Current Women’s Health Reviews, 2008, 4, 3-8
3
Menopause, A Universal Female Experience: Lessons from Mexico and Central America Tracie D. Locklear1, Brian J. Doyle1, Yue Huang2, Alice L. Perez3, Armando Caceres and Gail B. 1, Mahady * 1
Departments of Pharmacy Practice and Medicinal Chemistry and Pharmacognosy, UIC PAHO/WHO Collaborating Centre for Traditional Medicine, University of Illinois at Chicago, College of Pharmacy, 833 S. Wood St., Chicago, IL 60612, USA, 2Centro de Investigaciones en Productos Naturales (CIPRONA) and Escuela de Química, Universidad de Costa Rica, 2060, San Pedro, San José, Costa Rica, 3Universidad de San Carlos, Facultad de Ciencias Químicas y Farmacia, Guatemala City, Guatemala Abstract: In Mexico and Central America, women typically experience menopause up to 10 years earlier than their U.S. counterparts. This may be due in part to numerous pregnancies, long periods of lactation, poor nutrition, extreme environment, and the heavy workload of the Maya women. Unlike Western culture, there is no stigma associated with aging and the menopausal period in the Mayan culture. In fact, menopause is considered to be a welcome natural phenomenon in Central America that all Maya women, who come of age, will experience. Anxiety, negative attitudes, health concerns and stress for the Maya woman are all events that are commonly associated with pregnancy and childbearing, not with menopause. Maya women perceive the menopausal period very positively, as they are no longer burdened with menstrual bleeding and child bearing, and are more relaxed about sexual activities.
n tio
u rib
Thus, compared with their U.S. counterparts, Maya women have a better overall perceptions and attitudes toward the menopausal transition, have symptoms that appear to be short-lived, do not generally use HRT and appear to have a lower prevalence of osteoporosis. Besides genetics, diet and life-style may play a significant role in the overall impact of menopause in these women, as their diet is primarily plant-based, they get plenty of exercise over a lifetime, and they use primarily plant-based medicines and massage to control menopausal symptoms. Thus, the impact of culture and attitude on the menopausal transition in Mexico and Central America appears to be a positive one. Future research should focus on why the prevalence of osteoporosis is low in Maya women and how women in the U.S. might benefit from this information. In addition, collections of data on cognition, as well as cardiovascular and cancer risk between these groups would be of benefit, considering that Maya women do not generally use HRT.
t s i D r
o F t o N
Keywords: Attitudes, Costa Rica, ethnicity, Guatemala, menopause, Maya women, Mexico, osteoporosis, treatment, vasomotor symptoms. INTRODUCTION
The Global Impact of Menopause
Demographic data from the World Health Organization show that the elderly comprise the fastest-growing segment of the world population and that women make up the majority of the aging population in all countries [1]. It has been projected that by the year 2025 the number of people over the age of 65 years of age will be around 800 million (10% of the total population), of which 60% will be women [2]. By the year 2030 it is estimated that there will be more than 60 million postmenopausal women in the U.S. and 1.2 billion postmenopausal women worldwide [1, 3-6]. Menopause is defined as the cessation of menstruation due to a depletion of follicular stores and is retrospectively determined after 12 months of amenorrhea during the midlife period [4, 7]. Since menopause is a major physiological and psychological event in the lives of middle-aged women, how women respond to and cope with the menopausal transition depends on a variety of factors including cultural and *Address correspondence to this author at the Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St., MC 886, Chicago, IL 60612, USA; Tel: 312-996-1669; Fax: 312413-5894; E-mail:
[email protected] 1573-4048/08 $55.00+.00
socioeconomic status, level of education, degree of physical symptoms and attitudes toward treatment [8]. The menopausal transition is associated with increased risks of chronic diseases such as osteoporosis, cardiovascular disease, Alzheimer’s disease, and lower urogenital dysfunction that can significantly impact the quality of life for women [9-14]. A good example is osteoporosis, which is a progressive disease with important clinical implications because osteoporosis-related hip fractures are a great source of disability and mortality [13]. Data from the United States indicates that by the age of 60-70, only one in nine Caucasian women have normal bone mineral density. After the age of 80, about 70% of women have osteoporosis [13]. The incidence of osteoporosis is 80% higher in women than in men and approximately 15% of Caucasian women over the age of 50 will experience an osteoporosis-related hip fracture during their lifetime [14]. Conversely, there are published data suggesting that osteoporosis may be influenced more by ethnicity and lifestyle than estrogen levels alone, as there is little evidence of osteoporosis in Maya populations [15-17] and osteoporosis is rarely seen in Asian communities [18]. In fact, in the U.S., it has been shown that only 10% of Hispanic and 20% of Asian women over the age of 50 have osteoporosis [14].
