It is essential for the practicing physician to keep up-to-date with knowledge and reading medical journals is an important component in achieving this. As one of the many benefits of membership of the International Menopause Society (IMS), Menopause Live, an e-service for IMS members prepared by IMS members, is issued weekly, bringing a short abstract of a recently published study or review followed by a brief personal commentary. The opinions expressed in these commentaries are those of the commentary authors and are not necessarily supported by the IMS. The articles chosen for Menopause Live are selected by a search of the world literature on issues related to menopause medicine. In order to allow all readers of Climacteric to experience this service, some issues of Menopause Live are included in this section.
Ovarian conservation at the time of hysterectomy for benign disease: where is the pendulum now?
Steven R. Goldstein
Professor of Obstetrics and Gynecology, New York University School of Medicine, New York, New York, USA
Gaudet MM, Gapstur SM, Sun J, Teras LR, Campbell PT, Patel AV. Oophorectomy and hysterectomy and cancer incidence in the Cancer Prevention Study-II Nutrition Cohort. Obstet Gynecol 2014;123:1247–55
Ovarian conservation at the time of hysterectomy for benign disease has certainly become more common, mainly as the result of the landmark paper of Parker and colleaguesCitation1. This was a focal point in the beginning of a turnaround in the thinking of many clinicians. Now a new body of work examining a portion of this argument comes from the Cancer Prevention Study-II Nutrition Cohort published in Obstetrics & Gynecology by Gaudet and colleaguesCitation2.
It was a fairly straightforward cohort study involving over 66 000 postmenopausal women. In a median follow-up of just under 14 years, 8621 cancers were diagnosed (12.9% of the cohort). The authors compared hysterectomy with BSO at any age (1892 cases) with no hysterectomy (5586 cases) and found a statistically significant 10% reduction in all cancers. However, if the surgery was performed at age 55 or older, there was no reduction in overall cancer, yet hysterectomy with BSO at any age resulted in a 20% reduction in breast cancer that was statistically significant.
Finally, hysterectomy without BSO if performed in women at age 45 or younger, was associated with a 12% decrease in all cancer, and, at any age, with a 14% decrease in breast cancer, both of which were statistically significant. The authors concluded that this information should be used in counseling women undergoing hysterectomy.
Comment
A rallying cry for many of us with an interest in menopausal medicine has been and still is ‘one size does not fit all’. When I was a student another rallying cry was ‘no end organ, no end organ disease’. Virtually all women in the US over 45 and many over age 40 had routine BSO at the time of hysterectomy for benign disease. Certainly, the understanding of BRCA 1 and BRCA 2, as well as the existence of primary peritoneal carcinoma, underscores that that thought process is not always the case, although it is a minority of patients. Still, the wisdom and the data indicate that BSO will reduce subsequent ovarian cancer. However, hysterectomy, even with ovarian conservation, itself appears to reduce the risk of ovarian cancer by 10–40% – probably because abnormal appearing ovaries are usually removed at hysterectomyCitation3,Citation4 as well as the fact that almost one-third of women experience menopause within 2 years after hysterectomy, even with ovarian conservation.
What about Gaudet's epidemiologic findings about breast cancer? It is well known and not surprising that removing estrogen from premenopausal ovaries will be expected to and does reduce breast cancer risk. These findings of this reduction at any age and even without BSO deserve at least some hypothesis. Ovarian life is certainly diminished by hysterectomy, presumably due to a decrease in blood supply and, as mentioned above, one-third of such women are menopausal within 2 years.
In addition, postmenopausal ovaries continue to make androgens, which are converted into circulating estrogen, so a reduction in breast cancer, even when postmenopausal ovaries are removed, is not surprising.
Still, all of this must be balanced between the benefits of retaining ovaries, and this was the basis of this model first proposed by ParkerCitation1. In such a model, ovarian conservation reduced enough heart disease and hip fracture cases to more than offset new cases of ovarian and breast cancer. About half of all women older than 40 will die of heart diseaseCitation6 while less than 4% die of breast cancer and less than 1% die of ovarian cancerCitation7. So, if women undergoing hysterectomy for benign disease are roughly 50 times more likely to die from heart disease than ovarian cancer and 12 times more likely than breast cancer, then even a small protective effect of ovarian conservation on heart disease will outweigh the potential for ovarian or breast malignancies.
