Blog of the Society for Menstrual Cycle Research

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.

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

Should Symptoms Always Be Treated?

May 24th, 2012 by Heather Dillaway

An article on Medscape News on May 7th reported survey results that suggest that “fewer than one third of women with menopause symptoms are receiving treatment for those symptoms.” The article goes on to report that about half of women aged 45 to 60 report “menopausal” symptoms (e.g., hot flashes, sleep problems, mood swings, decreased sexual desire, irregular periods, etc.). In addition, the survey apparently reports that over half of the women reporting symptoms define those symptoms as having some negative effect on their lives. Thus, the assumption is that these symptoms should be treated and, at the very least, lessened.

However, in this same article, it is noted that only 7% of women on this survey reported “very negative” symptoms. Many women reported their symptoms as “moderate.” The article goes on to suggest that only about one-quarter of survey respondents contemplated using hormone therapies to treat symptoms and that too many symptoms go untreated.

So, my question is: did anyone ask women whether they wanted treatment for their symptoms? And did anyone ask women what they meant when they said they had “moderate” symptoms? Did anyone ask women what they meant when they said symptoms had a “negative” effect on their lives? And if all symptoms that are documented are “negative,” what does it mean to have “very negative” symptoms?

This article goes on to tell about a new “Menopause Map” developed by The Endocrine Society and a Hormone Health Network for women who need help figuring out whether and how to get treatment for symptoms. But, the assumption here is that symptoms should be treated and that any symptom that is documented is bad enough to warrant that treatment.
Over the last ten years I’ve interviewed a lot of perimenopausal women. Granted, a portion of women going through this reproductive transition have terrible symptoms that are indeed unmanageable and treatable. But, a lot of women (in fact, the majority) seem to be able to handle their symptoms on a daily basis. Movies like Hot Flash Havoc hype up the fact that “menopausal” symptoms are unmanageable for everyone. The new “Menopausal Map” referred to above also makes it seem like all symptoms are potentially unmanageable. The Medscape News article that I’m referring to here also assumes that “untreated” symptoms are problematic. But maybe they aren’t for everyone.

The Society for Menstrual Cycle Research often steers away from using the word “symptom” and often refers to “signs” of menopause or the menstrual cycle – specifically because of the negativity associated with the word “symptom.” If you have a “symptom” of any kind, the assumption is you should run to the doctor! And untreated symptom seems like a problem. But is it really?

One of the perimenopausal women I interviewed way back in 2001 said to me outright “symptoms are supposed to be negative.” The point she was making was that the minute you say you have a symptom, people assume you have a problem.

I’d like us to think more about whether all symptoms really need medical treatment. Maybe we just need to give ourselves time to breathe. Time to sleep 15 more minutes. Time for a break at work. Time to drink more water and less coffee. Time with our partners, kids, friends, parents. Time for ourselves. And then maybe we can really assess whether we need that Tylenol for our headache or hormone therapy for our hot flashes. And the very fact that there are so many non-pharmaceutical options perimenopausal symptoms these days tells us something – women don’t actually always want to run straight to the doctor because they have a “symptom.”

Does a symptom always have to be negative? Does it always need treatment? I think we need to work on what the word “symptom” really even means.

Understanding Research: Buyer Beware

April 2nd, 2012 by Paula Derry

xkcd.com // CC 2.5

I certainly believe that scientific research is important.  Research uncovers new knowledge and prunes away facts that are not accurate.  However, in our society, research is also a coinage to justify views of reality. A Biblical scholar might invoke a sentence from the Bible before holding forth on his own interpretation or opinions. In a similar manner, a scientific study might be cited or a scientist quoted to justify that something is real before jumping off into one’s own thoughts, opinions, theories, or justifications.  If a scientific result can be invoked, we can believe that something is true. Is there an unconscious?  Freud said so, but he’s out of date.  Are we intrinsically social beings?  Evolutionary theorists argue. Does meditation really result in an altered state of consciousness?  If I present results from research, preferably using a high tech measurement like a brain scan, or if I can come up with a theory that uses words like “neural nets” or “neurotransmitters,” then I can believe all of these things.

What’s wrong with this? Isn’t this science doing its job of uncovering truth?  There are two things wrong with this. One is that not all knowledge is scientific knowledge.  The second is that scientific results are often portrayed inaccurately in our society.

With regard to the first point, I’ll just give a few examples.  von Bertalanffy, a systems theory scientist, wrote that even a physicist will chase his (sic) hat when the wind blows it without knowing the mathematics determining which way the hat will blow.   Einstein famously said that not everything that was important could be measured, and not everything that could be measured was important.

