Blog of the Society for Menstrual Cycle Research

SMCR 2013: By the Numbers

May 13th, 2013 by Chris Bobel

With apologies to the Harpers Index, we present you with a snapshot of the upcoming 20th Biennial Society for Menstrual Cycle Research Conference held at Manhattan Marymount College, June 6-8, 2013.

 

Number of presenters on the program: 125

 

Number of these that are students: 32

 

Activists, artists, and clinicians: 32

 

That are Gloria Steinem, world-renowned feminist pioneer: 1

 

Number of Google hits for her iconic essay “If Men Could Menstruate”: 8,980

 

For  the words “Kim Kardashian Pregnancy Weight Gain”: 22, 2000

 

Number of countries represented by all presenters: 12

 

Other than the U.S: 11

 

Number of presentations that are research projects: 60

 

Workshops: 7

 

Posters: 17

 

Plenaries: 4

 

Performance Pieces: 2

 

Poetry Slams: 1

 

Number of scholarship requests made by conference attendees: 39

 

In 2011: 6

 

Number of presentations focused on MENOPAUSE: 13

 

On MENARCHE: 17

 

Number of presentation abstracts that mention the words LIBERATE, FREEDOM, JUSTICE or CHALLENGE: 18

 

That mention the words SHAME, SUFFER and PAIN: 15

 

Red Riding Hood: 1

 

The film Carrie: 1

 

Pharmaceuticals: 4

 

Education: 10

 

Gender, Men, Women, and/or Girls, : 133

 

Number of Days Before the Conference: 24

 

Days left until you can register: 24 (you can register on site)

Years you will have to wait for the next SMCR conference : 2

 

Creative Commons 2.0 // WordItOut.com

 

Join Us! Be Counted!

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Posted in New Research | 5 Comments »

Working Mothers

April 29th, 2013 by Paula Derry

“Working Mother and Son” Photo by Russell Chopping // Creative Commons 2.0
http://www.flickr.com/photos/russellchopping/3501039851/

Research is often reported as though it is news, as though the most recent article is the best and research that was not published this year is somehow not as interesting or is out-of-date. I recently dug out some articles I wrote about the psychology of working mothers that were based on a study I did in the mid-1980s. I interviewed psychotherapists about how being a mother had affected their professional lives. This study was qualitative research. I offer the results as interesting ideas, not as definitive conclusions.  Some points I think are still interesting:

  1. Overall, about 64% of the 25 mothers I interviewed opted for part-time work; when children were preschoolers, this was about 78%. Psychotherapists, unlike many other women, have the option of working part-time:  part-time jobs, especially for therapists who see clients in private practice, are the same jobs that a full-time worker would have.
  2. I compared the mothers with another group of 19 therapists who did not have children. The non-mothers tended to work full time (about 90%).  However, both groups of women were deeply and apparently equally committed to their jobs.
  3. Many of the mothers (about 60%) felt that work was not as important to them as it would be if they were childless. However, this did not mean that work was unimportant. For most women, it only meant that they now had two strong priorities instead of one.
  4. Almost all of the mothers (88%) felt that having children affected their work as psychotherapists by deepening their empathy, understanding, or emotional knowledge about parents and parenting. This was not simply intellectual, that they knew more facts, although this was also true. It was experiential understanding, a different experience of what facts mean. This was so even though their profession involves helping clients understand their parents or their parenting, and was reported whether they had a child while in graduate school or after they had worked for many years.
  5. One aspect of this increased knowledge was an experience of how passionate an experience mothering is. Another aspect was a less idealized view of both parents and children, and greater tendency to see the experiences of parents and children from their own perspectives. For example, in addition to seeing parents in terms of how their children felt (e.g., that the parent was mean or rejecting), the therapists might perceive more clearly where parents were coming from or that children might misunderstand or be unreasonable.
  6. This greater ability to see the position of both parents and children more clearly is what a psychologist might call psychological individuation. That is, the stereotype is that mothers are or should be all-giving, selfless, thinking only about their children. However, these mothers seemed to grow more realistic, clear about and accepting of who children as well as parents are. As I said in one paper:  “Interconnectedness, or intimacy, requires a sense of oneself and the other as separate but related. (If children really do lack a sense of this separation, that is no reason why their parents, who are adults, should identify with their perspective.)”

References

Derry, P.S. (1994) Motherhood and the importance of professional identity to psychotherapists. Women & Therapy, 15, 149-163.
Derry, P.S. (1992) Motherhood and the clinician/mother’s view of parent and child. In  J. Chrisler & D. Howard (Eds.), New directions in feminist psychology:  Scholarship/Practice/Research. New York: Springer.

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Posted in Communication, Motherhood, New Research | 1 Comment »

Understanding Research: Media Reports of Research

April 1st, 2013 by Paula Derry

The Huffington Post published a story last week titled “Last Menstrual Cycle Could Be Predicted With New Model”. The story stated that a research study had just been published about a new method for predicting the end of menstruation in which researchers developed a formula for using the levels of two hormones, estradiol and follicle stimulating hormone (abbreviated FSH), to make this estimate. This “new method for predicting a woman’s last menstrual cycle could have broader implications for menopausal women’s health”. Since “in the year leading up to the final menstrual period, women are met with faster bone loss and a greater risk of heart disease”, if the end of menstruation could be predicted, medical monitoring and interventions would become possibilities. The research was also reported as news on the medical website Medscape.