However, in my opinion, we still finish where we started … ‘one size does not fit all’. Each patient should be counseled and evaluated individually. A thorough discussion with each patient that takes in account her individual risk profile, but also the psychological weight she attaches to the various outcomes, is essential.
References
- Parker WH, Broder MS, Liu Z, Shoupe D, Farquhar C, Berek JS. Ovarian conservation at the time of hysterectomy for benign disease. Obstet Gynecol 2005;106:219–26
- Gaudet MM, Gapstur SM, Sun J, Teras LR, Campbell PT, Patel AV. Oophorectomy and hysterectomy and cancer incidence in the Cancer Prevention Study-II Nutrition Cohort. Obstet Gynecol 2014;123:1247–55
- Parazzini F, Negri E, La Vecchia C, Luchini L, Mezzopane R. Hysterectomy, oophorectomy, and subsequent ovarian cancer risk. Obstet Gynecol 1993;81:363–6
- Chiaffarino F, Parazzini F, Decarli A, et al. Hysterectomy with or without unilateral oophorectomy and risk of ovarian cancer. Gynecol Oncol 2005;97:318–22
- Siddle N, Sarrel P, Whitehead M. The effect of hysterectomy on the age at ovarian failure: identification of a subgroup of women with premature loss of ovarian function and literature review. Fertil Steril 1987;47:94–100
- National Cancer Institute, Statistical Research and Applications Branch. DevCan database: SEER 13 incidence and mortality, 2000–2002, release April 2005, based on the November 2004 submission. For more information see: http://www.srab.cancer.gov/devcan/
- American Heart Association. Heart disease and stroke statistics – 2005 update. Available at: http://www.americanheart.org./presenter.jhtml?identifier+1200026
Energy balance and mortality
Amos Pines
Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
George SM, Ballard-Barbash R, Manson JE, et al. Comparing indices of diet quality with chronic disease mortality risk in postmenopausal women in the Women's Health Initiative Observational Study: evidence to inform National Dietary Guidance. Am J Epidemiol 2014;180:616–25
Zheng C, Beresford SA, Van Horn L, et al. Simultaneous association of total energy consumption and activity-related energy expenditure with risks of cardiovascular disease, cancer, and diabetes among postmenopausal women. Am J Epidemiol 2014;180:526–35
The American Journal of Epidemiology recently published online two studies that are based on data from the Women’s Health Initiative Observational Study (WHIOS). The first one creates a platform for the upcoming national US dietary recommendationsCitation1. Four commonly used diet quality indices – the Healthy Eating Index 2010 (HEI), the Alternative Healthy Eating Index 2010 (AHEI), the Alternate Mediterranean Diet (aMED), and the Dietary Approaches to Stop Hypertension (DASH) – are known to be related to the risks of death from all causes, cardiovascular disease (CVD), and cancer among postmenopausal women. The WHIOS prospective cohort study included 63 805 participants (from 1993 to 2010) who completed a food frequency questionnaire at enrolment, which collected data on frequency of intake and portion sizes for 122 foods and food groups during the past 3 months. Multivariate hazard ratios and 95% confidence intervals for death associated with increasing quintiles of diet quality index scores were estimated. During 12.9 years of follow-up, 5692 deaths occurred, including 1483 from CVD and 2384 from cancer. Across indices and after adjustment for multiple covariates, having better diet quality (as assessed by HEI, AHEI, aMED, and DASH scores) was associated with statistically significant 18–26% lower all-cause and CVD mortality risk. Higher HEI, aMED, and DASH (but not AHEI) scores were associated with a statistically significant 20–23% lower risk of cancer death. These results suggest that postmenopausal women consuming a diet in line with a priori diet quality indices have a lower risk of death from chronic disease.
