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Women are born with a non-renewable ovarian reserve, which is depleted throughout reproductive life. When this reserve is exhausted, they experience menopause and cease ovulating. Importantly, menopause timing is highly variable and can impact health outcomes in later life. One in 100 women experience menopause before the age of 40. As natural fertility begins to decline 10 years prior to menopause, the age of menopause impacts reproductive options for many women, leading to increased demand for fertility treatments, which have low success rate. This is especially important as more women delay childbearing. Endocrine and imaging tests used in the clinical setting only record changes in ovarian function that have already taken place, thus disabling early prediction and timely identification of women with reduced reproductive lifespan. Human genetic studies have attempted to overcome this problem by identifying genetic markers associated with menopause timing and thus providing substantial insight into the biological mechanisms governing ovarian ageing. However, previous approaches have been largely restricted to assessing common genetic variation, leaving many aspects of the trait biology unexplored. This dissertation describes five distinct projects that advance our understanding of the genetic determinants of female reproductive ageing by employing state-of-art genomic and proteomic technologies with robust functional models. Chapter 3 uses whole exome sequence data to identify rare protein-coding variants associated with menopause timing in ~120K women in the UK Biobank (UKBB), and implicates five novel ANM genes with effect sizes up to ~5 times larger than previously discovered for common variants. Notably, heterozygous loss of ZNF518A shortens reproductive lifespan by delaying puberty timing in girls and reducing ANM by nearly 6 years in carriers, an effect larger than any variation currently tested in clinical genetics for premature ovarian ageing. Furthermore, I provide evidence that ZNF518A is a master transcriptional regulator of ovarian development and establishment of the ovarian reserve in foetal life, thus highlighting novel mechanisms involved in ANM aetiology. I also identify a new cancer predisposition gene, SAMHD1, which has a comparable effect size in women and men to well-established genes such as CHEK2, further reinforcing the link between cancer and reproductive ageing. Finally, I show that mothers with genetic susceptibility to earlier ovarian ageing have a higher rate of de novo mutations in their offspring. This provides direct evidence that female germline mutation rate is heritable and highlights a mechanism for maternal effects on offspring health. Chapter 4 extends the exome sequence analysis to an extreme form of early menopause, i.e. POI, which is often considered a monogenic disorder, with pathogenic mutations reported in ~100 genes. However, such reports are based 5 on small numbers of individuals without independent replication, or/and no functional validation. I systematically evaluate the penetrance of these reported genes in ~120K UKBB women, 2,231 of whom reported ANM before age 40. In this largest study of POI to date, I find limited evidence to support any previously reported autosomal dominant gene. For nearly all these genes I could rule out even modest penetrance, with 97.8% of all identified protein truncating variants found in reproductively healthy women with ANM over 40. In addition, I demonstrate novel haploinsufficiency effects in studied POI genes, including TWNK and SOHLH2. Collectively my results suggest that most POI cases are likely oligogenic or polygenic in nature, which has major implications for future clinical genetic testing and counselling. Chapter 5 presents the first proteogenomic study for the ANM targeting 4,775 distinct proteins measured from plasma samples of 10,713 European ancestry individuals in the Fenland study. Although this analysis did not identify robust protein candidates associated with ANM, it demonstrates the potential of such approaches to discover new biomarkers. Chapter 6 presents the largest genomic meta-analysis for age at menarche on ~566,000 women of European ancestry and 696 genomic loci that contribute to regulation of menarche timing. I use this data to explore biological mechanisms and overlap between genetic architectures of reproductive health outcomes. I provide the first evidence on the enrichment of DDR mechanisms for menarche timing, indicating the involvement of DDR in regulation of both extremes of reproductive lifespan, i.e. menarche and menopause. In addition, I report first gene candidates that I speculate may act via oocyte-specific mechanisms to modify reproductive longevity. I also highlight DDR and other novel mechanisms, including ribosome biogenesis, which impact multiple reproductive health outcomes, such as polycystic ovarian syndrome (PCOS), twinning and number of children (NEB). Finally, I demonstrate the first population genomic evidence on the role of DDR related mechanisms in various anthropometric, metabolic and reproductive health outcomes, indicating that DDR could act as a marker of health outcomes beyond cancer. Combining human genomic evidence with cutting edge CRISPR technology and the In vitro gametogenesis system, in Chapter 7 I investigate the role of PARP-1 in proliferation of primordial germ cells during the establishment of the ovarian reserve. I demonstrate suggestive evidence on the role of PARP-1 in decreasing ANM in women and, paradoxically, that deletion of PARP-1 increases the efficiency of primordial germ cell production in vitro. I speculate that, despite the initial increase in primordial germ cells in the PARP-1 knockout, the quality of these cells could be compromised, thus ultimately limiting the functional ovarian pool. Collectively, these findings provide significant insights into the biological processes of reproductive ageing in women and have the potential to guide future experimental work aimed towards identification of new therapies for enhancing reproductive function and preserving fertility in women, as well as designing intervention strategies to prevent or diminish menopause-related health outcomes.

