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). 

Ben Schwartz

Articles

Menopause symptoms through the seasons

Risk factors for candidiasis

Breast density laws and patient knowledge

Can a healthier diet reduce menopause symptoms?