The second study looked into the energy balance rather than the diet alone, namely calculating the inflow and outflow of calories from one’s bodyCitation2. Data were abstracted from the whole cohort in regard to dietary habits (frequency of intake and portion sizes for 122 foods and food groups during the past 3 months) and physical activity (frequency and duration of walking activity outside the home, as well as other mild, moderate, or strenuous recreational activities, expressed as MET-hour per week). A smaller subgroup was included in the Nutrition and Physical Activity Assessment Study (NPAAS), where several additional metabolic parameters were collected and analyzed. Overall, calibrated energy consumption was found to be positively related, and activity-related energy expenditure (AREE) inversely related to the risks of various CVD, cancers, and diabetes. Estimated hazard ratios for 20% increases in total energy consumption and AREE, respectively, were as follows: 1.49 (95% CI 1.18–1.88) and 0.80 (95% CI 0.69–0.92) for total CVD; 1.43 (95% CI 1.17–1.73) and 0.84 (95% CI 0.73–0.96) for total invasive cancer; and 4.17 (95% CI 2.68–6.49) and 0.60 (95% CI 0.44–0.83) for diabetes. Simultaneous total energy consumption and AREE changes of these magnitudes are associated with an approximately 50% lower risk of major CVD and cancers and an approximately 7-fold lower diabetes incidence.
Comment
It is very well known that healthy diet and physical activity are associated with reduced mortality (total, cardiovascular or cancer). In recent years, the term ‘diet quality’ was introduced and defined, and many studies investigated the significance of various diet quality scores on health. However, because of methodological, epidemiological reasons, there was not yet enough evidence to provide a definitive recommendation related to diet quality and health outcomes. Nevertheless, all scores emphasize intakes of fruit, vegetables, whole grains, and plants or plant-based proteins; most scores emphasize consumption of nuts, polyunsaturated and monounsaturated fats over saturated fats, moderate use of alcohol, as well as low intake of red and processed meat. Low salt intake has a value in regard to hypertension and its cardiovascular consequences. In the study of George and colleaguesCitation1, diet quality seemed to be a weaker and less significant predictor of death at high levels of body mass index (BMI), especially for BMI values of ≥ 30 kg/m2. Furthermore, among women with a waist circumference > 88 cm, associations between indices and CVD and cancer mortality risk were null. In the study by Zheng and colleaguesCitation2, most of the hazard ratio estimates became quite unstable when BMI was added to the disease risk model. Thus, both studies raised an interesting question on the role of BMI as an independent prognostic parameter in such risk estimation models. In other words, should we consider BMI measured at a pre-specified time point (i.e. enrolment to a study) as an independent confounder or that it is actually just a reflection of an individual’s total energy balance state that adds nothing if we already know the exact figures for energy consumption and energy expenditure. The WHIOS investigators believe that variations in BMI arise substantially from variations in energy consumption and physical activity patterns over time. They presume that there is a limited incremental signal from the self-reported energy consumption and AREE data beyond that reflected in BMI. However, they noted that exclusion of BMI from the disease risk models cannot be fully justified with available data.
References
- George SM, Ballard-Barbash R, Manson JE, et al. Comparing indices of diet quality with chronic disease mortality risk in postmenopausal women in the Women's Health Initiative Observational Study: evidence to inform National Dietary Guidance. Am J Epidemiol 2014;180:616–25
- Zheng C, Beresford SA, Van Horn L, et al. Simultaneous association of total energy consumption and activity-related energy expenditure with risks of cardiovascular disease, cancer, and diabetes among postmenopausal women. Am J Epidemiol 2014;180:526–35
The contraceptive needs of the perimenopausal woman
Risto Erkkola
Department of Obstetrics and Gynecology, University Central Hospital, Turku, Finland
Hardman SM, Gebbie AE. The contraception needs of the perimenopausal woman. Best Practice Res Clin Obstet Gynaecol 2014;28:903–15
In their recent review, Hardman and Gebbie provide a great service to colleagues who face questions on the need for contraception in the perimenopauseCitation1. The manuscript is very practical, giving a little background and mainly focusing on various options for contraception, and their advantages or side-effects. The authors also present an algorithm for a multitude of perimenopausal situations. Here is the review Abstract:
‘Perimenopausal women have low fertility but must still be advised to use contraception until natural sterility is reached if they are sexually active. Patterns of contraceptive use vary in different countries world-wide. Long-acting, reversible contraceptive methods offer reliable contraception that may be an alternative to sterilization. Hormonal methods confer significant non-contraceptive benefits, and each individual woman should weigh up the benefits and risks of a particular method. No method of contraception is contraindicated by age alone, although combined hormonal contraception and injectable progestogens are not recommended for women over the age of 50 years. The intrauterine system has particular advantages as a low-dose method of effective hormonal contraception, which also offers control of menstrual dysfunction and endometrial protection in women requiring estrogen replacement. Condoms are recommended for personal protection against sexually transmitted infections in new relationships. Standard hormone replacement therapy is not a method of contraception.‘
Comment
The main question to answer is, ‘When can a perimenopausal woman stop taking contraception’. The authors, correctly, state that a spontaneous pregnancy in women over 50 years old is rare. They also explain the UK principles for perimenopausal contraception. I believe that the limit at which to discontinue the progestogen-only pill, barrier methods or non-hormonal intrauterine device of 55 years is rather high. My advice is to stop using these methods already at the age of 52 years, but it is certainly a matter of personal opinion.