Advancing age increases the risk of cardiovascular disease (CVD), largely due to the development of systemic vascular endothelial dysfunction and stiffening of the large elastic arteries. This thesis included three studies, which investigated the independent and combined effects of exercise and short-term folic acid (FA) supplementation on cardiovascular responses in healthy middle-aged men (MM) and postmenopausal women (PMW). Young men (YM) and premenopausal women (PreM) were studied under the same experimental conditions to ascertain responses in the healthy arterial system. The methodology included pulse wave analysis, venous occlusion plethysmography and flow mediated dilation (FMD) to assess indexes of aortic wave reflection (AWRi), calf blood flow (CBF) and brachial artery endothelium-dependent vasodilation, respectively. The first experimental study (Chapter 4) explored the vascular effects of short-term FA supplementation on endothelial function and arterial stiffness in age-matched healthy middle-aged (56±1 years; mean±SEM) PMW (n=13) and MM (n=14), and young (26±1 years) PreM (n=12) and YM (n=14). Brachial systolic, diastolic, mean arterial blood pressure (BP), pulse pressure (SBPb, DBPb, MAPb, PPb; mmHg) and pulse pressure amplification were recorded. Flow-mediated dilation (FMD) was assessed using ultrasound methods. Pulse wave analysis (applanation tonometry) was used to determine central (aortic) BP (BPc) and indexes of aortic wave reflection (AWRi), including augmentation pressure (AP; mmHg), augmentation index (AIx; %), and AIx corrected for heart rate (AIx75; %). Measures were recorded before and after 4-weeks of FA supplementation (5 mg/day). Plasma nitrite, and asymmetric dimethylarginine (ADMA), an inhibitor of NO synthesis, were also analysed. Before FA, in PMW and MM, all AWRi were higher (p<0.05) in PMW yet SBPb, DBPb, MAPb, DBPc, MAPc and PPA were lower (p<0.05). In contrast SBPc did not differ (p > 0.05) between groups. In PMW, ADMA associated positively (p<0.05) with AWRi, and nitrite inversely (p<0.05) with central and peripheral SBP and MAP. In MM, nitrite was positively associated (p<0.05) with central and peripheral PP, and ADMA inversely (p<0.05) with central and peripheral SBP, DBP, and MAP. Post-FA, AIx, AIx75, nitrite and ADMA remained unchanged (p > 0.05) in MM and PMW, yet AP, MAPc, and central and brachial SBP and PP were reduced (p<0.05) in both groups. These BP changes associated inversely with changes in nitrite (p<0.05). All AWRi were higher (p<0.05) in older versus younger groups both before and after FA, with values being higher (p<0.05) in PreM versus YM. Excluding PPc which was reduced in YM, FA did not alter AWRi or BP in young men and women. This study demonstrated that FA may be an effective nutraceutical strategy to improve endothelial function, reduce large artery stiffness, and attenuate the age-associated development of hypertension in both men and women. The second experimental study (Chapter 5) investigated the effects of an acute bout of aerobic exercise on vascular function in the lower limb of untrained (PMWun; n=13) and habitually exercise trained (PMWtr; n=10) PMW. PreM (n=14) were also included as a healthy young comparator group. Using strain-gauge plethysmography, resting and peak calf blood flow (CBFr and CBFpk, respectively) and vascular resistance (CVRr and CVRpk) were assessed before and after reactive hyperaemia, and before and one-hour after 45 minutes of brisk walking at 60% V̇O_2peak. Blood samples were analysed for nitrite, triglycerides, low- and high-density lipoprotein cholesterol (LDLc and HDLc), insulin and glucose. Pre-exercise, CBFpk was higher (p<0.05) and CVRpk and triglycerides lower (p<0.05) in PMWtr. CBFpk was inversely and CVRpk positively associated (p<0.05) with insulin in PMWtr. In PMWun, CBFpk correlated inversely (p<0.05) with glucose, and positively (p<0.05) with HDLc. CVRpk also correlated positively with LDLc and triglycerides (p<0.05). Post-exercise, in PMW, resting and peak CBF were increased (p<0.05) and CVR decreased (p<0.05), yet CBFpk remained higher (p<0.05) and CVRpk lower (p<0.05) in PMWtr. In PreM, pre- and post-exercise CBF and CVR responses did not differ (p > 0.05) from PMWun, except for CVRr pre-exercise, which was lower in PreM. This study demonstrated that compared with untrained PMW, habitually trained PMW demonstrate augmented CBFpk both before and after exercise. Despite similar levels of cardiometabolic markers, CBFpk was inversely associated with insulin in PMWtr, yet was inversely associated with glucose and pro-atherogenic lipids in PMWun. Aerobic exercise training may favourably modulate the vascular effects of circulating cardiometabolic markers in PMW. The third experimental study (Chapter 6) investigated the independent and combined effects of exercise and FA supplementation on brachial artery endothelial function in habitually exercise trained (PMWtr; n=12) and untrained (PMWun; n=12) PMW, and healthy young PreM (n=12). Flow-mediated dilation (FMD) was assessed using ultrasound methods before and 60-min after an acute bout of dynamic exercise (45- min, 60% V̇O_2peak), before and after 4-weeks of FA supplementation (5 mg/day). Blood samples were analysed for plasma nitrite, and asymmetric dimethylarginine (ADMA), an inhibitor of NO synthesis. Baseline FMD% did not differ (p > 0.05) between PMWun and PMWtr (mean±SEM; 3.53±0.33% and 4.21±0.40%, respectively) but was higher (p<0.01) in PreM (8.77±0.96%). In all groups, FMD% was unchanged (p > 0.05) 60-min after exercise. FA augmented FMD% in PMWun only (4.65±0.50%; p<0.05) in association with a reduction in systolic blood pressure. Exercise combined with FA did not elicit additive effects to FMD% (p > 0.05) in any group. ADMA and nitrite levels were not associated with FMD% in PMW and were unaltered by FA. This study demonstrated that FMD in trained PMW is neither augmented post-exercise nor is it improved with short-term FA. In contrast, FA, but not exercise, improved FMD in untrained PMW. These findings suggest vascular responsiveness to exercise may be blunted in estrogen deficient PMW, regardless of training status, and that FA does not restore vascular adaptations to habitual exercise training. Collectively, these three studies demonstrate that exercise and FA are able to exert favourable cardiovascular effects in healthy middle-aged adults. Whilst the clinical implications of these findings are unclear, it is possible that through attenuating the development of arterial dysfunction, exercise and FA may play a role in reducing CVD risk.