But what I really want to talk about here is the second point.  We are inundated with scientific results in newspapers, websites, and other places. Most often, a brief summary of research is followed by broad generalizations about what the research means.   However, the outcome of research is not simple facts. Experiments are complicated things that must be evaluated by readers and understood in context.  When I was a graduate student in psychology, every class included practice in critiquing research.

To understand research, certain mathematical ideas are important.  “Statistical significance” is important to both accurate interpretation of research and to inaccurate or misleading reports. If you’ll bear with me, I’ll run through what I mean. Suppose you have a coin. If you toss the coin 100 times, it will come up heads about 50 times, not exactly 50 but close. Why?  That’s just the way the world we live in works, there are laws of probability. Since there are two possible outcomes—heads or tails—each will come up about half the time. If I toss my coin 100 times and it always comes up heads, I’ll probably conclude the coin is biased.  Why?  Because it just doesn’t happen; it’s extremely improbable, in the world we live in, that an honest coin would do this.

What if the coin came up heads 60 times? Is the coin honest or not?   The question is this: When is an outcome still “what you would expect by chance even though the numbers are not exactly alike (since we expect approximately 50 heads, not exactly 50)”?  On the other hand, when is the difference big enough that you would conclude that the coin is probably biased?   Sometimes it’s hard to tell.  In research, very often results are in the “hard to tell” category.   For example, if 55 percent of the women in my research prefer chocolate ice cream, while 65 percent of the men prefer chocolate, is there a real sex difference (it’s so improbable there’s a real difference) or is there not (the numbers seem different, but I’m not sure whether this is just because there is a range due to chance and not a real difference). Sometimes numbers that seem very different are actually what you could commonly get by chance, and sometimes numbers that don’t seem very different are very improbable.  In addition, what I’m studying may produce a weak rather than a larger, obvious effect because among us humans, for all kinds of psychological, social, and biological research, what is being studied is only one factor contributing to a situation and not the only thing going on.  In the example, even if men and women do have different likelihoods of preferring chocolate, there are many possible reasons for a person’s choices—diabetes, city you grew up in, getting rejected by a date while you were eating chocolate ice cream, etc.

Fog Warning Ahead

March 29th, 2012 by Heather Dillaway

As I embark on my 40th year I look ahead to menopause. I guess there is a good chance I’m approaching some foggy years. Brain fog, that is.

In the past week a flurry of online news articles review new research findings on the “brain fog” that many perimenopausal women experience. The brain fog is more easily understood as a slight memory problem, if you take the time to read through the various news stories. A new study analyzed how 75 individual women, aged 40 to 60, rated their memory performance based on factors like how often they forgot details and how serious their forgetfulness was. Researchers also gathered information about the women’s overall health, mood and hormone levels, as well as other menopausal symptoms, and tried to figure out the extent to which this “brain fog” exists. According to news reports, about 41 percent of the women in the study reported having forgetfulness that was “serious,” and those who felt that their memory problems were serious were more likely to score poorly on tests of working memory and attention. Some women who rated their memory problems as serious also reported some depression and other symptoms like hot flashes and sleeping problems. Other researchers suggest that the memory problems women experience are related to changing levels of estrogen in a woman’s body at menopause, but interestingly this new study did not find links to changing hormone levels.

The whole notion of “brain fog” is interesting, and I am suspicious of it as a strictly menopausal symptom. What about the brain fog we all experience when we’re tired or sick or just way too busy? Defining brain fog as a “menopausal” (really, perimenopausal) symptom further defines middle-aged women as somehow less than functional and set them up to be taken less seriously.

Putting this issue aside, though, what I actually find most interesting about all of the news coverage of this study is just how different each report of the study is. I am reminded that we should all be careful of which report we read about a study. For example, the first article I read on this study was placed in the Los Angeles Times and focused on the possible connections between menopausal brain fog, depression, and dementia. I was left feeling like the author of the article inferred that all menopausal women might have depression or dementia and that they should seek treatment. After reading this article I was angry because I felt as if I had been warned that midlife brain fog was the beginning of an inevitable decline for all women. Then I read a WedMD piece that simply described the study and did not concentrate on depression, dementia, or the need for treatment, and I wasn’t really sure what to make of the research study. Finally I read an article by a HealthDay reporter which quoted one of our own, SMCR member Nancy Wood, who reminds readers that “a number of other stressors in life, from work to taking care of children and parents, that pile up around the same time as menopause can hinder memory and ability to concentrate.” In addition, this article’s author states that “memory problems are not necessarily an early sign of dementia” and cognitive ability is regained after other perimenopausal symptoms subside. This third article concluded that the research study is helpful because findings suggest that brain fog is real – that women aren’t crazy – but that it is normal and not that detrimental to women’s long-term cognitive abilities.