Non-reversible, female sterilization is still the most important contraceptive method in many countries. Table 2 in the review by Hardman and Gebbie shows data from the Population Reference Bureau giving sterilization figures for married women aged 15–49 years in various countries; hence, the frequency of use by perimenopausal women must generally be remarkably high. (As to Japan, the figure of 43% is an obvious mistake; when I checked the same source, the correct figure is 3%). Therefore, regarding perimenopausal contraception, the statistics should preferably give data for women of 40–49 years. For example, in the USA, since 2002, about half of women aged 40–49 years have undergone sterilizationCitation2. Skewing this picture are the high numbers of hysterectomies in relation to sterilizations in many countries. In some countries, for tradition or religious reasons, hysterectomy may unfortunately be used for contraceptive purposes. In the USA, about 600 000 hysterectomies, 500 000 female sterilizations and 700 000 vasectomies are performed annually. In the UK, a little less than 30 000 hysterectomies are performed annually, while in England the annual number of sterilizations are decreasing and are in the range of 7500 per year. Hysterectomized women are not in need of contraception, but sometimes they may be included in statistics of married women who do not use contraception. During the last decade, the number of sterilizations has decreased in many countries (UK 74%, Finland 70%). It is obvious that the increased use of intrauterine systems may be an important factor behind this decrease, but it is very difficult to confirm this quantitatively.
The most useful sections of Hardman and Gebbie’s review are the chapters dealing with the benefits and side-effects of various contraceptive methods. The use of combined hormonal contraception until the age of 50 years is acceptable if the user has good general health with no contraindications, including smoking and being overweight. In all cases, low-dose combined oral contraceptives should be prescribed (preferably with 10–20 μg of ethinylestradiol), since the risks of venous thromboembolism increase with increasing doses of ethinylestradiolCitation3. Also the use of long cycles of 3–6–12 months could be consideredCitation4. Still with these doses of ethinylestradiol, the estrogenic potency is remarkable higher than when using standard oral doses of estradiol in hormone replacement therapy (HRT). Ethinylestradiol may, in fact, be ten times more potent than estradiol or conjugated estrogensCitation5.
The section focusing on progestin-only contraception correctly emphasizes the safety of these methods in comparison to combined hormonal contraception. Further, when progestin-only contraception is used, the symptoms of the climacteric become detectable once they occur. When selecting the mini-pill, one has to keep in mind that only the pill containing 75 μg of desogestrel inhibits ovulation efficiently and offers the most efficient contraceptionCitation6. The great benefits to the user of the intrauterine system (IUS) are well presented. Once menopausal symptoms start, the IUS offers an option to continue using it as a part of HRT. If a woman has an IUS (Mirena), releasing 20 μg levonorgestrel daily for contraception, I advice her to continue its use up to 7 years [7]. With Mirena in situ, she can add any type of systemic estrogen replacement therapy, if there is a need to treat climacteric symptoms, generally without bleeding disturbances. The newer IUS releasing 14 μg of levonorgestrel (Jaydess) has only come to the market recently, but I believe that the older IUS will be preferred for perimenopausal contraception.