Research results are often reported as news stories, as though these results are facts. However, “dog bites man” and “man bites dog” are facts, but research results are not facts in the same way. They are “evidence” that most often must be evaluated, understood, and put into the context of many other studies. There could very well be disagreement about whether a study’s methods really did accurately make a point, or whether the conclusions the researchers drew from their work were justified. Sadly, it happens all too often that research does not make the point that the headlines claim.

Photo by clarita // morgueFile

Here, we have a study by a respected researcher at a major institution, UCLA, funded by a grant from the National Institutes of Health and other prestigious grantors. However, we do not have the information with which to understand what the researchers actually did. UCLA issued a press release which states that the study “suggests” a way to predict the final period. The Medscape article states that “A new model MAY [my emphasis] help physicians determine how far a woman is from her final menstrual period”.

Suggests? May? I have no idea what this means. As a researcher, I want to look at the published article to see what was actually done. However, the publisher does not make a free copy of the article available. Anyone who wants to look at the published article—a researcher or an informed consumer—would need to pay the publisher $37.00 to access this 20-page article for one day. Predicting the last menstrual period from hormone levels, which is what is claimed, is something other researchers have tried but failed to do, so how these researchers worked with the difficult problems is an important question.

Assume for a moment that the model was a big success, and it did predict the last menstrual period. The idea that this has important implications for women’s health is stated as though it were another fact. However, this is not a fact; this is a complicated and controversial area. Bone density does decrease in the years surrounding menopause, but professionals disagree about how big an effect this has on bone disease. For example, current guidelines recommend testing bone density beginning at age 65, 15 years after the average age of menopause, because this is when the fracture rate has significantly increased. Heart disease risk factors may increase on average in the years surrounding menopause, but professionals disagree about whether menopause is important compared with other factors associated with aging.

Assume for a moment that bone disease really is an important negative health consequence of menopause. Whether interventions would be found that must be started in the year or two before menopause is another speculation. Such interventions might be found or might not. Predicting the last menstrual period, even if the claim is valid that a method to do so has been found, is a long way from preventing disease.

The medical satirist Andrew Vickers wrote an article called “News On Cancer Drug Fails to Raise False Hopes”, which begins: “A recent article on a novel cancer therapy has rocked the newspaper industry by giving a balanced and cautious review of an early-phase trial”. Satirists make extreme statements to make a point. Media reports are often written to sound definite and to portray a study as really important. A cautious approach to medical news is to withhold judgment unless the methodology of the study is clear and the context of the study is understood.

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Posted in Health Care, Hormones, Media, Menopause, New Research | No Comments »

Bored by Research Updates and News Headlines

January 3rd, 2013 by Heather Dillaway

"— Allons, à ton tour, ma petite... vas-y ! — Non, Papa ; si on devient si vilaine que ça en un an, j'aime mieux pas entrer".

By Achille Lemot (1846-1909) [Public domain], via Wikimedia Commons

Sometimes I think biomedical researchers and media spokespersons are just searching to find the pathology in our lives. Not that we don’t know this already, especially when it comes to women’s health. Because of how medicalization works, of course anything that veers from the defined “norm” for women (here, a young woman who menstruates every 28 days like clockwork) is pathological. Thus, menopausal women are pathological by definition. But, sometimes this gets pretty depressing, and really, it’s not very accurate considering that the vast majority of women go through menopause at some point during the midlife (so doesn’t that make menopause pretty normal and non-pathological?). In my Google alerts last week, here were the “menopause” headlines:

Diet, Exercise Post Menopause Help Reduce Risk of Breast Cancer
Medical Daily

Menopause linked to higher brain aneurysm risk
abc7.com

Healthy lifestyle during menopause may decrease breast cancer risk later on
Medical Xpress

Weight-y menopause
The Star Online

Diet To Overcome Menopause Problems
BoldSky

I do understand that there are many more health risks in middle age and beyond, and that changing/waning hormone levels at menopause induces different concerns/risks than women might have faced before menopause. Researchers, doctors, and media spokespersons have made it crystal clear over the past few decades that this is the case. But, as feminist and social science researchers have urged us to get beyond the “menopause as death” or “menopause as problem” perspectives, it seems that we’re not making much progress in thinking differently or more broadly about this transition. As I read the articles on menopause leading to more breast cancer risk, risk of brain aneurysm, and risk of weight gain, it is reaffirmed in my mind that we’ve made very little progress in broadening the dialogue (at least the published and mainstream dialogue) on this important life stage.

Sure, this life stage is filled with problems, risks, and interesting situations, but what life stage isn’t? Isn’t there published research coming out on ANYTHING ELSE about menopause? I want to read about something different! Readers, feel free to comment about any other interesting stuff you’ve read about menopause recently because I for one am searching for new takes on menopause. Seriously, people, was there nothing else new last week on menopause? As we head into 2013 I’m hoping for something new.

