Standard approaches to menopause symptoms discount non-Western experiences

Understanding menopausal symptoms through a simple checklist has serious limitations, particularly within different ethnic groups or populations, according to a new study of British Pakistani women's beliefs about and experiences of menopause.

01 jun 2014--Dr Mwenza T. Blell of the University of Bristol interviewed 257 British Pakistani women aged 39-61 living in West Yorkshire and found that the standard checklist approach to studying menopause symptoms, which ignores women's understanding of their own experience, leaves researchers and clinicians with gaps in their knowledge of the 'true' symptoms of menopause.

Many previous studies into the menopause have relied on standardised checklists, such as the Blatt-Kupperman index and the Menopause Symptom Checklist, that were derived from the clinical experiences of women living in New York and Chicago in the mid-twentieth century and so focus on a distinctly Western bio-medical model of menopause.

Dr Blell's study explored the potential of using an alternative approach to better identify women's beliefs about the experiences attributable to menopause. Information was gathered through interviews and in informal settings in order to gain a more rounded understanding of the variety of beliefs within the British Pakistani community. The findings suggest a considerable discrepancy between women's understanding of menopausal symptoms and the assumptions made by previous research.

Dr Blell said: "The standardised checklists claim to tell the whole story of what menopause is when really we haven't let everyone be part of the conversation. By adopting a more open-ended approach, instead of the standard checklist mode, useful data can be captured that specifically reflects varied beliefs and understandings of the experience of the menopause."

For example, the use of a more open-ended approach highlighted that many of the study participants mentioned an increase in the size of the abdomen – which many standard checklists consider to be unrelated to menopause – as one of their symptoms.

This is an important finding as it suggests other populations may have a different understanding about the relationship between changes in body fat patterning and menopause that has not been fully explored in Western medicine due to the established assumptions surrounding the experience of menopause.

Dr Blell said: "The amazing thing is that this finding has come up before in other studies of women of South Asian origin and has just been swept under the carpet, assumed to be a mistaken belief women need to be educated out of, when that really isn't the case."

The research concludes that the symptom experience of non-Western groups has not had the opportunity to inform theoretical developments around menopause symptoms in the same way that the experience of Western groups has.

The understanding of other groups may indicate new directions for research such as the identification of change in body fat distribution, which seems to apply cross-culturally, and its relationship with the local understanding of menopause and its population-specific chronic disease risk.

More information: 'Menopausal symptoms among British Pakistani women: a critique of the standard checklist approach' by Mwenza T. Blell in Menopause, The Journal of the North American Menopause Society.

Provided by University of Bristol

Using progesterone for hot flashes shown safe for women's cardiovascular health

Treatment with progesterone, a naturally occurring hormone that has been shown to alleviate severe hot flashes and night sweats in post-menopausal women, poses little or no cardiovascular risk, according to a new study by the University of British Columbia and Vancouver Coastal Health.

18 jan 2014--The findings, published today in PLOS ONE, help to dispel a major impediment to widespread use of progesterone as a treatment for hot flashes and night sweats, said lead author Dr. Jerilynn C. Prior, a professor of endocrinology and the head of Centre for Menstrual Cycle and Ovulation Research.

For decades, women used a combination of synthetic estrogen and progesterone to reduce the frequency and severity of hot flashes and night sweats, as well as to prevent osteoporosis. Use of this so-called "hormone replacement therapy" dropped dramatically after 2002, when a large study revealed that it increased risk of heart disease, breast cancer, strokes and other serious conditions.

To evaluate the cardiovascular risk of using progesterone to alleviate symptoms, Prior and her collaborators recruited 110 healthy Vancouver-area women who had recently reached postmenopause (a year after the final menstruation), giving half of them oral progesterone and the others a placebo for three months.

The team used each woman's age and changes in blood pressure and cholesterol levels to calculate their 10-year risk of a heart attack and other blood vessel diseases, and found no difference between those taking progesterone and the control group. The study also found no significant difference on most other markers for cardiovascular disease.

"Many women are apprehensive about taking progesterone for hot flashes because of a belief that it carries the same – or even greater – risks than estrogen," Prior said. "We have already shown that the benefits of progesterone alone have been overlooked. This study demonstrates that progesterone's risks have been overblown."

Provided by University of British Columbia

Soy may alleviate hot flashes in menopause, large-scale study finds

In the most comprehensive study to date to examine the effects of soy on menopause, researchers have found that two daily servings of soy can reduce the frequency and severity of hot flashes by up to 26 percent, compared to a placebo.

7 april 2012--The findings, published in Menopause: The Journal of the North American Menopause Association, reviewed 19 previous studies that examined more than 1,200 women.

Although the effectiveness of soy in alleviating hot flashes has been inconclusive, with some studies suggesting soy to be beneficial and others suggesting otherwise, much of the discrepancy is due to small sample sizes and inconsistent methodology, according to the authors.

"When you combine them all, we've found the overall effect is still positive," said Melissa Melby, a medical anthropology professor at the University of Delaware and co-author of the study.