References
- Hardman SM, Gebbie AE. The contraception needs of the perimenopausal woman. Best Practice Res Clin Obstet Gynaecol 2014;28:903–15
- Jones J, Mosher W, Daniels K. Division of Vital Statistics. Current contraceptive use in the United States, 2006–2010, and Changes in patterns of use since 1995. National Health Statistic Reports, Number 60, 2012 October 18
- Lidegaard Ø, Edström B, Kreiner S. Oral contraceptives and venous thromboembolism: five-year national case-control study. Contraception 2002;65:187–96
- Edelman AB, Gallo MF, Jensen JT, Nichols MD, Grimes DA. Continuous or extended cycle versus cyclic use of combined oral contraceptives for contraception. Cochrane Database System Rev 2005(3), Art. No: CD004695
- Mandel FP, Geola FL, Lu JK, et al. Biologic effects of various doses of ethinyl estradiol in postmenopausal women. Obstet Gynecol 1982;59:673–9
- Erkkola R, Landgren BM. Role of progestins in contraception. Acta Obstet Gynecol Scand 2005;84:207–16
- Erkkola R. Recent advances in hormonal contraception. Curr Opin Obstet Gynecol 2007;19:547–53
Prevalence of urinary incontinence according to hysterectomy status in the WHI observational study
Tommaso Simoncini
Department of Clinical and Experimental Medicine, University of Pisa, Italy
Kudish BI, Shveiky D, Gutman RE, et al. Hysterectomy and urinary incontinence in postmenopausal women. Int Urogynecol J 2014 Jun 26. Epub ahead of print
Urinary incontinence (UI) is a common and frequently overlooked problem in aging womenCitation1,Citation2. Leaking urine limits daily and working activities, social interaction and sexual intimacy, and therefore severely disrupts quality of lifeCitation3. The relationship between menopause, aging and hysterectomy is complex and still unresolved. While it is clinically appreciated that all these factors have some impact on the frequency and severity of urinary incontinence, epidemiologic evidence is contradictory and a clear demonstration of how these factors interact in favoring incontinence is not available.
Removal of the uterus is one of the most frequent surgical procedures performed in women, and appropriate counseling related to future risks, particularly that of UI or pelvic organ prolapse (POP), is currently based on feeble evidence.
The Women's Health Initiative Observational Study (WHI OS) has explored this issue, assessing prevalence, at baseline and after a 3-year time interval, of different forms of UI in 92 093 postmenopausal women between 50 and 80 years (53 569 with the uterus in place, 38 524 hysterectomized)Citation4. This is the largest cohort of women in which information on UI has ever been gathered.
The main finding of the study is that prior removal of the uterus is associated with a slightly higher prevalence of UI at baseline (odds ratio (OR) range 1.09–1.69, p < 0.0001) and over the 3-year study period (OR 1.18–1.20, p = 0.0002). All types of UI (stress UI, urge UI or mixed UI) were similarly related to previous hysterectomy. In parallel, no statistical association was found with removal or conservation of the ovaries or with use of menopausal hormone therapy.
Comment
An inherent bias in all studies looking at urinary incontinence lies in the definition of the problem itself. The WHI OS assessed UI using very strict definitions. Women who had ever involuntarily leaked even a very small amount of urine were categorized as having UI, whereas most scientific societies define UI as a condition where urinary leakage determines a clinical complaintCitation5. This explains the incredibly high prevalence of UI found in the study (66.5% of the population was categorized as incontinent) that does not correspond to clinical experience. Nonetheless, the study correctly identifies the expected association between known risk factors for UI, such as multiparity and obesity, with actual prevalence of UI, which supports the validity of the experimental setting.
Prior removal of the uterus is associated with an increased prevalence of UI that is similar to that linked to having had one or more children (OR 1.19–1.32, p < 0.0001) or to being overweight and obese (OR 1.24–1.57, p < 0001). In all cases, hysterectomized women differed from women with a conserved uterus only for the prevalence of medium or severe forms of UI, while only subtle differences were seen for very mild forms of UI, which makes sense in many ways.
The finding of a null effect of bilateral oophorectomy or of postmenopausal hormonal supplementation on UI is consistent with clinical practice and the discrepancy with previous studies, including the interventional part of the WHI trialCitation6 or the available meta-analysesCitation7 should not surprise, since the relationship between hormonal status and UI has so far only been assessed as a secondary outcome in settings that were not technically appropriate to diagnose it correctly. Thus these results have been considered with caution by urogynecologists.