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Posted in Communication, Media, Menopause, Menstruation, New Research | 7 Comments »

Getting from the Average to the Individual When Reading Reports of Research

December 10th, 2012 by Paula Derry

We are unique individuals. Or, we are like everyone else. Which is it? For menstrual periods and the menopausal transition, as perhaps for most things, we’re a little bit of both. For me, keeping in mind that both are somehow true, and understanding the ways in which each is true, is a crucial but tricky business. Scientific findings are often reported as though they are universal truths. “The normal menstrual cycle is regular and occurs every 28 days.” “Depression is more likely during the transition to menopause.” However, research most typically examines groups of people, and results are most often average findings. A discrepancy between the average and the range of real experience isn’t surprising.

Take, for example, a study of the transition to menopause. This was longitudinal research—that is, the same group of women was studied for many years, and the patterns of change in their menstrual cycles over time could be documented. The authors conclude that there are three stages in the transition to menopause. At first women experience, perhaps beginning in their thirties, subtle changes in menstrual flow (like periods becoming heavier or lighter) without cycle length becoming irregular. Next, periods become irregular. Finally, women skip periods in the run-up to menopause. The stages are based on what, in the authors’ words, occurs “most frequently”; the average or frequent result is the basis for understanding the underlying pattern. Yet there is also a lot of variation. As reported in the article, only 39% of the women progressed in a forward manner through the three stages. Almost half seesawed back and forth. In addition, it is known that a significant minority of women report that they have gone from regular cycle lengths straight to menopause without a time of menstrual irregularity. I remember that when I first read this study I felt a certain comfort that changes in my body, like lighter periods and other changes, were predictable and fit into a pattern that other women experience. Yet, on the other hand, the findings can’t be used as a blueprint for what is supposed to happen. We share experiences with others, but we’re also unique individuals.

The average menstrual cycle is said to be 28 days—well, I don’t know many women with a 28-day cycle, and while some women describe themselves as “regular as clockwork” other women are bewildered that anyone could think that the cycle was regular. Rates of depression have been found in many studies to increase during the menopausal transition. However, the great majority of women do not become depressed (the “relative risk” has increased, but the “absolute risk” remains low). Knowing that the rate increases might suggest to a woman that she consider this possibility, but does not answer the question of whether she will become depressed, or, if she does, whether her depression is related to perimenopause or something else.

In trying to use scientific facts to understand ourselves or the world around us, the difference between the particular and the general, the predictable and the unpredictable, is important. Our individual behavior and physiology aren’t random or without form, but neither are they completely predictable.

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Posted in Menopause, Menstruation, New Research | 2 Comments »

Is PMS Overblown? That’s What Research Shows

October 24th, 2012 by Elizabeth Kissling

If PMS is a myth, then what on earth can we blame for all the lady-rage?

Photo by Flickr user dearbarbie // CC 2.0

You may have seen the article in The Star or The Globe and Mail or The Atlantic about the recently published research review by a team of medical researchers who assert that “clear evidence for a specific premenstrual phase-related mood occurring in the general population is lacking.” Judging from the headlines and the online comments, this proposition is surprisingly controversial–probably because the headlines were frequently misleading, suggesting the findings are much broader than they are. Some online commenters are especially angry, insulting the intelligence and methods of the researchers, proclaiming that of course hormones affect moods, as does menstrual pain, citing examples of their own or their wives’ experience.

But Sarah Romans, MB, M.D.; Rose Clarkson, M.D.; Gillian Einstein, Ph.D.; Michele Petrovic, BSc and Donna Stewart, M.D., DPsych–the five medical scholars who reviewed all the extant studies of PMS based on prospective data–did not claim in the now-infamous Gender Medicine review study that PMS does not exist, or that hormones do not affect emotion or mood. The variety of research methods used in other studies prevented them from conducting a meta-analysis–a statistical technique that allows researchers to pool results of several studies, thus suggesting greater impact–so the authors instead looked at such study characteristics as sample size, whether the data was collected prospectively or retrospectively (that is, at the time of occurrence or recalled from memory), whether participants knew menstruation was the focus of the study and whether the study looked at only negative aspects of the menstrual cycle. Although their initial database searches yielded 646 research articles dealing with the menstrual cycle, PMS, emotions, mood and related keywords, only 47 studies met their criteria of daily prospective data collection for at least one full cycle.

When the authors scrutinized these studies, they found that, taken together, there is no basis for the widespread assumption in the U.S. that all (or even most) menstruating women experience PMS. In fact, only seven studies found “the classic premenstrual pattern” with negative mood symptoms experienced in the premenstrual phase only. Eighteen studies found no negative mood associations with any phase of the menstrual cycle at all, while another 18 found negative moods premenstrually and during another phase of the menstrual cycle. In other words, the symptoms these women experienced were not exclusively premenstrual, making the label inaccurate. Four other studies found negative moods only in the non-premenstrual phase of the cycle.

