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Depressive symptoms found likely to decrease after menopause

Depression has long been listed as a symptom characteristic of the menopause. In the Women’s Health Initiative Memory Study (WHIMS), a placebo-controlled prevention clinical trial examining whether opposed and unopposed hormone therapy reduced the risk of dementia in healthy postmenopausal women, 18% of more than 7000 women enrolled were found to have at least one psychiatric disorder, with depression being the most common (16%) followed by general anxiety or panic (6%) and alcohol abuse (1%). ¹

These, of course, were women beyond the menopausal transition, defined by the study's protocol as aged between 65 and 79 years, but the increased risk of depressive symptoms in the pre- and perimenopausal years has been repeatedly observed in population studies. However, while US national survey data indicate that the prevalence of depressive disorders is highest in women aged 40–49 years and lowest in women older than 60 years, the risk of depressive symptoms in the decade between these years has not been identified. ²

Now, however, a new study has confirmed the overall pattern of decreasing depressive symptoms in midlife women, in which the final menstrual period is described as ‘pivotal'.³ The study found that the risk of depression was indeed lower in menopausal women after their final menstrual period than before – with the risk of depressive symptoms higher in each year before and lower in each year after the final menstrual period. Only in women with a history of depression did the risk of depressive symptoms both before and after the menopause increase.

The study examined depressive symptoms over a 14-year period in 203 women who were premenopausal at baseline and progressed through the menopause during the study. Symptoms, assessed on the Center for Epidemiologic Studies Depression Scale, decreased from 10 years before to eight years after the final menstrual period, with a decrease of approximately 15% of baseline per year (OR 0.85; 95% CI 0.81–0.89).

However, the likelihood of depressive symptoms among those with a history of depression was more than 13 times greater overall and eight times greater after the menopause than in those with no depression history – although in women who first experienced depressive symptoms approaching the menopause the risk of depressive symptoms declined after the final menstrual period. The authors concluded:

Although only a small percentage of women experience mood difficulties in relation to menopause, many want to know what to expect in this transition period. Women overall can expect depressive symptoms to decrease after [the final menstrual period], although those with a history of depression have a continuing high risk of recurrence.

Cervical screening up to age 69 may reduce cervical cancer incidence in older women

Screening women for cervical cancer beyond the age of 50 ‘clearly saves lives', according to a new study supported by Cancer Research UK. Benefits of the smear test were seen not just in women in the study age range (50–64 years) but for many years afterwards. ¹ Indeed, according to the sponsors, the study provides evidence ‘that women with adequate screening history and normal (negative) screening results between age 50 and 64 have a lower risk of cervical cancer at least into their eighties'. ‘Adequate screening' was defined in the study as at least three cervical screening tests at age 50–64 years, with the last one over age 60, the last three of which were negative, and no evidence of high-grade abnormalities.

The study examined the link between cervical cancer screening in women aged 50–64 and the incidence of cervical cancer diagnosed at ages 65 to 83. The study included all 65 to 83-year-old women in England and Wales diagnosed with cervical cancer between 2007 and 2012, a total of 1341 women.

Results showed that women who had not been screened past age 50 had a six-fold higher risk of cervical cancer than those with an adequate negative screening history at ages 50–64. Thus, in women who were not screened between the ages of 50 and 64, 49 cervical cancers were diagnosed per 10,000 women aged 65–83 – in contrast to eight cervical cancers per 10,000 adequately screened women with normal results. Women who had been screened regularly but had an abnormal (positive) screening result between 50 and 64 had the highest risk of all – 86 cervical cancers per 10,000 women at age 65–83.

The results suggest that cervical screening in women aged 50–64 has a substantial impact on cervical cancer rates not only in the study age range but also for many years beyond. The level of protection provided by having normal screening results was found to decline over time, but even women in their 80s with adequate screening history and normal results had a lower risk of cervical cancer than those who were not screened.

Professor Peter Sasieni, Cancer Research UK’s expert on cervical screening and a co-author of the study, said:

Screening up to the age of 65 greatly reduces the risk of cervical cancer in the following decade, but the protection weakens with time and is substantially weaker 15 years after the last screen. With life expectancy increasing, it’s important for countries that stop screening under age 60 to look into their screening programmes to maximise the number of cervical cancer cases prevented and the number of cervical cancers caught at an early stage.