The large population enrolled in the trial allowed the picking up of small differences in the prevalence of UI based on the presence or absence of the uterus. However, important limitations in data collection do not allow the use of this study as evidence that hysterectomy increases the risk of UI.
There are different hypothetical reasons why surgical removal of the uterus could facilitate UICitation3. Lesions to the hypogastric nerve bundles during dissection of the ureters or the section of the uterosacral ligaments may result in pelvic floor muscle dysfunction. Equally, interruption of the continuity between the fascial support of the anterior and apical compartment may destabilize the pelvic floor. Vascular compromise due to uterine and/or superior vescical artery occlusion may also contribute. All these potentially harmful maneuvers are avoided by supracervical hysterectomy, which many gynecologists prefer for this reason. Information on possible differences in UI prevalence based on removal or conservation of the uterine cervix would have provided stronger evidence to dissect the relationship between surgical pelvic anatomic disruption and urinary incontinence. Unfortunately, this information is not available in the WHI OS.
Another major limitation of the study lies in the absence of any information on the route of hysterectomy or on the prevalence of prior UI or POP surgery. This is a major pitfall, since it is estimated that around 30% of postmenopausal women have a clinically evident pelvic organ prolapseCitation8, and a significant part of these women also have clinical or latent UI. In many (if not most) cases, these women receive a hysterectomy at the time of pelvic floor reconstruction. Thus, the number of women with pelvic floor defects that preceded (and not followed) hysterectomy should be assessed to be able to infer any conclusion on the role of hysterectomy on UI.
While the limitations of the study do not allow any information to be drawn on the causal role of hysterectomy in the development of UI, I agree with the authors’ conclusion that the suggestion of an increased risk of UI in women who undergo hysterectomy may be helpful as clinicians counsel their patients about the potential risks of this procedure. Too many uteri are still being removed world-wide for questionable indications. Every gynecologist should be aware that hysterectomy might have adverse consequences, so that optimal clinical judgement in surgery is taken. On the other side, the absence of any effect of hormone therapy on UI in this study clarifies how some of the available trials were simply not suitable to address the impact of hormonal interventions on urinary incontinence, and that they have been largely over-interpreted.
References
- Melville JL, Katon W, Delaney K, Newton K. Urinary incontinence in US women: a population-based study. Arch Intern Med 2005;165:537–42
- Irwin DE, Milsom I, Hunskaar S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006;50:1306–14
- Mannella P, Palla G, Bellini M, Simoncini T. The female pelvic floor through midlife and aging. Maturitas 2013;76:230–4
- Kudish BI, Shveiky D, Gutman RE, et al. Hysterectomy and urinary incontinence in postmenopausal women. Int Urogynecol J 2014 Jun 26. Epub ahead of print
- Haylen BT, de Ridder D, Freeman RM, et al.. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010;29: 4–20
- Hendrix SL, Cochrane BB, Nygaard IE, et al. Effects of estrogen with and without progestin on urinary incontinence. JAMA 2005;293:935–48
- Ismail SI, Bain C, Hagen S. Oestrogens for treatment or prevention of pelvic organ prolapse in postmenopausal women. Cochrane Database Syst Rev 2010(9): CD007063
- Handa VL, Garrett E, Hendrix S, Gold E, Robbins J. Progression and remission of pelvic organ prolapse: a longitudinal study of menopausal women. Am J Obstet Gynecol 2004;190:27–32
- Jackson KL, Janssen I, Appelhans BM, et al. Body image satisfaction and depression in midlife women: the Study of Women’s Health Across the Nation (SWAN). Arch Womens Ment Health 2014;17:177–87
Body image and depression
Amos Pines
Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Jackson KL, Janssen I, Appelhans BM, et al. Body image satisfaction and depression in midlife women: the Study of Women’s Health Across the Nation (SWAN). Arch Womens Ment Health 2014;17:177–87
With aging, women’s bodies undergo changes that can affect body image perception, yet little is known about body image in midlife. In a subset of the SWAN cohort from Chicago, the associations between body image and depressive symptoms were investigatedCitation1. Body image was measured using the Stunkard Adult Female Figure Rating Scale, and a clinically significant level of depressive symptoms was defined as a Center for Epidemiologic Studies Depression Scale (CES-D) score of ≥ 16 (total n = 405; depression n = 63 (15.6%)). Differences between perceived actual, perceived ideal and actual body size and responses to questions concerning weight satisfaction and attractiveness were examined using logistic regression for associations with a CES-D score of ≥ 16. Women with body image dissatisfaction (odds ratio, OR = 1.91; p = 0.04) or who perceived themselves as ‘unattractive’ (OR 7.74; p < 0.01) had higher odds of CES-D of ≥ 16. There was no significant difference by race, and results were not confounded by body mass index. To conclude, midlife women with poor body image may be more likely to have clinically significant levels of depressive symptoms.