© 2008 Bentham Science Publishers Ltd.
4 Current Women’s Health Reviews, 2008, Vol. 4, No. 1
In addition to chronic diseases, the relationship between the perceived change in the quality of life and the menopausal transition with regard to physical health, psychosomatic status, and personal life appears to be altered. One study has demonstrated that the menopausal transition is significantly associated with a decrease in perceived physical health and psychosomatic status [19]. Approximately 7983% of women reported that their physical health or energy levels had decreased over the previous year. Forty-one percent of women reported an increase in psychosomatic stress by the age of 48 years that increased to 47% by the age of 54 years. However, it is interesting to note that women with two or more children reported an improvement in psychosomatic domain and personal life, while only physical inactivity was a significant risk factor for declining physical health [19]. Attitudes, Symptoms and Treatment of Menopause in the United States In the United States, most women experience menopause by the age of 51, and between 55-82% of women will experience vasomotor symptoms (hot flashes) or other symptoms such as depression, mood swings, sleep disorders, vaginal dryness, and joint pain [20-25]. One five year study involving 454 women from the Massachusetts Women’s Health Study found that the frequency of hot flashes and night sweats correlated with poor education, a longer perimenopausal period, difficulties in psychological and physical health prior to menopause, and more negative attitudes towards menopause in general [26]. Body mass index, smoking, education and socioeconomic status were the greatest indicators of frequency and severity of symptoms and in some cases, predictors of an early onset of menopausal symptoms [25, 27-29]. Additionally, symptoms were reported more frequently in women who were less physically active [30]. However, one American based study showed that exercise does not decrease the risk of having menopause symptoms in overweight, postmenopausal women and actually increased severity of some of the symptoms in a small number of the women [31].
Mahady et al.
estradiol (E2) and follicle stimulating hormone (FSH), when measured longitudinally over the early menopausal transition, vary by race/ethnicity independently of each other, suggesting an ethnic-specific variation in the pituitary-ovarian relationship [32]. This study showed that E2 and FSH vary by ethnicity and age independently from menopausal status and that the effect of body mass index on serum E2 and FSH levels varies by menopausal status. Specifically, Chinese and Japanese women had lower E2 concentrations than Caucasian women, despite comparable FSH levels, whereas African-American women had higher FSH concentrations than Caucasian women, despite compar-able E2 levels. The E2 and FSH differences in ethnicity were not affected by menopausal status classification, and decreases in E2 and increases in FSH with age persisted even after controlling for the effects of progression through the different stages of the menopausal transition [32].
u rib
t s i D r
o F t o N
Several studies have found significant correlations between race/ethnicity and the prevalence of menopausal symptoms and hormone levels [18, 24, 32]. The Study of Women’s Health Across the Nation (SWAN) was one of the largest multiethnic studies focused on the relationship of socio-demographic and lifestyle factors on menopausal symptoms experienced by women in the United States [33]. The study involved 12,425 women of African-American, Japanese, Chinese, Hispanic, and Caucasian decent. Results from this study suggested that ethnicity serves as a significant predictor for the prevalence of menopausal symptoms. Over 50% of late peri-menopausal women surveyed reported hot flashes or night sweats. However, Hispanic and African American women reported having hot flashes and night sweats most frequently. Additionally, Hispanic women reported experiencing urine leakage, vaginal dryness, and heart palpitations most frequently, whereas Japanese and Chinese women reported fewer symptoms in general with the exception of heart palpitations and forgetfulness [33]. One investigation of 3,257 women involved in the SWAN study found that the serum concentrations of
n tio