So let’s be fair, angry online commenters (and careless journalists): The researchers aren’t telling you menstrual pain is all in your head, or that your very real period pain won’t affect your mood. Sarah Romans did tell James Hamblin of The Atlantic,

The idea that any emotionality in women can be firstly attributed to their reproductive function—we’re skeptical about that.

Rightly so–feminists have been saying this for decades. Feminist critiques of PMS as a construct point to both the ever-increasing medicalization of women’s lives and the dismissal of women’s emotions, especially anger, by attributing them to biology.

Part of what makes PMS difficult to study, and difficult to talk about, is the multiple meanings of the term. In the research literature, there are more than 150 symptoms–ranging from psychological, cognitive and neurological to physical and behavioral–attributed to PMS. There is no medical or scientific consensus on its definition or its etiology, which also means there is no consensus on its treatment.

In everyday language, its meaning is even more amorphous. Some women and girls use PMS to mean any kind of menstrual pain or discomfort, as well as premenstrual moodiness. Some men and boys, as well as some girls and women, use it to diminish a woman’s or girl’s emotions when they disagree with her, or want to dismiss her opinions, or are embarrassed by her feelings.

Even researchers are influenced by entrenched cultural meanings. Romans and her colleagues observed that none of the 47 studies analyzed variability in positive mood changes, which they attribute to biases of the researchers. Many women have reported anecdotally that they feel more energetic, more inspired or other positive feelings during their premenstrual phase, but this is seldom studied or regarded as a “syndrome.” Romans and colleagues note that most measures of menstrual mood changes only assess negative changes, so even if positive changes are occurring, researchers are missing them. They also cite research indicating that both women and men tend to attribute negative experiences to the menstrual cycle, especially the premenstrual phase, and positive experiences during the premenstrual phase to external sources.

Romans and her colleagues do not deny the existence of menstrual pain, or even the existence of PMS. What their study shows is that very few women experience cyclic negative mood changes associated with the premenstrual phase of their ovulatory cycle. PMS is not widespread, and the authors are careful to distinguish it from premenstrual dysphoric disorder (PMDD), which is rarer still. As Gillian Einstein, one of the researchers, told the Toronto Star, “We have a menstrual cycle and we have moods, but they don’t necessarily correlate.” She did not add, but I will, that it it is unfair and unreasonable to assume that every woman’s moods should be attributed to her menstrual cycle and to refuse to take her feelings seriously.

Cross-posted at Ms. blog.

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Posted in Hormones, New Research, Newspapers, PMS | 12 Comments »

Understanding Research: Expert Opinion Isn’t Enough

October 15th, 2012 by Paula Derry

Many of us do our own health research, either because we have a specific question or simply to keep up with the news. If we don’t read the original scientific articles, we rely on experts to provide summaries in newspapers, magazines, or on a variety of websites. It seems as though by choosing sources judiciously we should be able to count on finding information that is accurate. However, relying on authority, whether this authority derives from a writer having scientific or medical training, or the writer being a professional journalist, or some other reason, is not enough.

I thought about this recently when I saw an article on Medscape, a website for health professionals, especially physicians, called “Early menopause doubles CVD risk regardless of race.” A summary of a new journal article, it was highlighted on the Medscape home page for many days. It began: “Women who experience early menopause–before their 46th birthday–are twice as likely to suffer from coronary heart disease and stroke as women who don’t enter menopause prematurely, and this finding is independent of traditional risk factors.”  Johns Hopkins University, where one of the authors is employed, issued a press release entitled “Early Menopause Associated With Increased Risk Of Heart Disease, Stroke” which also begins:  “Women who go into early menopause are twice as likely to suffer from coronary heart disease and stroke, new Johns Hopkins-led research suggests.” Similar articles appeared in Medline+ (a National Institutes of Health and National Library of Medicine website), a Blue Cross Blue Shield healthcare news website, and many print newspapers.

So, what was in the original scientific article? The article was published in Menopause, which, like many journals, does not post its articles free online for non-subscribers. Many academic libraries do not carry this journal. However, if a reader does get the original article, these are some of the details: The women in this research were studied for a number of years. The researchers collected information about many predictors of circulatory problems (smoking, diabetes, etc.). The women were also asked at what age they had reached menopause. If this was when they were younger than 46, they were classified as having an “early menopause” whether menopause was caused by surgery (ovaries removed) or occurred naturally. The researchers looked at whether the women developed heart problems or strokes, and created mathematical models to study which predictors of these problems were important.

Twice the number of women with “early menopause” had heart problems compared with women who reached menopause later. This is what is called “relative risk.” The “absolute risk” numbers were: 3% of the women with early menopause had heart problems compared with 1.4% of those who did not; for stroke, the numbers were 2.6% vs. 1%. This is still a difference, but not as dramatic as a twofold increase. In addition, the way the strength of the association was mathematically computed was to first predict heart problems and stroke with more usual predictors: age, risk factors like diabetes. The difference in risk due to menopause was in the uncertainty left after all these other factors had already been taken into account. Further, we don’t know whether the “early menopause” group had other associated characteristics leading to a health difference—if they were unhealthy in other ways. The authors, for example, state that if a woman had a family history of heart problems, and if this was mathematically taken into account before looking at menopause, then early menopause was no longer a predictor of her having a problem. In accounting for results, the article cannot distinguish between surgical and natural menopause, which differ in many ways.

