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RRP 07-354 – QUERI Project

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RRP 07-354
Study of Women in Menopause (SWIM)
Sarah L. Krein PhD RN
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: October 2007 - April 2008

BACKGROUND/RATIONALE:
In healthy women, menopause symptoms have been associated with decreased quality of life, impaired work performance, limitations in physical functioning, and perceived declines in health status. Most menopause research is limited to the study of healthy women and to date, virtually nothing is known as to how menopause symptoms manifest themselves in women with type 2 diabetes mellitus (DM). Systematic study is needed to obtain accurate clinical information regarding the menopause symptom experience of women with diabetes to inform the direct care management of these women.

OBJECTIVE(S):
The overarching objective of this research was to examine the menopause symptom experience of women with type 2 diabetes, including the influence of clinical features of diabetes on those symptoms. The aims of this study were: 1) To describe the menopause symptom experience of women veterans with and without type 2 diabetes, 2) To determine the influence of type 2 diabetes and its clinical features (glycemic control, duration of illness) on the menopause symptom experience, 3) determine the influence of menopause symptoms on perceived health status; and 4) explore the influence of diabetes and postmenopausal status on clinical services utilization by women veterans.

METHODS:
This study employed a comparative group design to examine the menopause symptom experience of three groups of women veterans: women without DM, women with controlled DM (Hemoglobin A1c [HbA1c] <7%) and women with poorly controlled DM (HbA1c >7%). Surveys were mailed to a national sample of 900 women veterans who met baseline study criteria of age (45-60 years) stratified by diabetes status, with 300 per study group as defined above. The survey included screening questions to determine reproductive status and for those who were self-identified as being in menopause, collected information about the menopause symptom experience, general health status and diabetes symptoms. Women with DM were also asked about diabetes management and self care behaviors. Additional clinical data were extracted from national electronic medical record databases. Descriptive statistics were used to characterize the sample and study groups, while group differences were evaluated by chi square, ttest and ANOVA. Relationships among specific variables were assessed using multivariate regression techniques.

FINDINGS/RESULTS:
A total of 538 surveys were returned (59.8%). However, elimination of those not eligible according to our survey screening criteria, resulted in a final sample of 328 menopausal participants not using hormone therapy: 91 women without DM, 135 women with controlled DM and 102 women with poorly controlled DM.

Overall, study respondents were obese (mean body mass index [BMI] 33.9 + 0.4 kg/m2), a mean 55.0 + 0.2 years of age and 11.30 + 0.2 years postmenopause with 4.7 + 0.1 chronic medical conditions. Women without DM were younger, of smaller BMI and had fewer chronic medical problems compared to those with controlled and poorly controlled DM. Fifty eight percent of the sample was white, twenty eight percent were black, and seven percent were of Hispanic ethnicity. The remaining seven percent were Native American Indian (n = 4), Asian (n =2), Hawaiian Pacific Islander (n =1) or identified with more than one race (n = 14).

Most women veterans (55.2%) experienced an induced menopause for primarily surgical (53.1%) reasons; only 44.8% reported a spontaneous natural menopause. The average age of menopause (all causes) was 43.3 + 0.4 years and similar across study groups. In women with natural cessation of menses, the average age of menopause was 49.2 + 0.3 years and did not differ by diabetes status, but is earlier than the mean of 51 years common to Western women.

The majority (n=313; 95%) of women reported at least one menopause symptom. Muscle and joint aches, hot flashes and trouble sleeping were the most commonly reported symptoms within all study groups. Menopause symptom prevalence was similar between women with and without DM, but higher than observed in studies of healthy women. ANOVA results showed that total menopause symptom severity scores were higher in women with poorly controlled DM compared to women without DM and those with controlled DM (15.4 + 0.8 vs. 12.3 + 0.8 vs. 12.2 + 0.8 respectively; p <0.05). In women with DM, level of glycemic control as measured by HbA1c was positively associated with menopause symptom severity (r = 0.17; p = 0.02).

In multivariate analysis with the entire sample, diabetes did not demonstrate an independent association with menopause symptom severity, but altered mood diagnosis, tobacco use, age of menopause and non-white, non-black, non-Hispanic ethnicities were independently associated. In the model for women with diabetes, glucose control along with altered mood diagnosis and cigarette smoking were independently associated with menopause symptom severity.

Postmenopausal women without DM reported higher (indicating better health) general health scores compared to both groups of women with DM. Mental health composite scores were similar among the groups, while physical health composite scores were higher in women without DM compared to those with controlled DM with a trend for higher scores (p = 0.06) compared to those with poor glucose control. In multivariate analysis menopause symptom severity and glucose control were independently associated with physical health status in women with DM.

IMPACT:
The study findings show women veterans with type 2 DM experience menopause at the same age and report similar menopause symptoms as women veterans without DM, substantiating the importance of addressing menopause health issues in the clinical management of women with DM. The data provide evidence that among women with DM, glucose control is an important correlate of menopause symptom severity, suggesting intervention efforts targeting glycemic control may improve the menopause symptom experience for women with DM. The combined impact of menopause symptom severity and glucose control adversely affected the perceived physical health, but not mental health status of women veterans with DM

This research also identifed factors that may suggest women veterans who use VA services are a unique subset of the female population. The high rate of surgical menopause (53%) at an early age coupled with an earlier age of natural menopause merit further consideration, given the increased cardiovascular disease risk associated with early menopause. Further, prevalence rates for some menopause related symptoms (muscle/joint aches, altered mood, sleep disturbance) were notably higher in this sample than in other investigations of healthy women. Whether an earlier age of menopause or the increased symptom prevalence is a function of the unique characteristics of this sample or a factor related to military service experience is beyond the scope of this study, but does suggest other opportunities for further inquiry.

PUBLICATIONS:

Journal Articles

  1. Rouen PA, Krein SL, Reame NE. Postmenopausal Symptoms in Female Veterans with Type 2 Diabetes: Glucose Control and Symptom Severity. Journal of women's health (2002). 2015 Jun 1; 24(6):496-505.
Conference Presentations

  1. Rouen P, Krein SL, Roberts J, Reame N. Menopause Symptoms in Women with Diabetes: Glucose Control is an Important Correlate of Severity. Paper presented at: North American Menopause Society Annual Meeting; 2009 Sep 30; San Diego, CA.


DRA: Aging, Older Veterans' Health and Care
DRE: Prevention
Keywords: Diabetes, Women - or gender differences
MeSH Terms: none

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