The menopause is a natural transition that occurs at midlife for a woman and is accompanied by a number of symptoms which can significantly affect quality of life, the most commonly reported being hot flushes. Impaired cognitive function has also been observed in menopausal women and natural alternatives to hormone therapy for the alleviation of menopausal symptoms are being sought. The aim of this thesis was to investigate the effects of soya isoflavones on cognitive function and menopausal symptoms in post-menopausal women. In an observational study, food diaries were completed by post-menopausal women (n=75). Principal component analysis was used to determine dietary patterns and associations with cognitive function, as assessed by CANTAB, were investigated. 5 final dietary patterns were identified. The 'meat and dairy' dietary pattern was associated with greater performance in the spatial working memory cognitive test. 'The social' dietary pattern was associated with negative effects on cognitive performance as was the 'potatoes and poultry' dietary pattern. A randomised controlled trial in post-menopausal women (n=101) was conducted to investigate the effects of soya isoflavones on cognitive function and menopausal symptoms. Participants consumed a volume of soya drink providing a low (10mg; control group), medium (35 mg) or high (60 mg) dose of soya isoflavones daily for a period of 12 weeks and cognitive function was assessed using CANTAB (spatial working memory, spatial span, pattern recognition memory, 5-choice reaction time and match to sample visual search). Menopausal symptoms were also assessed using a validated questionnaire. Isoflavone supplementation had no effect on the primary outcome measure, cognitive function, although consumption of 350ml of soya drink/day (providing 35mg isoflavones) significantly reduced hot flushes in post-menopausal women with more severe symptoms at baseline. An observational study was conducted using focus groups to determine overall perceptions towards soya in post-menopausal women and to partly evaluate the soya intervention. Post-menopausal women reported barriers and enablers of consumption as well as attitudes towards soya products in an Irish and Northern Irish population. The main findings from the focus groups include the awareness of soya in the diet and also the benefits that can be attained from consuming soya. Main barriers to soya consumption include price and lack of knowledge about soya products while enablers of consumption include Alpro® being considered a reliable and good brand. This thesis questions the potential benefits of soya isoflavones on cognitive function in healthy post-menopausal women within 7 years post-menopause. Future studies should investigate effects in earlier post-menopausal women and/or in those with mild cognitive impairment. Soya isoflavone consumption in post-menopausal women had no effect on cognitive function although may alleviate vasomotor symptoms in those with more severe symptoms at baseline. With the potential risks associated with hormone therapy, soya isoflavones may be a natural alternative for the alleviation of vasomotor symptoms.

The Hadza, residing near Lake Eyasi in northern Tanzania, represent one of the last remaining hunter-gatherer populations. Inhabiting the same area as our hominin ancestors and exploiting very similar resources, the Hadza maintain a foraging lifestyle characterised by a sexual division of labour. Studies of their foraging and food sharing habits serve as the foundation to numerous hypotheses of human behaviour and evolution. Data from the Hadza have featured heavily in debates on the sexual division of labour. These debates focus predominantly on men’s foraging, including how and why men provision. Women’s provisioning, on the other hand, is seldom explicitly examined and is often presumed to be constrained by reproduction. This thesis contributes to debates on the sexual division of labour by investigating how a woman’s reproductive status affects her foraging behaviours. Observational data on women’s foraging are investigated from 263 person/day follows (1,307 hours total) across 10 camps between 2004 and 2006. These data present the first quantitative documentation of forager women’s eating and sharing outside of camp. Interview data on women’s reproductive timeline are also analysed from in-depth interviews with 58 women from 9 camps in 2015. Spanning from menarche to menopause, these data offer the first quantitative and qualitative documentation of forager women’s menstruation. The results demonstrate that Hadza women eat and share over 800 kilocalories outside of camp per person/day. They regularly give and receive food, including gifts of honey from men. Breastfeeding women are more likely to give gifts and give more gifts than non-breastfeeding women. When they bring nurslings with them outside of camp, they forage less kilocalories per hour. Post-menopausal women eat less relative to what they forage, are less likely to receive gifts, rest less and forage more than pre-menopausal women. Although Hadza women describe their foraging workload as most difficult during late pregnancy, no significant differences in eating, sharing, resting or foraging are observed for pregnant women. Menstrual data from the Hadza reveal that menstruation is not only culturally relevant to the sexual division of labour, but it is also biologically relevant to current understandings of fertility. The majority (60%) of Hadza women report not doing their normal work during menstruation. They also report menstruation-related taboos for berry picking. The thesis presents an in-depth review of women’s menstruation, from the duration of menses to the menstrual cleaning process.