Comment
Body image was defined by Slade as ‘the picture we have in our minds of the size, shape and form of our bodies; and to our feelings concerning these characteristics and our constituent body parts’Citation2. The scope of body image may also include one’s perception of one’s visual appearance, esthetics and sexual attractiveness. Body image is distorted in anorexia nervosa, but this is part of the psychiatric features of the disease. Disturbances in self-body image may accompany disease situations such as cancer or disfiguration, but my commentary will not discuss this type of issue. Many studies have looked into the potential emotional consequences of dissatisfaction with one’s physical appearance in the healthy population, a situation which is more common in women and in aging persons. For example, dissatisfaction with body appearance or image may lead to depression. Overweight and obesity may be the trigger for potential problematic body image and ensuing depressionCitation3, although this may not be the rule, as many fat persons are happy with what they see in their mirror. In fact, the study by Jackson and colleaguesCitation1 actually showed that body mass index was not a confounder for depression related to body image.
As mentioned before, studies on body image and related depression in menopausal women are very scarce. A PubMed search using the key words ‘depression, menopause and body image’ yielded publications that mainly focus on breast or genital aspects rather than on the holistic perception of body size and shape. The association of body size from childhood to age 40 with depression in postmenopausal women was recorded in the French E3N studyCitation4. Participants reported birth characteristics and silhouettes matching theirs at age 8, at puberty, at 20–25, and 35–40 years (n = 41 144). Depression was assessed by CES-D and split into new-onset and recurrent depression according to women’s history of psychological disorder. Low or high birth weights were associated with risk of depression. A large body size at age 8 and a large body size over the life course were both associated with the risk of new-onset depression specifically, while women with a large increase in body size at puberty were at risk of recurrent depression. Largest body sizes at 20–25 or 35–40 years were associated with both the risk of new-onset and recurrent depression, especially in normal weight women. However, a lean silhouette at 35–40 years was associated with the risk of recurrent depression only. Women with a large body size from childhood to adulthood might be at higher risk of new-onset postmenopausal depression, while leanness in adulthood could be associated with a higher risk of recurrent depression.
A study from Korea, of which the abstract was the only section written in English, used the five-item General Health Short Form (SF-36) Health Survey Questionnaire to measure health perceptionCitation5. Body image was measured by the Semantic Differential scale, and CES-D indicated the level of depression. Participants included 182 perimenopausal and postmenopausal women who had not received hormonal replacement therapy. In a stepwise regression analysis, 21.7% of variance in depression was attributed to perceived health and body image in the postmenopausal women. However, in perimenopausal women, perceived health and sexual function explained 34.5% of variance in depression. In another study from Austria (51 patients, aged 43–63), about half of women were not satisfied with their physical appearanceCitation6. They filled a symptom questionnaire (0–3 scale) which included the items ‘depression’ and ‘feeling misery’, and a self-esteem score was recorded as well. A significant connection was found between high self-esteem and high satisfaction with one's own body. Women who were satisfied with their physical appearance experienced fewer troublesome menopausal symptoms. Specifically, significant differences between women with high and low self-esteem could be ascertained in regard to self-reported ‘depression’.
Body image is a combination of what we see, what we feel and what we expect, with some additional impact from the signals we receive from surrounding people. Any dissatisfaction may lead to, or contribute to, depression. Ironically, treatment of depression with SSRIs and SNRIs may be associated with weight gain and may jeopardize body image.