In the U.S., approximately 25-30% of women will seek treatment from their health care provider for the symptoms of menopause, and for many, hormone replacement therapy (HRT) will be recommended as the first line treatment for menopausal symptoms [20, 34]. HRT has been the Western medicine’s gold standard for the symptomatic treatment of menopause. A number of studies have demonstrated the acute and chronic benefits of HRT, including the reduction of menopausal symptoms such as hot flashes and insomnia, as well as possible reductions in the risk of osteoporosis [20, 35]. However, the results from the Women’s Health Initiative (WHI) have suggested that HRT maybe more harmful than beneficial [36]. Data from WHI revealed an increase in heart disease by 29%, and an increase in breast cancer by 26% [36]. Thus, a significant number of women have refused or discontinue HRT due to the perceived risks, medical contraindications, or a general reluctance to use “unnatural” exogenous hormones [37]. Consequently, many women in the U.S. have chosen alternative treatments for menopause, including botanical dietary supplements (BDS) [5, 38, 39]. Common BDS for the treatment of menopausal symptoms used among U.S. women include dong quai (Angelica sinensis L., Apiaceae), ginseng (Panax ginseng C.A. Meyer, Araliaceae), evening primrose oil (Oenothera biennis L., Onagraceae), black cohosh (Actaea racemosa L., Ranunculaceae; [syn.: Cimicifuga racemosa (L.) Nutt.]), red clover (Trifolium pratense L., Fabaceae) and soy (Glycine max Merril, Fabaceae). Although red clover, soy and black cohosh appear to be promising candidates for the symptomatic relief of menopausal symptoms, further studies are needed to ascertain their long-term safety [38]. Interestingly, while HRT is readily available for Hispanic menopausal women, studies have shown that Hispanic women in the U.S. are among the ethnic groups least likely to use conventional HRT to treat their menopausal symptoms [30, 40-44]. Herbal teas, diet, vitamins and exercise were frequently mentioned as treatment alternatives, while other Hispanic women let the symptoms subside on their own [43-45]. Attitudes, Symptoms and Treatment of Menopause in Mexico and Central America In urban areas of many Latin American countries, women enter menopause at an average age of 48.6 years [46,47]. However, for the rural Maya women of Mexico, menopause
Menopause, A Universal Female Experience
Current Women’s Health Reviews, 2008, Vol. 4, No. 1
usually occurs between the ages of 41-48 years (mean 44.5 years), almost 10 years earlier than in women in the United States [17, 48, 49]. The lifestyle of rural Maya women is such that they tend to marry in their early teens before menstruation, become pregnant at 2.5-year intervals, and breastfeed each child for about two years with associated lactation amenorrhea of approximately 18 months [50]. Additionally, the everyday workload of the rural Maya women is high and they are constantly performing weightbearing activities such as carrying firewood, grinding corn, pulling water from the well and walking an average of two hours per day [16,17]. Thus, numerous pregnancies, long periods of lactation, altitude, poor nutrition, extreme environment, low socioeconomic status and heavy workloads are thought to be the main reasons why Maya women have an earlier onset of menopause [28, 46, 51]. The hormone-associated symptoms U.S. women experience during menopause such as hot flashes and night sweats are not observed as frequently in the rural Maya populations, and menopause is not associated with a decline in health [52]. Data from studies in Mexico indicate that Mexican women tend to have more positive attitudes toward menopause and fewer menopausal symptoms as compared with their counterparts in the U.S. and Europe [15, 52]. One small, frequently cited, study among Maya women (n = 78) in Chichimila, Mexico demonstrated that, although FSH and luteinizing hormone (LH) levels were as high as those in American postmenopausal women, none of the Maya women reported any of the vasomotor symptoms usually associated with such hormonal changes [49, 52]. Another small study involving 107 Maya women from Yucatán also found no symptoms associated with the menopausal transition, other than the cessation of menstruation [15]. In addition, bone density measurements have revealed that although bone demineralization occurs at rates similar to U.S. women, no evidence of osteoporosis has been found [15-17, 52]. In the Yucatán, menopause was considered a natural part of aging, and not a condition that normally required treatment [15].
and that an increase in education and awareness of medical alternatives may influence tolerance of symptoms and the perception of bodily changes [54]. In addition, urbanization in Mexico is associated with significant dietary changes and a decline in fertility, factors that may also alter menopausal symptoms [54]. In rural Mexico, the attitude towards the menopausal transition appears to be a positive one of relief, freedom, and “feeling young” [15]. Anxiety and frustration are more associated with menstruation and pregnancy than with menopause. During menstruation, women have food restrictions, constantly worry about spotting, are not allowed to participate in community activities, and have to stay at home and arrange their activities around their menses [15]. In the urban areas of Mexico, the views toward menopause were mixed. In Puebla, Mexico, 755 women ages 28-70 were interviewed and asked how a woman feels about menopause [55]. Seventy-five percent of the women viewed the menopausal woman as “successful” and 62% said “complete”, indicating a positive attitude overall [55].