The aim of my work was to identify additional genetic and non-genetic factors influencing female reproductive ageing in humans. Although approximately 50% of population variation in age at menopause is due to genetics, less than 3% of variation had been accounted for by common genetic variants. Of non-genetic risk factors, only smoking had consistently been found to have a strong effect on age of menopause. In the wider context of female reproduction, our understanding of the role of genetics in determining sex hormone levels was limited. By combining the results of research in these different areas, I hoped to improve our knowledge of the biology of female reproductive ageing. Chapter 1 is an introduction in which I discuss the biology of menopause, describe relationships with health and present current knowledge regarding non-genetic and genetic risk factors influencing menopause age. Chapter 2 is an analysis of the associations between non-genetic risk factors occurring in early life with early menopause. We identified an association between multiple births and early menopause, connecting events pre-birth, when the oocyte pool is formed, with reproductive ageing in later life. Chapter 3 is a genome-wide association study to identify genetic variants associated with levels of nine sex hormone related phenotypes. We highlighted loci of relevance to reproductive function, which suggested overlaps in the genetic basis of hormone regulation. Chapter 4 is a genome-wide association study of menstrual cycle length. We showed that a common genetic variant related to follicle stimulating hormone levels and age at menopause is associated with several reproductive traits including length of menstrual cycle. Chapter 5 is an investigation of the relationship between differences in length of normal FMR1 triplet repeat alleles and timing of menopause. We found no association between the length of normal FMR1 alleles and timing of menopause, contradicting the results of smaller studies and replicating a null result in another large study. Chapter 6 is large genome-wide meta-analysis to identify common and low-frequency genetic variants associated with age at menopause. We identified 44 regions containing 54 independent common signals and two rare missense alleles of large effect. Finally, in Chapter 7 I evaluate how this work has benefitted our knowledge of female reproductive ageing and describe directions for future research.

Women who experience early natural menopause, or surgical menopause, may be prone to any morbidity and mortality risk related to oestrogen deficiency. The thesis aimed to explore the long-term sequelae of the menopause by investigating current knowledge about the relationship between early age at natural menopause, any surgical menopause, and early age at surgical menopause, and future mortality, incident cancer, and incident circulatory disease. The thesis also investigated the long-term sequelae of menopause using data from a nested cohort of UK women from the Royal College of General Practitioners’ Oral Contraception Study [RCGP OCS]. Methods A portfolio of systematic reviews was conducted. To assess whether a young age at natural menopause, any surgical menopause, and a young age at surgical menopause were associated with mortality and ill-health, data from the RCGP OCS were analysed using Cox regression and competing risks. Results Systematic reviews: 153 papers were included, of varying quality. The heterogeneity of included studies’ exposure and reference groups meant that meta-analysis was not possible. Younger age at natural menopause was strongly associated with an increased risk of all-cause mortality, but not cancer-related death. A suggestion of an increased risk was found for cardiovascular death. Young natural menopause protected strongly against incident endometrial and weakly against ovarian cancers. Few studies examined cervical cancer and age at natural menopause was not a risk factor. Colorectal cancer was not consistently associated with age at natural menopause. Young age at natural menopause was associated with an increased risk of coronary heart disease [CHD], but not cerebrovascular disease. Little evidence was found that surgical, compared with natural menopause was associated with any mortality outcomes. Surgical menopause tended to protect against ovarian cancer but no effect was found for cervical cancer. The relationship between colorectal cancer, or cerebrovascular disease, and surgical menopause is unclear. More evidence showed that surgical menopause may increase the risk of CHD. Limited evidence for young age at combined natural and surgical menopause found it to increase the risk of all-cause mortality and perhaps cardiovascular death. There was no association with risk of cancer death. No clear associations were found for early age at combined natural and surgical menopause and any of the specific cancers examined, or cerebrovascular disease. There may be an association with CHD, but its evidence base was weak. Nested cohort of the RCGP OCS: Premature menopause was associated with decreased risk of: all-cause, cancer-, and circulatory-related mortality, all incident cancer, other cancers, and CHD. Premature menopause was not associated with: incident breast, main gynaecological, or colorectal cancer; all circulatory disease, cerebrovascular disease, or other circulatory disease. For early natural menopause, a significantly decreased risk was observed for: death from all causes, cancer, and non-cancer, non-circulatory causes; incident all cancer, colorectal cancer (borderline), other cancers; incident all circulatory disease and CHD. No significant risk was observed for circulatory mortality; incident breast or main gynaecological cancer; incident cerebrovascular disease or other circulatory disease. Compared with natural menopause, surgical menopause increased circulatory-related mortality only. The risk of incident main gynaecological cancers was decreased. The other incident cancer outcomes were not associated with surgical menopause. Risk of any, and each type of incident circulatory disease was not significantly altered with surgical menopause.