Examining the impact of soy isoflavones, chemicals found in soy that exert a mild estrogen-like effect, Melby and her colleagues found:

• Ingesting at least 54 milligrams of soy isoflavones daily for six weeks to a year reduces menopause hot flash frequency by 20.6 percent and severity by 26 percent, compared to a placebo.
• The total reduction in frequency and severity might be even greater due to the placebo effect.
• In longer duration studies (where women consumed soy isoflavones for 12 weeks or more), the decrease in hot flash frequency was approximately threefold greater than in shorter-duration trials.
• Isoflavone supplements with higher levels (at least 19 milligrams) of genistein, one of the two main types of isoflavones, were more than twice as effective at reducing hot flash frequency than lower amounts.

Melby called the genistein result particularly notable because the compound is the primary isoflavone in soybeans and soy foods, suggesting that, "Eating soy foods, or using supplements derived from whole soybeans, may work better for women."

Each gram of soy protein in soybeans and traditional soyfoods provides approximately 3.5 mg of isoflavones. Two glasses (16 oz) of soymilk or seven ounces of tofu provide approximately 50 mg of isoflavones.

The interest in soy and menopause stems from observational evidence in Japan, where researchers have found the low frequency of hot flashes in Japanese women might be attributed to the high soy consumption that often begins in utero and continues throughout their lifespan.

"Soy is probably more effective in these women," Melby said. "But if you're 50 and you've never touched soy, it's not too late. We've found that it still helps."

Provided by University of Delaware

Use of antidepressant associated with reduction in menopausal hot flashes

Women who were either in the transition to menopause or postmenopausal experienced a reduction in the frequency and severity of menopausal hot flashes with the use of the antidepressant medication escitalopram, compared to women who received placebo, according to a study in the January 19 issue of JAMA.

19 jan 2011--"Hormonal agents have been the predominant therapy for menopausal hot flashes, but their use decreased substantially following the shifts in risk-benefit ratios that were identified in the Women's Health Initiative Estrogen plus Progestin randomized controlled trial. However, no other treatments have U.S. Food and Drug Administration approval for menopausal hot flashes, and the efficacy of alternative pharmacologic and nonpharmacologic agents is inconclusive," according to background information in the article. Selective serotonin and serotonin norepinephrine reuptake inhibitors (SSRIs and SNRIs) have been investigated for hot flash treatment with mixed results. The SSRI escitalopram reduced hot flashes with minimal toxicities in 2 pilot investigations, but conclusions were limited by the small samples and unblinded treatment.

Ellen W. Freeman, Ph.D., of the University of Pennsylvania School of Medicine, Philadelphia, and colleagues evaluated the efficacy of escitalopram vs. placebo to reduce the frequency and severity of hot flashes in healthy women, and examined whether race, menopausal status, depressed mood, and anxiety were important modifiers of any observed effect. The multicenter, 8-week, randomized trial enrolled 205 women (95 African American; 102 white; 8 other) between July 2009 and June 2010. Women received 10 to 20 mg/d of escitalopram or a matching placebo for 8 weeks. The primary outcomes measured included frequency and severity of hot flashes assessed by prospective daily diaries at weeks 4 and 8.

The average frequency of hot flashes at the beginning of the study was 9.8 per day. Escitalopram was associated with a significant reduction in the frequency of hot flashes relative to placebo, adjusted for race, site, and baseline hot flash frequency. In the escitalopram group, average hot flash frequency at week 8 decreased to 5.26 hot flashes per day (47 percent decrease or an average of 4.6 fewer hot flashes per day than at the beginning of the study). In the placebo group, hot flash frequency decreased to 6.43 hot flashes per day (33 percent decrease or an average of 3.2 fewer hot flashes per day).

Clinical improvement at week 8 (decrease of 50 percent or more from baseline in hot flash frequency) was significantly greater in the escitalopram group than in the placebo group (55 percent vs. 36 percent). Also, use of escitalopram significantly reduced hot flash severity compared with placebo, adjusted for race, site, and baseline severity.

Race did not significantly modify the treatment effect. Overall discontinuation due to adverse events was 4 percent (7 in the active group, 2 in the placebo group).

"The 3-week postintervention follow-up demonstrated that hot flashes increased after cessation of escitalopram but not after cessation of placebo, providing further evidence of escitalopram's effects," the authors write.

The researchers note that although the decreases in hot flash frequency and severity appear modest, the study participants perceived these improvements as meaningful, as indicated by their reported satisfaction with treatment and desire to continue the treatment.

"Our findings suggest that among healthy women, 10 to 20 mg/d of escitalopram provides a nonhormonal, off-label option that is effective and well-tolerated in the management of menopausal hot flashes. Further studies are needed to directly compare the relative efficacy of SSRIs and SNRIs with hormone therapy in the treatment of menopause-related hot flashes."

More information: JAMA. 2011;305[3]:267-274.

Provided by JAMA and Archives Journals