It is true that, in the media accounts of this research, if a reader reads the entire article, qualifiers do appear embedded in the article in some of the sources. Some do say that the number of women in the study who developed heart problems or strokes was small; that this was a correlation, not a cause-and-effect association; or that when family history of cardiovascular disease was taken into account the relationship disappeared (although in Medscape, the author of the study was quoted as saying that “the pattern was still similar”). A piece of misinformation that reappeared in some of the sources was that the increased risk was similar whether the women had early menopause naturally or because their ovaries had been surgically removed. The research article clearly states that the authors did not have sufficient power (in research this means, basically, enough subjects to get an accurate answer to the question) to determine this.

I was puzzled why so much publicity was given to this study.  In my opinion, it did provide some interesting, suggestive results and contributed information about women from a range of ethnic groups (who have been understudied in the past), but the study’s results were modest and inconclusive.  However, what the article did do was to claim to support the underlying assumption that menopause and heart disease are related, an idea that keeps re-occurring in the professional literature, even stated as though it is a fact, although the evidence for it has been at the very best arguable and weak.  A recent SMCR blog post by Chris Hitchcock analyzed media misreporting of the results of another research project intended to test this relationship. In the study I am discussing, highlighting weak data that seems to suggest a relationship between menopause and ill health, blurring the distinction between natural and surgical menopause, contribute to this meta-message.  Ages 40 to 45 would be considered within the normal age range for menopause by many professionals, but is here defined as creating health risks.  I would hate to think that meta-messages promoting ideas that menopause is unhealthy and causes risk of heart disease contributed to the perceived importance of the article.

Reference

Early menopause predicts future coronary heart disease and stroke: the Multi-Ethnic Study of Atherosclerosis.  Melissa Wellons, MD, NCMP, Pamela Ouyang, MBBS, Pamela J. Schreiner, PhD, David M. Herrington, MD, and Dhananjay Vaidya, PhD, Menopause: The Journal of The North American Menopause Society, 2012.  Vol. 19, pp. 1081-1087

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Posted in Menopause, New Research | 4 Comments »

When Can We Write the Obituary for the Critical Timing Hypothesis?

October 12th, 2012 by Chris Hitchcock

What Happened?

The highlight of last week’s meeting of the North American Menopause Society (NAMS) meeting was a presentation of the primary results of the KEEPS study (Kronos Early Estrogen Prevention Study). A press release describing the findings, along with a list of FAQ (frequently asked questions), is available on the Kronos website. KEEPS was designed to confirm the critical timing hypothesis by looking at the use of menopausal hormone therapy in healthy women who were 6-36 months from their last menstrual period. Primary outcomes were progression of two atherosclerosis markers: carotid artery wall thickness (cIMT) and coronary artery calcification (CAC). In both cases, there were no statistically significant differences among the three groups (two hormone therapy formulations and a placebo group). The study failed to meet the stated goals by the stated criteria. Medical and popular coverage of these preliminary, non-peer-reviewed results have been almost uniformly positive, advocating renewed use of estrogen as menopausal therapy to women, provided they are young and healthy.

The timing hypothesis1 was born out of the collective cognitive dissonance following the unexpected findings of the Women’s Health Initiative, which failed to confirm the widespread belief that menopausal hormone therapy (specifically, estrogen) would protect menopausal women from cardiovascular disease.

The birth of KEEPS

Soon after the results of the Women’s Health Initiative were published, the discredited idea of menopausal hormone therapy for the prevention of cardiovascular disease was resurrected in the form of the critical timing hypothesis. In 2005, the KEEPS study was launched with much fanfare in the popular press and the medical literature. The lead editorial2 in the journal Climacteric heralded it as a move “[t]owards safer women, safer doses, safer routes and safer timing of administration of safer menopausal therapies,” and the journal invited an article describing the study design3.

Study Design

KEEPS is a “prospective, randomized, controlled trial designed, using findings from basic science studies, to test the hypothesis that MHT when initiated early in menopause reduces progression of atherosclerosis. KEEPS participants are younger, healthier, and within 3 years of menopause thus matching more closely demographics of women in prior observational and epidemiological studies than women in the Women’s Health Initiative hormone trials. KEEPS will provide information relevant to the critical timing hypothesis for MHT use in reducing risk for CVD.”4 The target sample size was 450 women completing the study, with a goal of at least 150 women in each arm. The recruitment goal was 720 women.

Rather than using the synthetic hormones (conjugated equine estrogen, CEE and medroxyprogesterone acetate, MPA) from the WHI, KEEPS included more “natural” hormonal products, comparing oral conjugated equine estrogen (o-CEE, derived from pregnant mares’ urine, and taken as a pill – Premarin, 0.45 mg) with transdermal estradiol (t-E2, taken by patch – Climara, 50 mcg). Estrogen taken alone causes endometrial cancer; KEEPS added oral micronized progesterone (OMP, 200 mg for 12 days per month), which is identical to the human hormone molecule.