In contrast, some of the more recent studies from various rural and urban centers in Mexico report that 28-50% of postmenopausal Mexican women complained of hot flashes and night sweats [47, 53-55]. These data are more consistent with what is known about U.S. women [47, 53-55]. Women in rural areas of Yucatán, Mexico, predominately Maya, commonly experienced backache and tiredness during the menopausal transition, as well as sweating and hot flashes (31-35%) [53]. In 2002 a study involving 7,632 women between the ages of 45-60 from the rural and urban areas of three states in Mexico: Guanajuato, Coahuila, and Yucatàn measured the influences of modern cultural conditions on the symptoms of menopause [47]. The occurrence of hot flashes varied from 32-73%, and was significantly associated with poorer education, rural lifestyle, higher body mass index and the state of residence. The study concluded that ethnic, socio-cultural and environmental factors are involved in the appearance of symptoms but that, interestingly, urbanization may reduce symptoms [47]. Discrepancies in the results between studies may be explained by the shift from a more rural existence to a more urban lifestyle, as many families in Mexico move to the cities. It has been suggested that the medicalization of menopause may increase with urbanization
n tio
The data for menopausal symptoms, attitudes and treatments from Central American countries are more limited than Mexico and come primarily from Guatemala and Costa Rica. In Guatemala, there are 22 ethno-linguistic groups of Mayan origin making it an extremely good site to investigate menopausal symptoms in traditional rural ethnic populations [17, 56]. In one small study, Maya women from three ethnolinguistic groups in highland Guatemala were asked about their menopausal symptoms and experience [48]. Approximately 75% of women interviewed reported having hot flashes lasting a few seconds to a few minutes, 41% of women described hot flashes with sweating at night that would disturb their sleep, and 50% reported sleep disturbances [48]. Fifty-eight percent of women reported increased irritability, moodiness and anger, while few women reported heart palpitations and occasional light-headedness or faintness. Although, these women found the symptoms associated with menopause inconvenient, they reported that their symptoms lasted only a few months, and felt that they were only temporary. Thus, the menopausal symptoms reported by women from Western Highland Guatemala are similar to those reported by women in the United States including hot flashes, night sweats, changes in libido, irritability, mood swings, anxiety, heart palpitations, lightheadedness, menstrual flooding and irregularity prior to cessation of menses. However, these symptoms are not severe and do not last for long periods of time. Treatment for the symptoms of menopause included steam baths, lower abdominal massage by midwives and herbs. No Western-style medical treatment was sought to manage menopausal symptoms. These Maya women also had little problem with osteoporosis in the postmenopausal period, which has been attributed to the typical Maya diet and work patterns [48].
u rib
t s i D r
o F t o N
5
Another qualitative study published in 2006 explored symptoms, attitudes and treatments surrounding women’s health and menopause among the Q’eqchi Maya of the eastern tropical lowlands of Guatemala [17]. Data for this study were obtained through participant observation, semistructured interviews, and focus groups. The results of this study showed that the Q’eqchi Maya of Livingston possess
6 Current Women’s Health Reviews, 2008, Vol. 4, No. 1
Mahady et al.
their own cultural perceptions of women’s health that affected attitudes, symptoms and treatment choices during the menopausal transition. Ninety percent of the postmenopausal women interviewed indicated experiencing one or more symptoms during the menopausal transition, including headaches, anxiety, muscular pain, depression, and hot flashes [17]. In general, most women in Guatemala had a very positive perspective about their entrance into menopause. They welcome the knowledge that they would no longer become pregnant, no longer have the inconvenience of bleeding, and could have more sexual freedom [48]. It is also a relief to women that they will no longer have to deal with the dangers of pregnancy in a country with a high maternal mortality rate [57].
of myocardial infarction by 38% [65], and 600 milligrams per day of ipriflavones have been shown to increase bone density in postmenopausal women [66].