References
- Jackson KL, Janssen I, Appelhans BM, et al. Body image satisfaction and depression in midlife women: the Study of Women’s Health Across the Nation (SWAN). Arch Womens Ment Health 2014;17:177–87
- Slade PD. What is body image? Behav Res Ther 1994;32: 497–502
- Preiss K, Brennan L, Clarke D. A systematic review of variables associated with the relationship between obesity and depression. Obes Rev 2013;14:906–18
- Perquier F1, Lasfargues A, Mesrine S, Clavel-Chapelon F, Fagherazzi G. Body-size throughout life and risk of depression in postmenopausal women: Findings from the E3N cohort. Obesity (Silver Spring) 2014 Jun 4. Epub ahead of print
- Kim JH, Moon HS. [Health perception, body image, sexual function and depression in menopausal women according to menopausal stages]. (Korean). Taehan Kanho Hakhoe Chi 2006;36:449–56
- Bloch A. Self-awareness during the menopause. Maturitas 2002;41:61–8
Preventive medicine: GYNs or GPs?
Amos Pines
Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Stormo AR, Saraiya M, Hing E, Henderson JT, Sawaya GF. Women’s clinical preventive services in the United States: who is doing what? JAMA Intern Med 2014;174:1512–14
From 2007 to 2010, an average of 281 406 600 medical visits occurred annually in the USA according to data from medical records of national representative visits to office-based physicians and visits to outpatient departments. The current study analyzed 63 million preventive care visits, of which 44% were visits to OB/GYNs and 56% were to primary-care doctorsCitation1. Women 50 years or older had a higher percentage of preventive care visits to general practitioners (GPs) than younger women: for age 30–49 years, 55% of women saw OB/GYNs vs. 45% who saw GPs; for age 50–64 years, 38% vs. 63%; and for > 65 years old, 19% vs. 81%, respectively (p < 0.001). The OB/GYN visits focused predominantly on reproductive health-related services, whereas visits to GPs provided a wider range of services and higher volume of counseling, even among women of child-bearing age. Women who saw OB/GYNs were more likely to get screened for cervical and breast cancers, Chlamydia and osteoporosis, compared to those who went to primary-care doctors. Contrarily, those who went to primary-care doctors were more likely to get screened for colon cancer, high cholesterol and diabetes and to be counseled about diet, exercise and obesity. To note that the majority of the total medical visits (about 82% of visits to OB/GYNs and 74% of visits to GPs) did not report on counseling. Because physicians have had little to no incentive in most payment systems to document counseling performed during clinic appointments, counseling services may have been underestimated.
Comment
The results of the above study clearly point at a known and rational fact that gynecologists limit their engagement with preventive medicine to OB/GYN-relevant issues during consultations. Because young to midlife women tend to visit OB/GYNs more often than GPs, it seems necessary to preach for a more active involvement of OB/GYNs in a wider range of preventive measures. Preventive medicine for middle-aged women has been one of the main educational goals of the International Menopause Society (IMS), as expressed in the latest version of the IMS recommendations on menopausal hormone therapy and preventive strategies for midlife healthCitation2. Commitment of OB/GYNs to discuss preventive medicine with their patients should be based on two components. The first is obtaining the knowhow on what to do and how to implement it in routine clinical work. Various relevant guidelines and recommendations probably make this easier. The second is the compensation any physician should receive for giving time to discuss these issues with his/her patients. If this factor is not properly settled with the health maintenance organizations, the incentive to do it will obviously be low. Nevertheless, the IMS believes that being a menopause specialist dictates a more holistic approach. Although most IMS members are either OB/GYNs or reproductive endocrinologists, they should integrate their traditional role in the field of gynecology into another mode of operation that includes screening and counselling menopausal women on prevention of the chronic diseases of aging.
References
- Stormo AR, Saraiya M, Hing E, Henderson JT, Sawaya GF. Women’s clinical preventive services in the United States: who is doing what? JAMA Intern Med 2014;174:1512–14
- de Villiers TJ, Pines A, Panay N, et al. Updated 2013 International Menopause Society recommendations on menopausal hormone therapy and preventive strategies for midlife health. Climacteric 2013;16:316–37