Background: Age-standardised mortality rates for cardiovascular disease (CVD) are generally higher among men than women, prompting suggestions that reproductive factors may be partly responsible. Moreover, there have been major changes in women’s reproductive patterns and CVD rates in China over the last few decades, but the association between them is still poorly understood. Objectives: To start addressing these issues, this thesis examines the secular trends and correlates of age at menarche and menopause (the major physiological events defining a woman’s reproductive window), as well as their association with blood pressure and anthropometry in 302,180 women born in 1930-74 from 10 areas across China using cross-sectional demographic, behavioural, physical and reproductive data from the China Kadoorie Biobank. Results: Mean age at menarche decreased by 2 years over a 44-year period (1930-1974), with the exception of an increase of about 1 year for women exposed to the Great Chinese Famine in early adolescence. No other factor showed as large an effect on age at menarche. Among women aged >57 years at the baseline, mean age at menopause increased by 1.4 years over a 21-year period (1930-1951) and was significantly associated with several reproductive and behavioural factors, notably gravidity (2 years later menopause) and smoking (6 months earlier menopause). Blood pressure and anthropometry were weakly inversely associated with age at menarche (0.2mmHg and 0.2kg/m² lower per year later menarche) and even more weakly positively associated with age at menopause (0.06mmHg and 0.04kg/m² higher per year later menopause). These trends and associations all varied to some extent by area and socioeconomic status. (All p-values <0.0001) Conclusion: This study adds new information on the secular trends and correlates of age at menarche and menopause in a large Chinese population born around the mid-20th century and provides a basis for further prospective work on the association of reproductive history with the incidence of CVD in China.

Introduction: Most women will experience symptoms at menopause, some will be bothersome. Little is known about the experience of menopausal symptoms in Scotland since the 2002 change in clinical guidelines for managing menopausal symptoms. This study aimed to reassess the impact and management of menopausal symptoms in the community, and identify factors associated with symptom experience. Methods: In 2009 a postal questionnaire was sent to 8,206 women aged 45-54, registered with 16 Scottish general practices. To validate the shortened illness perception measure, 360 respondents to the main survey were sent one of two postal questionnaires. Results: Most commonly reported symptoms were tiredness, aches and pains and sleep difficulties. The classic menopausal symptoms of hot flushes, night sweats and vaginal dryness were reported by 46.7%, 46.4% and 28.2% of women, respectively. Common menopausal symptom management strategies included talking to friends and family, wearing cotton clothes, sleeping in a cool room, and exercise. Herbal remedies were more commonly used than prescription drugs. Nearly one fifth of women had used HRT. Menopausal status, education, social support, reporting other symptoms, BMI, smoking status, use of management strategies, possible presence of depression, and physical health were associated with reporting classic menopausal symptoms. Factors associated with “doing well” or “doing badly” with hot flushes or night sweats was symptom dependent. Bother from menstrual periods, children, BMI, education, smoking, physical health, use of psychological strategies, and perceived consequences of symptoms were associated with “doing well” or “doing badly” with hot flushes or night sweats. The shortened IPQ-R scale had good reliability, moderate validity but poor internal consistency. Conclusion: Menopausal symptoms are common and often bothersome. Identifying women who appear to do well or badly with hot flushes and night sweats could be useful for tailoring interventions. A more robust measure of illness perceptions is needed.

This thesis builds upon the existing scholarship such as that by Patricia Crawford, Helen King, Alexandra Lord, and Michael Stolberg, to analyse the ways that all aspects of menstruation were accounted for in early-modern England. Broadly informed by cultural materialism, and starting with the wide-range of medical treatises that were published in the early modern period, which theorise the female body, the thesis incorporates a broad range of material from private journals, diaries, and letters to the more public conventionally literary texts such as poetry, prose fiction, and plays. The thesis is structured according to the physiological order of vaginal bleeding as understood in the early-modern period. Starting with menarche the thesis argues that just as the medical texts broadly agree that the ideal age for menarche is fourteen, so social conventions also saw this as a significant age in a girl s growth to maturity. Since fourteen was considered to be the optimum age for menarche any wide variation in this age was seen as problematic; the thesis includes analysis, therefore of early and late menarche. The thesis next examines the surviving accounts of menstruation, arguing that menstruation was something that women were disinclined to write about, preferring to manage the condition privately. The chapter offers an account of how women might have managed the practical aspects of their cycle such as sanitary protection, theorising that the negative associations of menstrual blood in the Bible influence women s position on the matter. The other significant occasions of female bleeding were hymenal and lochial bleeding and the thesis argues that these were seen as analogous to menstrual bleeding, and theorised as such. The thesis demonstrates that hymenal blood was eroticised in the period because of the importance of virginity to this society. Like all occasions of bleeding, pregnancy and lochial bleeding was seen as a dangerous event. The thesis concludes with a review of the presentation of menopause in the period.

The study investigated whether dietary flavonoid intake and dietary patterns were associated with bone mineral density (BMD) and bone turnover in postmenopausal Scottish women. The subjects were recruited in 1990-3, and the majority of them returned 6.3 ± 0.6 y later (mean age (SD) at baseline 54.7 (2.2) y). At the both visits they had bone density scans of the lumbar spine (LS) and hip (FN) and at the second visit they provided urine samples for analysis of bone resorption markers. Flavonoid intakes were calculated using food frequency questionnaires, “validated” for flavonoid intakes using 4-day food diaries. (R=0.76, p≤0.001 for energy adjusted total flavonoids). FN BMD was associated with flavonoid intakes at baseline and follow up (p=0.012, p=0.001 respectively after adjusting for confounders) and LS BMD at follow up only (p=0.038). Dietary flavanones had a negative correlation with bone resorption markers; catechins and procyanidins were associated with annual change in FN and LS BMD. Principal components analysis was used to identify five important patterns in the diets. The “healthy” diet, rich in fruit and vegetables, was negatively associated with bone resorption markers and the nutrient diets were both negatively associated with FN and LS BMD. Partial least squares analysis identified that tinned fruit and root vegetables were associated with greater bone resorption, and berries, tomatoes and juice with decreasing bone resorption. Tomato intakes were the most important when predicting bone resorption marker excretion. Tomatoes, salad, berries, and green vegetables were associated with increased BMD. Berries, applies, root vegetables and salad were the most important fruit and vegetables for predicting BMD. Results from this work confirm that fruit and vegetables are important in bone health.