The three arms were:

  1. PLACEBO – placebo pill, placebo patch, placebo OMP
  2. o-CEE + OMP – active pill, placebo patch, active OMP
  3. t-E2 + OMP – placebo pill, active patch, active OMP

The purpose of KEEPS was to test the critical timing hypothesis, that is, to answer the question:

Does estrogen therapy, when administered during the critical timing period, protect women from cardiovascular decline?

A study of this size and duration in healthy young(er) women cannot hope to address clinical outcomes, such as stroke, heart attack and the like. Therefore the study had two surrogate markers of atherosclerosis (a part of cardiovascular health) as primary outcomes:  Continue reading...

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Posted in Hormones, Menopause, New Research, Perimenopause | 6 Comments »

Could use of the pill be linked to insulin resistance?

October 3rd, 2012 by Elizabeth Kissling

Adapted from a photo by anna marie-grace // CC 2.0

The pill is one of the most intensely studied drugs in history, and believed to be among the safest – safer than aspirin, as an editorial in the American Journal of Public Health noted twenty years ago. Yet young women seem to be quitting in droves, for a variety of reasons: to restore feelings of psychological and emotional health, regain lost libido, relieve cardiovascular symptoms and disorders, or ease anxiety about these or other health issues.

When women report these side effects of birth control pills, physicians often recommend they try another brand, but many of these side effects are common to hormonal birth control, especially oral contraceptives. A new study published this month in Human Reproduction suggests there may be yet another common side effect: Researchers in Finland found that oral contraceptives may worsen insulin sensitivity and are associated with increased levels of circulating inflammatory markers.

The study was very small and ran only for a short time, so drawing conclusions is premature, but since the beginning of the year, I’ve been following several online discussions of young women quitting the pill. Although I have yet to see development of Type 2 diabetes or insulin resistance cited as a reason to quit the pill, I have seen such a variety of health issues and medical problems described that this study caught my eye immediately. Current estimates indicate that 12.6 million, or 10.8 percent, of all U.S. women ages 20 years or older have diabetes (diagnosed and undiagnosed). Could it be related to their birth control? Perhaps in those already genetically predisposed.

Research from the Guttmacher Institute indicates nearly 60% of pill users take it for non-contraceptive reasons, such as for cramps or other menstrual pain, menstrual regulation, acne, endometriosis, as well as for prevention of unintended pregnancy. Fourteen per cent of US pill users (more than 1.5 million women) take birth control pills solely for non-contraceptive reasons. If the Finland study proves to hold true for larger groups over extended periods, there’s another reason to be more cautious prescribing the pill.

 

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Posted in Birth Control, coming off the pill, Health Care, New Research | 10 Comments »

Musings on Menopause and Heart Disease

August 27th, 2012 by Paula Derry

A recent article by Swift et al. looked at the effects of aerobic exercise on heart health. Midlife women with high blood pressure were assigned to one of three exercise groups—a program of exercise that met National Institutes of Health (NIH) guidelines, one that was half the amount of exercise recommended by the NIH, or one that was 150% of the NIH recommendations. The study did not examine who actually got heart disease. Instead, the researchers looked at the ability of arteries to function normally, which is a precursor to disease. Specifically, the researchers measured one component of artery health called “flow mediated dilation” (FMD)—the ability of arteries to respond normally to changes in blood flow by dilating (getting larger), which is one indicator of “endothelial (the inner lining of the artery) function.” The authors found that aerobic exercise improved flow mediated dilation. The amount of exercise was not important—the authors suggest that once some minimum amount of exercise exists, improvements will occur. They also found that women with problems benefited from exercise, but not those with normal FMD.

Well, I have to admit this isn’t an area of my expertise. I’m not going to evaluate how solid the methodology was, how close to normal the improvements brought the women, compare these results with the entire body of knowledge, all of which are important to really understanding the import of a study. However, I’d like to share some musings that the article triggered.

First, the article assumes that menopause and the menopausal transition increase a woman’s chances of getting heart disease by modifying her precursors and risk factors. The title of the article is: “The Effect of Different Doses of Aerobic Exercise Training on Endothelial Function in Postmenopausal Women With Elevated Blood Pressure”. The introduction states that their research is important because menopause is associated with worsening of heart disease risk factors. However, they are not studying postmenopausal women. They are studying overweight, sedentary women with high blood pressure who are old enough to be postmenopausal. It used to be more commonly stated, as though it is a fact, that menopause increases a woman’s chances of getting actual heart disease. However, this assertion does not appear to be supported by the facts. A recent paper in the British Medical Journal concluded that aging rather than menopause was key: “Heart disease mortality in women increased exponentially throughout all ages, with no special step increase at menopausal ages”. In 2011, the American Heart Association issued the Effectiveness-based Guidelines for the Prevention of Cardiovascular Disease in Women—2011 Update. These guidelines include a long list of risk factors and suggestions for how to prevent disease, such as modifying lifestyle factors like cholesterol and inactivity. Menopause is not included as a risk factor and is mentioned in just one sentence in the document. The line of research that has now arisen which states with equal certainty that risk factors and precursors to heart disease increase with the menopausal transition thus must be looked at critically. Do these changes in precursors really co-vary with menopause? Do they lead to actual disease? How important are they relative to other factors leading to heart disease, like aging or lifestyle?  Continue reading...

