of FV and citrus fruits showed an inverse relationship with TMRSS and SS, and the inverse association between consumption total FV and PS approached significance. Higher intakes of total FV, total vegetables, green leafy vegetables, dark yellow vegetables, other vegetables, and citrus fruit were also associated with higher US. 

However, the authors note that more research is needed to confirm the findings.

Safabakhsh M, Siassi F, Koohdani F, et al. Higher intakes of fruits and vegetables are related to fewer menopausal symptoms. 

. 2020:1. doi:10.1097/gme.0000000000001511

New research indicates that women may be able to reduce menopausal symptoms by increasing their intake of fruits and vegetables (FV). 

Can a healthier diet reduce menopause symptoms?

 indicates that risk of high-grade cervical neoplasms is lower with copper (Cu) intrauterine devices (IUDs) than with the levonorgestrel-releasing intrauterine system (LNG-IUS).  More than 100 million women worldwide use IUDs as contraception so these findings could have global implications.

The current study was a retrospective cohort analysis of 10,674 patients who received IUDs at Columbia University Medical Center. The authors restricted their cohorts to women age 45 years or younger at time of IUD insertion. Patients with a history of endometrial or cervical neoplasms or who had a prior IUD placement were excluded.

By default, women were in the Cu IUD cohort unless documentation of LNG-IUS appeared in the database. The outcome of the study was high-grade malignant cervical neoplasm or cervical neoplasm with a high association with malignancy, such as cervical intraepithelial neoplasia (CIN) grade II or III. Cervical polyps, CIN grade I, and metastatic spread of neoplasm to the cervix were excluded.

Patients in the cohort and their outcomes were identified by a combination of procedure codes, condition codes, and medication exposures in billing and claim data. The authors adjusted for confounding with propensity score stratification and 1:1 matching.

A total of 10,674 patients were studied. Of them, 8,274 patients were in the Cu IUD cohort and 2,400 were in the LNG-IUS cohort. Ninety-seven percent (2,332) of the LNG-IUS users received a 52-mg device. Median age was 29 years (range 24-35) years in the Cu IUD cohort and 28 years (23-34) in the LNG-IUS cohort.

During follow-up, 1,820 (22.0%) Cu IUD users and 797 (33.2%) of LNG-IUS users had a documented IUD removal procedure.

Before propensity score adjustment, the authors identified 114 cases of cervical neoplasm: 77 (0.9%) in the Cu IUD cohort and 37 (1.5%) in the LNG-IUS cohort. Propensity score matching analysis identified 7,114 Cu IUD and 2,174 LNG-IUS users, with covariate balance achieved over 16,827 covariates.

Of the women with Cu IUDs, 0.7% were diagnosed with high-grade cervical neoplasia versus 1.8% in the LNG-IUS cohort (IR 2.4 [95% CI 1.9-2.9] cases/1000 person years and IR 5.2 [95% CI 3.7-7.1] cases/1000 person years, respectively). Relative risk for high-grade cervical neoplasms among Cu IUD users was 0.38 (95% CI 0.16-0.78, 

The authors noted that the association between IUD usage and high-grade cervical neoplasm incidence has implications for public health on a global scale becuase more than 100 million women worldwide use the devices for contraception. The approximate 1% difference in high-grade cervical neoplasm incidence between Cu IUD and LNG-IUS user could have a large effect, especially in areas with the highest incidence of cervical cancer.

Spotnitz ME, Natarajan K, Ryan PB, Westhoff CL. Relative risk of cervical neoplasms among copper and levonorgestrel-releasing intrauterine system users. 

. 2020;135(2):319-327. doi:10.1097/aog.0000000000003656

More than 100 million women worldwide use IUDs as contraception so these findings could have global implications.

Does IUD type impact cervical cancer risk?

Miscarriages and preterm birth (PTB) can be a difficult experience for expectant mothers, and many seek out positive support systems to help cope. As the world has become more digital, social media has become a support system for women who have experienced these events, according to new research published in 

The study aimed to better understand how Twitter users discuss the topics of miscarriage and PTB, analyze the trends and drivers, and describe the perceived emotional state of women who have experienced a miscarriage.

The authors obtained 291,443 Twitter posting on miscarriages and preterm births from January 2017 through December 2018. They applied Latent Dirichlet Allocation (LDA) to identify major topics in the data. LDA models are used for uncovering latent topics within a large set of text.

Words are assigned weights within particular topics given assumed probability distributions. The authors also used time series decomposition methods to assess temporal trends and identify major conversation drivers. In order to determine the emotional content of 7282 personal miscarriage disclosure tweets, the authors classified the tweets into six non-mutually exclusive categories: grief/sadness/depression, anger, relief, isolation, annoyance, and neutral. 

Based on their findings, the authors discovered that the topics in their data fell into eight groups: celebrity disclosures, Michelle Obama’s disclosure, politics, healthcare, preterm births, loss and anxiety, flu vaccine and ectopic pregnancies.

However, they noted that the political discussions around miscarriages were largely a result of a misunderstanding between abortions and miscarriages. Within miscarriage disclosures, grief and annoyance were the emotions most commonly expressed by users 50.6% (95%CI 49.1 – 52.2) and 16.2% (95% CI 15.2 to 17.3), respectively.

The authors also noted that postings increased with celebrity disclosures; celebrities were considered strong and brave for publicly discussing the topic and Michelle Obama’s disclosure generated substantial response. These celebrity disclosures also led to increased disclosures by women who had similar experiences.

For example, Obama’s disclosure resulted in a response approximately 3.6 times higher than the weekly average of postings in 2018. Postings also increased with pharmacists’ refusal of prescribed medications and with outrage over the high rate of preterm births in the United States.

Based on the results of their study, the authors believe that celebrity disclosures lead to the biggest increase in discussions of miscarriage on social media. They also believe that the results provide an insight of current public perceptions of miscarriage and illustrate how individuals use Twitter to share information and/or seek support.

A better understanding of how individuals who have experienced miscarriage use social media may be informative for clinicians who provide miscarriage care and treatment. 

Cesare, N., Oladeji, O., Ferryman, K., Wijaya, D., Hendricks, MuÃ±oz, K. D., Ward, A., & Nsoesie, E. O. (2020). Discussions of miscarriage and preterm births on Twitter. Paediatr. Perinat. Epidemiology. doi: 10.1111/ppe.12622