Activation of centrally expressed luteinizing hormone receptor (LHCGR) rescues spatial memory function and dendritic spine density losses associated with gonadectomy and high circulating gonadotropin levels in females. However, whether this extends to the AD brain, and the mechanisms that underlie these benefits remain unknown. To address this question, we delivered the LHCGR agonist human chorionic gonadotropin (hCG) intracerebroventricularly (ICV), under reproductively intact and ovariectomized conditions to mimic the post-menopausal state in AD model mice. Then, to delve deeper into the fundamental role of this receptor in the CNS, we developed a CRISPR/cas9 conditional knockout system to knockdown LHCGR in the hippocampus and hypothalamus. Central LHCGR activation restored spatial ability, hippocampal dendritic spine density, and BDNF expression in ovariectomized AD model female mice to wild-type levels without altering Aβ. Oppositely, hippocampal LHCGR knockdown in gonadally intact wild-type adult animals lead to spatial memory deficit and reduced BDNF transcription. Additionally, hypothalamic LHCGR knockdown uncovered novel physiological roles of the receptor on HPG and HPA axis function. Together, this work highlights the relevance of the LHCGR on cognition and its therapeutic potential in the “menopausal” AD brain, as well as its functional relevance in the CNS.

Cardiovascular disease is the leading cause of death and an important cause of morbidity in postmenopausal women, the incidence being particularly high in the West of Scotland. Retrospective studies strongly suggest an aetiological link between oestrogen deficiency and cardiovascular risk, and moreover have suggested that mortality can be reduced by up to 50% by the administration of hormone replacement therapy. However, recently reported randomised controlled studies have challenged this view (Hulley et al, 1998). The mechanism by which the apparent cardioprotective benefit occurs is multi-factorial and incompletely understood. Direct effects on the vessel wall particularly at the level of the endothelium, as well as indirect effects on metabolic risk factors such as lipid and carbohydrate metabolism, may play an important role in any underlying protective mechanism. The aim of this project was to study the effect of oestrogen on the vessel wall, more specifically by examining its effect on vascular reactivity and its influence on nitric oxide synthesis and release from the vascular endothelium. In vivo studies using forearm venous occlusion plethysmography were used to assess the effect of oestrogen on forearm vasodilator responses, and on the release of nitric oxide from the intact endothelium. To compliment this work, the effect of sex steroids on the growth and function of endothelial cells, and on the synthesis and release of nitric oxide from vascular endothelial cells, was studied in vitro using cultured human aortic endothelial cells. The effect of short and longterm oestrogen on endothelial nitric oxide synthase (eNOS) gene expression was studied in cultured cells using northern analysis. No change in forearm blood flow was observed following intra-arterial infusion of 17beta-oestradiol, suggesting that oestrogen is not an acute vasodilator in the forearm vasculature. Forearm blood flow responses to NG-monomethyl-L-arginine, a stereospecific inhibitor of nitric oxide which provides an index of basal nitric oxide synthesis, were unchanged following 4 weeks' of transdermal 17beta-oestradiol treatment, suggesting that oestrogen supplementation did not enhance basal nitric oxide release in the forearm vascular bed. In cultured endothelial cells, a significant increase cell number was observed following long term oestradiol treatment. The underlying mechanism for this observation is unclear. Expression of messenger RNA for the eNOS gene was confirmed by northern analysis, however the results of these studies did not demonstrate any change in eNOS mRNA expression following oestrogen treatment, supporting the findings of the in-vivo study. With the exception of the growth studies which yielded interesting results requiring further evaluation, the negative results of the remaining carefully designed and well executed studies, while at variance with the results of other investigators, nevertheless generate interesting new data which appears to be in broad agreement with the albeit limited results of the randomised control studies currently available. From our present knowledge base, there remain many unanswered questions about the true risks and benefits of hormone replacement therapy, and a better understanding of the mechanisms contributing to any beneficial effects will lead to better prescribing practices and may ultimately lead to improvements in womens' health.

This study was prompted by the negative images of midlife women portrayed in the literature and popular culture. Apart from a few accounts of extraordinary feats, which counter the generalisations about midlife women, for example, a 76 year old grandmother going sky-diving, there is very little written about midlife women living enjoyable, independent lives. This work presents a detailed analyses of the way in which thirty women have been able to, or are in the process of, actively structuring an enjoyable midlife. Previous research has tended to view aspects of women's lives in isolation, such as leisure, body, health, or work. The artificial boundaries that have arisen because of this separation reinforce societal notions of fragmentation within social life. This research was designed to challenge these divisions and, by investigating women's enjoyable experiences, to develop concepts that are common across the composition of these women's lives. A feminist phenomenological methodology was used and semi-structured in-depth interviews were undertaken to access women's lived experience of enjoyment, their lifeworld, and also to determine participants understanding of the concept of leisure and their experience of menopause. All interviews were transcribed and subjected to a systematic content analysis, as advocated by phenomenological research practitioners. The findings contradict the predominantly negative popular images of midlife women and show that most of the women in the study are in the act of resisting the earlier views of women and ageing. Their responses also indicate they tend not to recognise the fragmentation of their lives into work, leisure and health issues, but rather regard their lives as 'all together and not separated out'. An enjoyable lifeworld means being regarded as an individual and independent person and having 'a sense of being in charge', over their own time and space, making opportunities for physical, social, creative and intellectual activity, as well as preparing for the future. The thesis concludes with a discussion of how midlife women are creating enjoyable lifestyles. The concept of enjoyment and enjoyable experiences appear to defy segmentation, and the women are in the act of composing their own lives.