In contrast to Guatemala, Costa Rica has historically been a model for Central America in that it is politically stable and has a relatively high standard of living as compared with other countries. It is an unusual developing country in that only 1% of its population is indigenous, it has a very high literacy rate (93%), and there has been concerted effort focused on improving healthcare [58,59]. Over the past 10 years, Costa Rica has implemented health care programs to improve women's health, particularly in the field of reproductive health (e.g., high coverage of institutional deliveries and prenatal care) [58,59]. However, like most other countries, it faces key challenges associated with rapid changes in age demographics and epidemiologic transition, such as cardiovascular disease, control and treatment of cervical cancer, breast cancer, poor nutrition, mental health, and the problems associated with menopause [57]. Women in Costa Rica enter menopause around the same age as women in the U.S. and have similar symptoms [57]. Recognizing the changing age demographics, numerous women’s groups and physician’s associations have been organized in Costa Rica to address the chronic sequelae of menopause which will be an increasing problem in the near future. However, while the symptoms of menopause are similar to the U.S., and osteoporosis is a problem due to poor nutrition [60], there are no further published data, making this an ideal future research topic.
Lessons to be Learned from Our Mexican and Central American Counterparts
The consumption of foods rich in phytoestrogens, such as yams and legumes, is purported to ameliorate hot flashes [67], and one recent study suggested that incorporation of yams (replacing rice) into the diet of postmenopausal women significantly increased the serum concentrations of estrone (26%), sex hormone binding globulin (SHBG) (9.5%), and estradiol (27%) [67]. Thus, there are many lifestyle factors in the Mayan culture that may explain why the Maya women experience less severe symptoms than Western women and have a lower prevalence of osteoporosis.
I.
Attitude. Limited cross-cultural research on menopause suggests that attitudes and incidences of symptoms vary considerably depending on environment, health status and cultural paradigms around women’s health [24, 68, 43]. Data on menopause in Latin America comes primarily from Mexico and some from Guatemala, and most studies suggest that these women have more positive attitudes toward menopause as compared with their counterparts in the U.S. and Europe [15, 52]. Most Maya women welcome menopause and this transition for them represents becoming a respected and revered member of the community. This positive attitude may directly impact the severity of symptoms and the duration of these symptoms. Menopausal women are entitled to the same (perhaps more) respect as women of any other age group. Fears about health and increased chronic disease during this post-menopausal period need to be dealt with by the new “preventative paradigm” of health care as proposed by Palacios et al [69]. Dealing with such issues may improve the overall health of menopausal women, and thus improve their overall outlook on aging.
u rib
t s i D r
o F t o N
In the rural areas of Mexico, Guatemala, and Costa Rica women tend to consider menopause a natural phenomenon and treat the symptoms with herbs, teas, and hot baths [17, 48]. Menopausal symptoms are treated for a short period of time with little reliance on Western medicine. In addition, the impact of diet and exercise should not be underestimated for these women. As mentioned previously, the lifestyle of the rural Maya women is extremely labor intensive. Numerous pregnancies, long periods of lactation, living in high altitudes, poor nutrition, extreme environment, low socioeconomic status and heavy workloads are thought to be the main reasons why Maya women have an earlier onset of menopause [28, 46, 51]. In addition, the traditional Mayan diet is very high in vegetables, fiber, vitamin A, and fish, but also lower in red meat [17, 48]. Thus, their diet is also very high in plant-based flavonoid constituents and phytoestrogens from vegetables. Phytoestrogens have both weak estrogenic activity as well as antiestrogenic activity [61-63], and evidence suggests that phytoestrogens could protect against bone loss and heart disease [61,62, 64]. In fact, one serving per day of legumes has been shown to lower the risk
n tio
II. Osteoporosis Prevention. By far, one of the most common issues that impact the quality of life (QOL) for menopausal women is osteoporosis. Osteoporosis is a systemic, progressive disease in which the quality and quantity of bone mass are both decreased. Osteoporosisrelated fractures, mainly of the hip, are a great source of disability and mortality to predominantly older women in Westernized countries. The risk of disability after a hip fracture is > 50% and the risk of mortality is 1020%. Thus, prevention, detection and treatment of osteoporosis are major public health concerns [13]. Studies of menopausal women in Mexico and Guatemala indicate that these women exhibit little or no evidence of osteoporosis [15, 17, 48]. In fact, investigation of bone density measurements have revealed that bone demineralization does occur in Maya women at rates similar to women in the U.S.; however, no evidence of osteoporosis has been found [15, 52]. Why this is the case is not understood, although the plantbased diet and heavy physical exertion over a lifetime may play a role. Their physically strenuous lifestyle that includes weight-bearing activities may contribute to the low reporting of osteoporosis in these populations. Such