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The Biology of Reproduction Isn’t Just About You

July 23rd, 2012 by Paula Derry

Photo by Minyoung Choi // CC 2.0

A scientific paper was recently published which looked at how shifting patterns of daily light and darkness affect pregnancy in mice.   The authors were interested in this question because studies have suggested that humans who experience such patterns, such as shift workers or women who travel repeatedly across time zones, have reduced fertility. In their study, pregnant mice were divided into three groups. All groups had 12 hours of light followed by 12 hours of darkness.  The control group had the same pattern throughout the 21 days of pregnancy.  The other two groups had shifting patterns.  In one, the 12 hours of light started six hours earlier every five days (phase advanced group); in the other, six hours later (phase delayed group). In the control group, 90% of the mice had successful pregnancies and deliveries; in the phase advanced group, 22%; in the phase delayed group, 50%.

Circadian rhythms is the general term for biological activities that have a 24-hour cycle, like sleeping and waking, or like hormones whose amounts vary during the course of a day. There are many circadian rhythms in humans, animals, and plants.

They are internal, determined by the physiology of the animal or plant. However, they are also entrained (synchronized with) environmental events like the amount of light at night vs. during the day. This entrainment means the rhythms match what is going on in the environment and also can adjust to environmental change. In the pregnant mouse experiment, the light shifts were so large they disrupted the internal circadian timekeeper, which had cascading effects on mouse physiology and success in maintaining a pregnancy.

There are also many physiological rhythms that mesh with environmental patterns on longer or shorter time scales, for reproduction as well as many other aspects of biology. Zucker (1988), for example, found an annual rhythm to whether the amounts of a hormone called luteinizing hormone (LH) had a feedback relationship (that is, interaction) with the amounts of estrogen in ground squirrels. Typically in a mammal, LH increases estrogen production, and then when estrogen levels reach a high point the LH surges which initiates ovulation. For ground squirrels, who only become pregnant during January to March instead of having a regularly repeating cycle throughout the year, this relationship between hormones only exists during the breeding season. If the ovaries of females are surgically removed (so that their bodies don’t make estrogen), LH levels still go up to initiate the breeding season at the correct time of year; that is, levels of LH appear to be controlled by some environmental factor.

There are also social influences on the biology of reproduction in animals. Nelson (1999) summarized some of them: If four or more female mice were housed together in a cage, their cycles occurred less frequently. If they were then exposed to a male, they ovulated at the same time. In a study of albino mice, if a strange male was introduced into the cage of pregnant females, the females spontaneously aborted about 25% of the time. If the male who impregnated the female was re-introduced into the cage, there were no miscarriages. Female rats that were handled daily by researchers reached puberty at an earlier age than did rats who were not, and mice housed alone reached puberty sooner than mice housed with other females.

What does this mean for humans? There are not necessarily direct correspondences between animal and human research. Sometimes human physiology is simply differerent; sometimes, exactly the same. In addition, humans may have many influences where animals have fewer, so big, determining effects in animals may be mere suggestions in humans, one factor among many. On the other hand, the circadian research I discussed above was suggested by the possibility that shift workers and frequent travelers have fertility problems. Many social influences on human menstruation — synchronized menstrual cycles among college roommates, effects of stress — have been reported.

The possibility that intrigues me is this:  We are individuals, but we are also intrinsically part of larger environments. Reproductive biology is about our inner organization of hormones, brain chemicals, goals and interests, but it is also about the viability and value of conception in specific social groups and physical environments. Our physiology is inside our skins, internal to us, but is also related to maintaining a state of balance with our physical and social environments.

References

Nelson, R.  (1999). An introduction to behavioral endocrinology.  Sunderland, MA: Sinauer.

Summa, K., Vitaterna,M., & Turek,T.  (2012).  Environmental perturbation of the circadian clock disrupts pregnancy in the mouse” PLoS One 7(5): e37668.  doi:10.1371/journal.pone.0037668

Zucker, I. (1988). Neuroendocrine substrates of circannual rhythms.  In D. Kupfer, T. Monk, & J. Barchas (Eds.), Biological rhythms and mental disorders (pp. 219-252).  New York: Guilford.