Female sex hormones are presumed responsible for the relative cardiovascular youth of premenopausal women compared with men. It is unclear how these hormones achieve this effect, but suggested mechanisms include lipoprotein metabolism, release of vasoactive substances, and direct effects on vascular smooth muscle. Information on female cardiovascular physiology is very scanty, and results of studies performed in men are usually extrapolated to women. I, therefore, investigated the circulatory effects of age and the characteristic sex hormones in women. Limb blood flow, measured by venous occlusion plethysmography and blood pressure, monitored with an automatic device were relatively unchanged in successive age decades until the age of 64 when they increased. This pattern differs from that in men. In individual subjects limb blood flow was proportional to systolic pressure, but not to age. Peripheral vascular reactivity, as indicated by the reactive hyperaemic response, decreased abruptly after the age of 64, and was inversely related to time since menopause. Resting forearm flow fell, without any change in blood pressure, in the mid-luteal phase of menstrual cycles, and after oral micronized progesterone therapy in postmenopausal women. Transdermal 17β-oestradiol therapy, which produces physiological oestrogen levels, increased forearm flow in non-flushing postmenopausal women but reduced flow in flushers. Stroke distance, stroke volume and left ventricular contractility, measured by Doppler echocardiography increased but frontal cerebral flow, measured by 133Xenon inhalation technique fell. Addition of cyclical progestogen caused no further vascular change over eight weeks. Subcutaneous oestradiol implants, however, increased resting forearm flow, irrespective of flushing frequency. The vascular changes observed with age provide essential reference ranges for assessment of circulatory responses in women. The cardiovascular effects of oestradiol may contribute to the cardiovascular superiority of younger women and the vasoconstrictor action of progesterone might be clinically relevant to disturbances such as menstrual migraine or pelvic pain syndrome.

Menopause-related symptoms can affect the lives of both partners in couples, and the way in which partners perceive and respond to menopause-related issues is likely to affect both partners’ psychological and relational well-being. Adopting the concept of communal coping, this study investigated how open communication was associated with the relational and psychological well-being of couples through shared appraisal and joint action using Actor-Partner Interdependence Models. After collecting dyadic data from 47 heterosexual couples, this study found that communal coping can emerge in heterosexual couples during the menopausal transition of female partners. This study also showed that: (a) joint action could be negatively associated with the relational well-being of menopausal couples while shared appraisal was positively related with individuals’ well-being, (b) open communication can promote both communal coping and well-being in menopausal couples, and (c) communal coping can serve as a mediator between open communication and relational well-being. This study makes a substantial contribution to the field of research on couples in which the female partner had transitioned through menopause and broadens the application context of communal coping. In addition, it contributes to the discussion on communal coping by highlighting that at least one dimension of communal coping could have negative effects on the well-being of individuals. Detailed interpretation of this study’s results and analyses of future research directions are presented.

Spatial navigation is a complex cognitive skill and multisensory process with large individual and sex differences, and deficits in navigational abilities are apparent in older adults (ages 65+ years). When in the aging process these changes first emerge is unclear. Further, little is known about whether endocrine aging during the midlife transition to menopause (ages ~45-55 years) impacts navigation behavior and the neural circuitry that processes spatial information. Given accumulating evidence of the overlapping neural circuitries that are sensitive to cognitive aging, enriched with sex hormone receptors, and support spatial navigation abilities, this represents a critical gap in our knowledge for how the brain’s navigational system changes with age.In this dissertation, the three main lines of inquiry that are addressed are: (1) whether spatial navigation abilities and strategies change early in the aging process; (2) whether endocrine changes that occur during the menopausal transition are associated with spatial navigation abilities and strategies; and (3) whether endocrine changes during endocrine aging alter the brain’s navigation circuitry. To execute this, three virtual reality paradigms testing distinct aspects of spatial navigation were used in conjunction with structural magnetic resonance imaging. The results provide evidence that: (1) age-related changes in some aspects of navigation emerge as early as midlife; (2) spatial strategy is influenced by endocrine aging in women; and (3) age-related changes during endocrine aging impact the neural circuitry that supports spatial navigation performance.By studying the brain’s navigational system from a women’s health perspective, this dissertation work provides novel insight into the biological factors that influence spatial navigation. These findings will inform future studies investigating the utility of spatial navigation as a behavioral marker for the early detection of individuals at risk for neurodegenerative disease. Women make up about two-thirds of patients living with Alzheimer’s disease, suggesting that sex-specific factors are crucial to understanding disease risk.