Menopause, A Universal Female Experience
Current Women’s Health Reviews, 2008, Vol. 4, No. 1
results should be confirmed in large-scale studies, and if proven to be correct, the possible benefit to women in Westernized countries could be significant. III. Menopausal Treatments. Since the menopausal symptoms experienced by the Maya women in Mexico and Central America are less severe, these symptoms are treated with botanicals, teas and steam baths, with little reliance on Western medicine. In fact, this trend appears to continue with immigrant Hispanic women in the U.S. who elect not to use HRT, but instead opt for exercise, diet, botanicals and other self-care activities to manage their symptoms of menopause [40, 43]. While the wide array of botanicals used for the treatment of menopausal symptoms in Mexico, Guatemala, Costa Rica and other Central American countries have not been extensively investigated, a few studies have been published [17, 69]. Most of these plants have no in vitro, in vivo or clinical data to support their use; however, women continue to use botanicals for the alleviation of menopausal symptoms. These plant species should be tested for safety and effectiveness and pursued as much needed therapies for the treatment of menopausal symptoms. ACKNOWLEDGEMENTS
[14] [15]
[16] [17]
[18] [19] [20] [21] [22]
[23] [24]
[25] [26] [27] [28]
REFERENCES
o F t o N [1]
[2] [3]
[4]
[5] [6]
[7]
[8] [9] [10]
[11]
[12] [13]
National Osteoporosis Foundation. Disease Facts. http://www.nof. org/osteoporosis/diseasefacts.htm. Accessed November 07, 2006. Beyene Y. Cultural significance and physiological manifestations of menopause: a biocultural analysis. Cult Med Psychiatry 1986; 10: 47-71. Stewart DE. Menopause in Highland Guatemala Mayan women. Maturitas 2002; 43(1): 11-19. Michel JL, Mahady GB, Valiz M, Sojarto DD, Càceres A. Symptoms, attitudes and treatment choices surrounding menopause among the Q'eqchi Maya of Livingston, Guatemala. Soc. Sci Med 2006; 63(3): 732-42. Lock M, Kaufert P. Menopause, local biologies, and cultures of aging. Am J Hum Biol 2001; 13: 494-504. Mishra G, Kuh D. Perceived change in quality of life during menopause. Soc Sci Med 2006; 62: 93-102. Brosage P. Hormone therapy: The woman’s decision. Contemp Nurse Pract 1995; S1: 3. Feldman BM, Voda A, Gronseth E. The prevalence of hot flash and associated variables among peri-menopausal women. Res Nurs Health 1985; 8(3): 261-68. Fitzpatrick LA. Selective estrogen receptor modulators and phytoestrogens: new therapies for the postmenopausal women. Mayo Clin Proc 1999; 74(6): 601-607. Freedman RR. Physiology of hot flashes. Am J Hum Biol 2001; 13: 453-64. Gold EB, Sternfeld B, Kelsey JL, et al. Relation of Demographic and lifestyle factors to symptoms in a multi-racial/ethic population of women 40-55 years of age. Am J Epidemol 2000 152(5): 46373. McKinlay SM, Brambilla DJ, Posner JG. The normal menopause transition. Am J Hum Biol 1992; 4: 37-46. Avis NE, Crawford SL, McKinlay SM. Psychosocial, behavioral, and health factors related to menopause symptomology. Women’s Health 1997; 3: 103-20. Schwingl PJ, Hulka BA, Harlow SD. Risk factors of menopausal hot flashes. Obstet Gynecol 1994; 84(1): 29-34. Harlow BL, Signorello LB. Factors associated with early menopause. Maturitas 2000; 35(1): 3-9. Ortega-Ceballos PA, Moran, C, Blanco-Munoz, J, Yunes-Diaz, E, Castaneda-Iniguez, MS, Salmeron J. Reproductive and lifestyle factors associated with early menopause in Mexican women. Salud publica de Mexico 2006; 48(4): 300-307. Avis NE, Ory M, Matthews KA, Schoken M, Bromberger J, Colvin A. Health-related quality of life in a multiethnic sample of middle aged women: Study of women’s health across the nation (SWAN). Med Care 2003; 41: 1262-76. Aiello EJ, Yasui Y, Tworoger SS, et al. Effect of a year-long, moderate-intensity exercise intervention on the occurrence and severity of menopause symptoms in postmenopausal women. Menopause 2004; 11(4): 372-74. Randolph JF Jr., Sowers M, Bondarenko IV, Harlow SD, Luborsky JL, Little RJ. Change in estradiol and follicle-stimulating hormone across the early menopausal transition: effects of ethnicity and age. J Clin Endocrinol Metab 2004; 89(4): 1555-61. Avis NE, Stellato R, Crawford S, et al. Is there a menopausal syndrome? Menopausal status and symptoms across racial/ethnic groups. Soc Sci Med 2001; 52: 345-56. Grodstein F, Stampler MJ, Colditz GA, et al. Postmenopausal hormone therapy and mortality. New Eng J Med 1997; 336:176975. Burkman RT, Collins JA, Greene RA. Current perspectives on benefits and risks of hormone replacement therapy. Am J Obstet Gynecol 2001; 185: S13-23. Rossou JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA 2002; 288: 321-33. Adams C, Cannell S. Women’s beliefs about “natural” hormones and natural hormone replacement therapy. Menopause 2001; 6: 433-40. Kronenberg F, Fugh-Berman A. Complementary and alternative medicine for menopausal symptoms: A review of randomized; controlled trials. Ann Intern Med 2002; 137(10): 805-13. Low Dog T, Powell KL, Weisman SM. Critical evaluation of the safety of Cimicifuga racemosa in menopause symptoms relief. Menopause, 2003; 10(4): 299-13.