Jessica Kirby, Cancer Research UK’s senior health information manager, said in a press statement:

These results provide reassurance that there is a real benefit to women over 50 having cervical cancer screening. Screening can pick up abnormal cells in the cervix that could develop into cervical cancer if left alone – removing these cells prevents cancer from developing. Screening is a great way of reducing the risk of cervical cancer, and saves up to 5000 lives a year in the UK. We encourage women to take up cervical screening when invited.

In a further follow-up to the study, the UK's Health and Social Care Information Centre was quoted as saying that the proportion of women screened for cervical cancer declines from the age of 55 – and that around one quarter of those aged 50 to 64 skip the 5-min test. Figures show that in 2013 some 82% of women aged 50–54 years had been recently tested, but that this proportion dropped to 76% among 55–59-year-olds and to 73% among 60–64-year-olds.

Meanwhile, a study from Sweden using cancer registry data has shown that women previously treated for abnormal cells on the cervix (cervical intraepithelial neoplasia grade 3, CIN3) are at an increased and accelerating risk of developing and dying from cervical or vaginal cancer when compared with the general female population. ² The study covered a total of 3,160,978 women-years and found that there were 355 cause-specific deaths during the study period. There was a steep increase in mortality risk with increased age after a previous CIN3 diagnosis. This risk was more than doubled after 30 years following treatment when compared with that of the general population.

The investigators described cervical screening to prevent cervical cancer is ‘a medical success story', with examinations ‘proven to be an effective way to reduce deaths'. However, they caution that ‘the risk of cervical cancer is not eliminated when abnormal cells are detected and removed and as such women are asked to participate in follow-up programmes'. Nevertheless, they reassuringly insist that women treated for CIN3 cells ‘are well protected from cervical cancer' and only a minority of those treated will develop the disease.

Castanon A, Landy R, Cuzick J, et al. Cervical screening at age 50–64 years and the risk of cervical cancer at age 65 years and older: population-based case control study. PLoS Med 2014; 11: e1001585. DOI:10.1371/journal.pmed.1001585.

It's not what you don't do, but the way you don't do it

Sedentary behaviour, even more than overall physical inactivity, has become a scourge of our times and is now established as an independent risk factor for a whole range of non-communicable diseases. Indeed, a systematic review of 46 studies found a consistent relationship of self-reported sedentary behaviour (mainly watching TV) with mortality and weight gain from childhood to the adult years. ¹ However, according to researchers from the Women's Health Study (WHS, a 1992–2004 randomised trial of aspirin and vitamin E in the prevention of cardiovascular diseases and cancer), few data exist on how this sedentary behaviour is ‘patterned' – in a few long bouts or in many short bouts – and whether these patterns are relevant for health.

Now, a follow-up ancillary study to the WHS begun in 2011 has assessed the patterns of physical activity (or inactivity) from more than 7000 women (mean age 71 years) persuaded to wear an ‘accelerometer' for a week, and has found that they spent around two-thirds of their waking time in sedentary behaviour. ² Most of these sedentary episodes occurred in ‘bouts lasting less than 30 minutes'.

For the record, an accelerometer is a small electronic device which effectively measures the force of acceleration – and thus the movement and speed of the wearer. Accelerometer has been incorporated into running shoes and in smart phones as an app. In this study, a bout of sedentary behaviour was defined as consecutive minutes in which the accelerometer registered fewer than 100 counts per minute.

Results of the study showed that the mean number of sedentary bouts per day in this population of older women was 85.9, with 9.0 breaks per sedentary hour. Adjusting for wear time and smoking status, total sedentary time increased and the number of bouts and breaks per sedentary hour decreased as age and BMI increased. Such findings, say the authors, will be useful when the time comes to provide doctors with sedentary behaviour guidelines. Meanwhile, a study from the Women's Health Initiative Observational Study concluding in 2010 has found a linear relationship between lengthy periods of sedentary inactivity and mortality risk after controlling for multiple potential confounders.³ Postmenopausal women who spent more than 11 hours a day in sedentary behaviour faced a 12% higher risk of all-cause premature mortality than the most energetic group – those with four hours or less of inactivity. The former group increased their risk of death from cardiovascular disease, coronary heart disease and cancer by 13, 27 and 21%, respectively.

‘The assumption has been that if you're fit and physically active, that will protect you, even if you spend a huge amount of time sitting each day’, said investigator Rebecca Seguin from the Cornell College of Human Ecology in New York. ‘In fact, in doing so you are far less protected from negative health effects of being sedentary than you realize.’