Of course, nothing is a substitute for reading the original article published by Miriam Weber and her co-authors this March in the journal, Menopause. But if you need a quick synopsis of what a research study finds just make sure you know its source and think about whether the coverage of the details makes sense! I for one like the tone of the HealthDay news article – that, if brain fog exists, it is temporary and normal and could be caused by lots of things. It is not necessarily an indicator of depression or dementia or even a permanent memory problem.

The woman, the serpent and the cycle

March 13th, 2012 by Chris Hitchcock

According to a recent study, women are best at picking out a picture with a snake during the days immediately before their period. You might think this would be a surprise, given the general idea of premenstrual compromise in women. Mind you, there isn’t much data to support poorer thinking or performance for women during the premenstrual period.

However, the authors were able to salvage the idea of premenstrual compromise here. They argue that about 30% of women have premenstrual syndrome, and most of the rest of us show some kind of cyclicity. And so they attribute the 200 millisecond (1/5 of a second) faster response to anxiety and fear. Either that, or it is maternal instinct, protecting the small cluster of cells that might possibly be an impending pregnancy.

Media has picked this up, with headlines about PMS being good for something after all.

Sometimes it seems that women can’t win for losing.

Earlier menopause with ovary-saving hysterectomy

November 22nd, 2011 by Chris Hitchcock

Recently Heather Dillaway blogged about the challenges and frustrations of naming, and this blog continues with that theme, looking at a recent article about increased rates of ”ovarian failure” following ovary-preserving hysterectomy.

Ovary-saving hysterectomy linked to early menopause,” reads the USA Today on-line headline, and the article opens with the statement that:

Younger women who have a hysterectomy that spares the ovaries are almost twice as likely to go through early menopause as women who do not have their uteruses removed, according to a new study. 

It’s an alarming statement, and one likely to alarm an already anxious woman. The study in question was a longitudinal study following 406 women aged 30-47 at the time of their surgery and a control group of 465 similar-aged women who did not have a hysterectomy. The study will be published in the December 2011 issue of the peer-reviewed journal Obstetrics & Gynecology, and the news coverage was drawn from the Duke University press release, entitled “Hysterectomy Increases Risk for Earlier Menopause In Younger Women”.

The first challenge of naming is in the subtle difference between the press release’s earlier menopause, and the USA today article’s early menopause. Early menopause is defined as menopause that occurs before the age of 40; the earlier menopause in the article is a difference of about 2 years — an important difference.

In women who no longer have menstrual flow, how did the authors establish menopausal status, or ”ovarian failure”, as they called it? In women with a uterus, menstrual flow is a convenient landmark, which is roughly aligned with the hormonal changes to decide when menopause (or is it post-menopause?) has begun. We assume that 12 months without menstrual flow likely means that there will be no further flow (although that is not always true), and that it is a good estimate of when ovarian hormonal cycles have stopped. In this article, the authors used an annual blood sample to measure a hormone called FSH (follicular stimulating hormone). FSH is high in menopausal women, and an FSH>40 IU/L was used as a criterion for reaching menopause. However, we have known since 1994 that a high FSH level is not diagnostic of menopause, and, indeed, 6 of the 504 women were excluded because they had a baseline FSH > 40 IU/L, despite having menstruated within the previous three months. Regularly cycling women in their 40′s can have high FSH levels, and later have low FSH levels and ovulatory cycles. In menstruating women, blood samples would also be timed, which is not possible for women who don’t menstruate. It would be interesting to know how the high FSH criterion corresponded to menstrual cycle history in the control group.

Studies like this are hard to do. The authors were careful — they enrolled women prior to surgery and followed control women in the same way. To get 403 women with complete data, they started with over 900 women.  The controls were fairly well matched — similar in age, age at first period, c-section and oral contraceptive history. However, women undergoing surgery were more likely to have had at least one full-term pregnancy (84.5% vs 68.3% in controls), and more likely to have had a previous tubal ligation. In addition, fibroids, endometriosis, ovarian cysts and previous surgery for fibroids were more common in those having a hysterectomy. Both the hysterectomy itself and the history of previous surgery, particularly tubal ligation, may also contribute to a difference between the two groups. Finally, women with hysterectomy were heavier than the control group.

By following the two groups, the authors were able to estimate that hysterectomy accelerated the rate of reaching the FSH threshold by about 2 years. This is consistent with other research, and fits with the finding that hysterectomy and other reproductive surgeries are associated with a lower rate of breast cancer, presumably due to lower estrogen exposure.

Readers should note that statements published in re: Cycling are those of individual authors and do not necessarily reflect the positions of the Society as a whole.