Anon. WHO Annual Report 2001, WHO Publications Office, Geneva, Switzerland, 2003. World Health Report 1999. Making a difference. http://www.who. int/whr/1999. Accessed December 3, 2006. Hill K. The demography of menopause. Maturitas 1996; 23: 11327. Houmard BS, Seifer DB. In: Seifer DB, Kennard EA, Eds, Menopause, Endocrinology and Management. Totowa, NJ. Humana Press, 1999; 1-20. Mahady GB. Black cohosh (Actaea/Cimicifuga racemosa): review of the clinical data for safety and efficacy in menopausal symptoms. Treat Endocrinol 2005; 4:177-84. Mahady GB, Doyle BJ, Locklear TD, Cotler S, Hartman G. Krishnaraj R. Black cohosh (Actaea racemosa) for the mitigation of menopausal symptoms: recent developments in clinical safety and efficacy. Women’s Health 2006; 2: 773-83. World Health Organization Scientific Group. Research on the menopause. WHO Technical Report Ser. 670, World Health Organization, Geneva Switzerland, 1981. Rice VM. Strategies and issues of managing menopause-related symptoms in diverse populations: ethnic and racial diversity. Am J Med 2005; 118(12B): 142S-7S. Knight DC, Eden JA. A review of the clinical effects of phytoestrogens. Obstet Gynecol 1996; 87: 897-904. Gorodeski, G. Update on cardiovascular disease in postmenopausal women. Best Practice and Research Clinical Obstetrics and Gynecology 2002; 16(3): 329-55. Yoon B, Kim DK, Kang, Y, Kim J, Shin M, Na DL. Hormone replacement therapy in postmenopausal women with Alzheimer’s disease: a randomized, prospective study. Fertility and Sterility 2003; 79(2): 274-80. Bradley JV. Genitourinary symptoms in the menopausal transition. Am J Med 2001; 118(12b): 47S-53S. Palacios S, Sanchez-Borregp R, Forteza A. The importance of preventative health care in post-menopausal women. Maturitus, 2006; 52: S53-S60.
[29]
[30]
[31]
[32]
[33]
[34] [35]
[36]
[37] [38]
[39]
n tio
u rib
t s i D r
This publication was made possible by Grant Number R21-AT02381 from the National Center for Complementary and Alternative Medicine, NIH. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NCCAM or NIH.