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Posted in Fertility, Hormones, New Research | 4 Comments »

PMDD: No News Is News, for the APA

July 11th, 2012 by Elizabeth Kissling

Guest Post by Joan Chrisler, Connecticut College

I have to admit that I have not been closely following the news about the forthcoming edition (5th) of the Diagnostic and Statistical Manual of Mental Disorders, which is expected to be published by the American Psychiatric Association in May 2013.  So, when our blog editor Elizabeth Kissling asked me to take a look at a recent update on PMDD in Psychiatric News, I was intrigued.  As I read the article I found myself becoming irritable, very irritable, even angry – but, don’t worry about me; I couldn’t possibly have PMDD, as I no longer menstruate.  No, my emotional lability has more to do with the psychiatrists’ tendency to play fast and loose with facts than it does with my physiology.

Photo by Ben Husmann // CC 2.0

The “news” begins with a statement that PMDD has been “proposed” to be included in the section on depressive disorders rather than in the appendix, which is reserved for disorders that need more study and shouldn’t yet be used clinically.  This is a canard.  PMDD appears in both the appendix and the depressive disorders section of the current edition – the DSM-IV-TR, which was published in 2000.  As a result, it is already being used clinically.  Perhaps what they really mean to say is that it is being removed from the appendix because we already know enough about it.  Hmmm.

Next, we are told that there has been an “explosion” of research on PMDD in the “past 20 years.”  Why 20 years?  PMDD was originally named Late Luteal Phase Dysphoric Disorder and proposed for listing in the DSM-II-R (1987); early research that was intended to support the new diagnosis was not convincing, which probably factored into the decision to change its name. The current edition of the DSM was published 12 years ago, and the original DSM-IV in 1995 (17 years ago).  According to PsycINFO, the largest psychology database, there have only been 259 articles published since the most recent edition of the DSM appeared, which hardly seems like an explosion, especially if we consider that many of them are about PMS, not PMDD.  Others are not empirical reports of studies about PMDD; they are literature reviews, critiques of the diagnosis, and articles about psychotherapy for women with the diagnosis. The 259 even include random studies of migraines, schizophrenia, bipolar disorder, and menopause.  The psychiatrists believe that these studies provide “greater legitimacy” for the diagnosis.  Sorry, but I am not convinced.

The news report indicates that the criteria have been sharpened to require the presence of at least five of eleven symptoms during “most” menstrual cycles of the previous year.  Prospective daily ratings are recommended, but it seems unlikely to me that most patients would be willing to wait or that most doctors would really insist that women rate themselves daily for a year before prescribing medication for PMDD.  Another change is that the symptoms must produce “clinically significant distress” and “interference” with work, school, relationships, or social activities. These require judgment calls: “clinical significance” is the doctor’s call, and “interference” is the patient’s call.

I predict that these “sharper” descriptions are still vague enough to be overused. Example: A student in one of my classes told me in all seriousness that her menstrual cramps interfered with her daily life because she had to take an aspirin occasionally.  Did she have to skip class and lay down with a heating pad?  No, she took her pill and went about her business.  “Then, how is that interference?”, I asked. “I don’t usually have to take an aspirin!”, she insisted. Now, I hope that that young woman is unusual, but I ask you to consider that the youth culture seems to value anything “extreme” and consider much of their experience to be unusual. My students think that (almost) everything is “awesome”, “incredible”, and “amazing”. If they were asked if their irritability is “extreme”, I suspect they would be much more likely than I would be to say “yes”.

Perhaps the most interesting (well, in a bad way) part of the news is that symptoms have been reordered to give priority to emotional lability, irritability, and anger and to deemphasize depressed mood. Why? “The work group agreed that clinically depressed mood is not the first thing you think of when you think of PMDD”.  Perhaps the work group is thinking about cultural stereotypes of premenstrual women!  If depressed mood is no longer a key criterion for PMDD, why is it still called PMDD?  Shouldn’t the work group have proposed a name change that would drop “dysphoric disorder”?  Why will it be continue to be classified with depressive disorders if it isn’t one?

Finally, the news report notes that how much distress and/or interference premenstrual symptoms produce depends on women’s personality, coping style, and life circumstances. Well, of course. There are many studies in the literature that show this. Stress, trauma, and even frequency of perceived discrimination (Pilver et al., 2011) predict severity of premenstrual complaints. There is much that psychotherapists can do to help women to manage their symptoms, but all the DSM suggests is drug treatment: SSRIs (selective serotonin reuptake inhibitors — the most commonly prescribed anti-depressants in the U.S.).

In conclusion, I refer readers to the SMCR’s resolution dated June 2001.  Women should continue to be cautious about whether their premenstrual symptoms constitute a mental illness and whether they want to take a strong anti-depressant medication for the rest of their menstrual lives. Other types of help, without potentially serious side effects and the stigma of a psychiatric diagnosis, might be effective.

For more information about PMDD and the DSM, see:

Caplan, P. J. (1995).  They say you’re crazy: How the world’s most powerful psychiatrists decide who’s normal.  Reading, MA: Addison Wesley.

Chrisler, J. C., & Caplan, P. (2003).  The strange case of Dr. Jekyll and Ms. Hyde: How PMS became a cultural phenomenon and a psychiatric disorder.  Annual Review of Sex Research, 13, 274-306.

 

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Posted in Hormones, New Research, PMDD, PMS | 3 Comments »

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