Can the severity of menopausal symptoms be predicted?BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.d7664 (Published 08 February 2012) Cite this as: BMJ 2012;344:d7664
Women with severe menopausal symptoms may ask their doctor how long their symptoms, particularly hot flushes and night sweats, are likely to last. To date, doctors have been able to advise only that most women’s symptoms will resolve within a few years of their final menstrual period, but that a small proportion will have vasomotor symptoms into their 70s and 80s.1 This is of little comfort to the woman experiencing night sweats, sleep deprivation, and mood changes in her late 40s.
In the linked cohort study (doi:10.1136/bmj.e402), Mishra and Kuh used annual responses to the Medical Research Council National Survey of Health and Development from women around the years of their natural menopause to create symptom profiles and track their trajectories across the menopause.2 Will these observations enable clinicians to make better predictions about what patients should expect as they transit the menopause? The answer is yes, but only to a limited degree.
Mishra and Kuh took a data driven analytical approach and reaffirmed the classic symptom clusters that characterise the natural menopause: vasomotor symptoms, psychosocial symptoms, somatic symptoms, and sexual symptoms.3 4 They did this within the limitations of a community based observational study and excluded women who had undergone hysterectomy and menopausal hormone therapy. Exclusion of hormone therapy users may have affected some of the reported associations, because many highly symptomatic women would have been excluded. We also do not know what proportion of women were taking antidepressants. About 14% of women at midlife take antidepressants, most commonly selective serotonin reuptake inhibitors.5 In addition to their antidepressant effect, selective serotonin reuptake inhibitors can alleviate vasomotor symptoms,6 so that vasomotor symptoms and menopausal mood changes may have been masked in the women who took these drugs.
The study’s findings, in terms of symptom associations, are generally in line with previous reports. An interesting departure from the other large prospective study of the menopause transition, the Study of Women Across the Nation (SWAN), was the lack of an association between obesity and vasomotor symptoms. In SWAN, obesity was a key risk factor for vasomotor symptoms.7 This held true for adiposity assessed by bioelectrical impedance, computed tomography, and body mass index.8 However, neither study provides advice on what clinicians should tell obese patients about their likelihood of experiencing flushes and sweats.
The main messages from this new study are that women who have minimal vasomotor, psychological, somatic, or sexual discomfort symptoms around the time of their final menstrual period are unlikely to develop severe symptoms later, and that without intervention, the severity of somatic symptoms remains fairly static across the menopause. Of key clinical importance, women with moderate to severe menopausal symptoms are likely to have them for several years. As a group, women who had early severe vasomotor symptoms—onset of bothersome symptoms up to three years before the menopause—were more likely to experience a reduction in symptoms by their fourth postmenopausal year, whereas women with later onset severe vasomotor symptoms were more likely to have persistent symptoms. However, this model relies on accurately classifying women as having severe vasomotor symptoms at an early or late stage. This is a challenge in clinical practice because many women do not present until their symptoms become severe, at which point severity does not distinguish the groups, and recall of the time of symptom onset is not reliable.
Severe menopausal symptoms can be debilitating. With women increasingly delaying childbirth, many women are having to cope with sleep deprivation, irritability, anxiety, hot flushes, and sweats at a time when they are still responsible for young or adolescent children, as well as trying to maintain a sexual relationship and remain employed. Most women with severe menopausal symptoms seek relief, but despite all the investment in menopause related research, treatment options are increasingly limited. Several highly effective oestrogen and progestin treatments are no longer available as a result of commercial decisions and hormone therapy for menopausal women is now considered a taboo.9 Women globally are resorting to unconfirmed, often ineffective, and occasionally unsafe, alternatives.
Mishra and Kuh have suggested that over time menopausal symptom profiles may develop as a guidance tool for health professionals. The key outcome of their research is that women at menopause who are relatively asymptomatic are likely to remain so, but that symptomatic women are likely to experience symptoms for several years. We therefore need to refocus on what we have to offer symptomatic women to improve their quality of life.
Cite this as: BMJ 2012;344:d7664
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; SD has received research grants and honorariums from Bayer Pharma AG and Biosante USA, has been a consultant to Warner Chilcott, Biosante, and Servier Laboratories, and is a board member of the International Menopause Society; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.