7
8 Current Women’s Health Reviews, 2008, Vol. 4, No. 1 [40] [41]
[42] [43] [44] [45] [46]
[47] [48] [49] [50]
[51] [52]
[53] [54]
Longworth, JC. Hispanic women's experience with "el cambio de vida". J Am Acad Nurse Pract 2003; 15(6): 266-75. Gavaler, JS. Oral hormone replacement therapy: Factors that influence the estradiol concentrations in a multiracial study population. J Clin Pharmacol 2002; 42: 137-44. Laws M, Carballeira N. Use of nonallopathic healing methods by Latina women at midlife. American J Pub Health 2003; 93(4): 524. Mahady GB, Parrot J, Lee C, Yun GS, Dan A. (). Botanical dietary supplement use in pre- and postmenopausal women. Menopause 2003; 10(1): 65-72. Bell ML. Attitudes toward menopause among Mexican American women. Health Care Women Int 1995; 16: 425-35. Kay M, Voda A, Olivas G, Rios F, Imle M. Ethnography of the menopause-related hot flash. Maturitas 1982; 4(3): 217-27. Blümel JE, Chedraui P, Calle A, et al. Age at menopause in Latin America. Menopause: J North Am Menopause Soc 2006; 13(4): 706-712. Malacara JM, Canto de Cetina T, Bassol S, et al. Symptoms at preand postmenopause in rural and urban women from three States of Mexico. Maturitas 2002; 43(1): 11-19. Stewart DE. Menopause in highland Guatemala Mayan women. Maturitas 2003; 44: 293-97. Beyene Y, Martin MC. Menopausal experiences and bone density of Mayan women in Yucatan. Am J Hum Biol 2001; 13(4): 505-11. Beyene Y. From menarche to menopause: reproductive lives of peasant women in two cultures. Albany: State University of New York Press. 1989. Vermeulen A. Environment, human reproduction, menopause, and andropause. Environ Health Perspect 1993; 101 Suppl 2: 91-100. Martin MC, Block JE, Sanchez SD, Arnaud CD, Beyene Y. Menopause without symptoms: the endocrinology of menopause among rural Mayan Indians. Am J Obstet Gynecol 1993; 168: 1830-46. Cant-de-Cetina TE, Canto-Cetina P, Polanco-Reyes L. Survey of climacteric symptoms in semi-rural areas of Yucatan. Rev Inves Clin 1998; 50:133-35. Sievert LL, Freedman RR, Garcia JZ, et al. Measurement of hot flashes by external skin conductance and subjective hot flash report in Puebla, Mexico. Menopause 2002; 9: 367-76. Sievert LL, Espinosa-Hernandez G. Attitudes towards menopause in relation to symptom experience in Puebla, Mexico. Women’s Health 2003; 38(2): 93-106.
Received: April 30, 2007
[56]
[57] [58]
[59] [60] [61] [62] [63]
[64] [65]
[66]
Giron L, Freire V, Alonzo A, Caceres A. Ethnobotanical survey of the medicinal flora used by the Caribs of Guatemala. J Ethnopharmacol 1991; 34(2-3): 173-87. Pan American Health Organization (PAHO). Traditional Health Systems in Latin America and the Caribbean: Base Information Technical Project Report, 1999. Bixby LR. Assessing the impact of health sector reform in Costa Rica through a quasi-experimental study. Rev Panam Salud Publica 2004; 15: 94-103 Rosero-Bixby L. Spatial access to health care in Costa Rica and its equity: a GIS-based study. Soc Sci Med 2004; 58(7): 1271-84. Monge-Rojas R, Nunez HP. Dietary calcium intake by a group of 13-18 year old Costa Rican teenagers. Arch Latinoam Nutr 2001; 51(2): 127-31. Gris Martinez JM. Isoflavones in menopause women. Med Clin (Barc) 2006; 127(9): 352-56. Knight DC, Eden JA. A review of the clinical effects of phytoestrogens. Obstet Gynecol 1996; 87: 897-904. Knight DC, Lyons Wall P, Eden JA. A review of phytoestrogens and their effects in relation to menopausal symptoms. Aust J Nutri Diet 1996; 53: 5-11. Anderson JW, Johnstone BM, Cook-Newell ME. Meta-analysis of the effects of soy protein intake on serum lipids. N Engl J Med 1995; 333 (5): 276-82. Kabagambe EK, Baylin A, Ruiz-Narvarez E, Siles X, Campos H. Decreased consumption of dried mature beans is positively associated with urbanization and not fatal acute myocardial infarction. J Nutr 2005; 135(7): 1770-75. Valente M, Bufalino L, Castiglione GN, et al. Effects of 1-year treatment with ipriflavone on bone in premenopausal women with low bone mass. Calcif Tissue Int 1994; 54: 377-80. Murkies AL, Wilcox G, Davis SR. Phytoestrogens. J Clin Endocrinol Metab 1998; 83: 297-303. Sommer B, Avis N, Meyer P, et al. Attitudes toward menopause and aging across ethnic/racial groups. Psychosom Med 1999; 61: 868-875. Palacios S, Borrego RS, Forteza A. The importance of preventive health care in post-menopausal women. Maturitas 2005;52 Suppl 1:S53-60.
[67]
[68] [69]
Revised: December 7, 2007
n tio
u rib
t s i D r
o F t o N [55]
Mahady et al.
Accepted: December 7, 2007
