Long-term impacts of early and surgical menopause.

T here is growing evidence that both surgical menopause (removal of ovaries or oophorectomy) and premature menopause (menopause that occurs before the age of 40 y) have negative consequences for psychological and physical health. Regardless of cause, women who experience menopause at an age well before the median age of natural menopause are now recognized to be at an increased risk of premature morbidity and mortality. Although the impact on hormonal regulation differs for women with spontaneous premature ovarian failure compared with women who experienced induced menopause due to bilateral oophorectomy or to cancer treatment, both conditions are associated with long-term health risks. These include premature death, cardiovascular and neurological disease, and osteoporosis, in addition to menopausal symptoms, psychological symptoms, and impaired sexual function. The effects tend to be more pronounced for women who have menopause before the age of 45 years and who do not take hormone therapy (HT). HT use is recommended for women with early menopause up until the age of 50 years. HT seems to reduce some, although certainly not all, of the long-term health consequences of surgical or premature menopause. In this issue of Menopause, Tom et al investigate the long-term impact of both surgical menopause and the timing of menopause on objective measures of physical functioning. The study is noteworthy because of the current age of the participants (60-90 y) as well as the inclusion of standard objective measures of physical performance. A total of 1,765 women who participated in the National Health and Nutrition Examination Survey III, a cross-sectional sample representative of the United States population, were asked to recall age at final menstrual period and/or age at removal of the uterus and ovaries and completed an assessment of current physical performance. This was assessed using objective methodsVa walk trial and chair risesVand subjective methods (ie, their appraisal of their functional limitations). Of the total sample, 1,157 (average age, 71 y) had had a natural menopause, and 608 (average age, 69 y) had a surgical menopause; the mean age at natural menopause was 49 years, and at surgical menopause, it was 42 years. The authors were able to investigate the relative impacts of the timing and type of menopause by comparing natural versus surgical menopause and by comparing the age of menopause in both of these conditions. The main findings were that women with surgical menopause had an average chair rise time that was significantly (4.3%) slower than that of women with natural menopause; there were no between-group differences in walking speed or self-reported functional limitations. In terms of timing of menopause, later age at natural menopause was associated with faster walking speed and less self-reported functional limitation than earlier age at natural menopause, whereas later age at surgical menopause was related to a moderately decreased likelihood of self-reported functional limitation but not to differences in walk speed or chair rise time. Although these differences are relatively small, they are considered clinically relevant. These results, taken together, do suggest some negative impacts of surgical and early menopause in the longer term (ie, many years after the event). However, the interpretation of the findings is not straightforward. There are methodological issues such as recall of last menstrual period or surgery that relied on memory in these older adults and could be affected by low mood and cognitive impairment, both of which have been associated with early and surgical menopause. A mainly biological interpretation of the findings is proposed, but there are also psychological sequelae of early menopause and surgical menopause that can be long-lasting and that might have a range of psychosocial and well as biological causations. The authors adjusted for a range of sociodemographic variables, but current mood, ill health, and fitness were not included. Moreover, using a crosssectional design, it was not possible to exclude common determinants of both early or surgical menopause and subsequent physical functioning. The inclusion of mood, cognitive performance, ill health, and exercise/fitness in future studies might help explain the discrepancies between subjective and objective measures of physical functioning, as well as possibly increase the understanding of the mediators of the relationships between surgical menopause and long-term physical functioning found in this study. These findings differ from those of a previously reported UK prospective study that included measures of physical performance; in this study, women who had surgical menopause before the age of 40 years had decreased grip strength compared with those who had a surgical menopause aged 50 to 53 years. However, there were no associations between menopause status or age at hysterectomy and chair rise time, nor were there any associations between the timing of menopause and performance measures. Interestingly, in the study of Tom et al of women born between 1928 and 1934, the women who had a natural menopause