Since its inception, the field of neuroendocrinology has provided evidence for a tightly coupled relationship between the nervous and endocrine systems. In rodents and nonhuman primates, estrogen and progesterone’s impact on the brain is evident across a range of spatiotemporal scales. Yet, the influence of sex hormones on the structural and functional architecture of the human brain is largely unknown. The body of work presented in my dissertation aims to advance our understanding of the human brain through the lens of neuroendocrinology by examining how distinct hormonal transition periods shape brain morphology and function. In Study 1, I present findings from my keystone ‘28andMe’ precision imaging experiment, in which a participant underwent brain imaging and venipuncture every 24 hours over 30 consecutive days across a complete menstrual cycle and again, one year later, while on an oral hormonal contraceptive regimen. The results from this study reveal the rhythmic nature in which brain networks reorganize across the cycle, with transient increases in estradiol enhancing global efficiency of several large-scale networks. In Study 2, this approach was expanded by conducting the first precision imaging experiment on pregnancy, in which a primiparous woman underwent 26 MRI scans and venipuncture beginning 3 weeks pre-conception through two years postpartum. Pronounced decreases in gray matter volume and cortical thickness paired with increases in white matter microstructure were evident across the brain, with few regions untouched by the transition to motherhood. Finally, in Study 3, I present findings from our Midlife Hormones and Cognition Study, where a highly characterized sample of 85 midlife women (ages 43–60) in various states of ovarian decline underwent MRI scanning and venipuncture to establish how endocrine aging influences whole-brain intrinsic network organization. Results suggest that the frequency of menopause-related vasomotor and neurological symptoms exacerbate network connectivity decline in postmenopausal women, especially among higher-order cognitive networks. Together, these studies provide novel insight into the spatiotemporal extent of human brain–hormone relationships over the lifespan, a severely understudied area in cognitive neuroscience with significant implications for women’s health.

Menopause and pregnancy are crucial events in women’s lives because women experience a series of physical and psychological changes at these stages. One of the most critical challenges is excessive weight gain during both of these stages, which could contribute to various adverse health events in their later lives. In addition to weight gain, another critical health concern that women face is fragility-related factures. The rate of fragility fractures begins rising in women during their 40s and increases to the end of life. Fractures result in impaired mobility and hospitalization, which can decrease the life quality of women significantly. Identification of modifiable dietary risk factors for excessive weight gain and fracture risk is crucial. The objectives of this dissertation are to estimate the independent effects of total dairy and individual dairy foods (e.g., yogurt, milk, and cheese), alone and in combination with overall diet patterns, physical activity, and other lifestyle factors, on three outcomes among women: weight change during the menopausal transition, weight retention after pregnancy, and risk of fragility-related fractures throughout mid-life and older adult years. Data from two prospective studies of nurses were used: Nurses’ Health Study I (NHS I) and Nurses’ Health Study II (NHS II). NHS II was used for both weight change analyses, while NHS was used for the fracture analyses. The first specific aim for the analysis of weight change during the menopausal transition was to investigate the effects of total dairy, yogurt, milk, and cheese intakes on menopausal weight change (N = 35,177) and risk of obesity (N = 38,892) among women in NHS II. Weights were self-reported in biennial questionnaires. Diet was assessed with food frequency questionnaires (FFQ) every 4 years. Generalized estimating equations were used to assess the adjusted mean weight change using repeated measures of weight change. Cox proportional hazards models were used to estimate risk of obesity, controlling for confounding. The second specific aim relates to the postpartum weight change analyses and were to investigate the effects of total dairy, yogurt, milk, and cheese intakes on postpartum weight retention (N = 18,366) and risk of postpartum obesity (N = 17,126) among women in the NHS II. Generalized linear models were used to assess postpartum weight change as continuous outcomes and multivariable models with a Poisson distribution were used to estimate risk of postpartum obesity. The third specific aim was for the fragility fracture analyses and included investigating the effects of total dairy, yogurt, milk, and cheese on fragility fractures of the hip, wrist, and vertebrae in women ages 40 years and older in NHS I. In total, there are 99,072 women included. Fractures at the wrist and hip were self-reported. For vertebral fractures, we relied on medical record confirmed cases. Proportional hazards models were used to estimate risk of first fracture (including wrist, hip, or vertebral fractures). Results associated with the first aims suggested that more than 2 servings per week (s/w) of yogurt led to consistently less weight gain than that observed in women consuming less than 1 serving per month (s/m) throughout the menopausal transition. Further, this same yogurt intake was associated with a 31% reduced obesity risk (95% CI: 0.64 - 0.74) after adjusting for potential confounders and baseline body mass index (BMI). Higher total dairy intake was also associated with less obesity risk, but the effect was somewhat weaker than that for yogurt. There was a U-shaped relation between milk consumption and obesity risk during perimenopause. Moderate (0.5 s/d -< 1 s/d vs. < 0.5 s/d) milk consumption reduced obesity risk by 17% (95% CI: 0.78 - 0.89), while higher milk (≥1 s/d vs. < 0.5 s/d) consumption led to a marginally statistically significant 6% higher obesity risk. Cheese intake was not associated with obesity risk in perimenopausal women. In the postpartum weight retention analyses, women who consumed moderate amounts of yogurt (1 s/m -< 2 s/w) and higher amounts of yogurt (≥ 2 s/w) had a 0.38 lb and 0.63 lb reduction in postpartum weight retention, respectively, than those who rarely consumed yogurt (< 1 s/m). Moderate and higher cheese intakes were associated with 0.30 lb and 0.64 lb less postpartum weight retention, respectively, than lower cheese intake (< 2 s/w). In the obesity analysis, moderate (1 s/m -< 2 s/w) and higher yogurt (≥ 2 s/w) intakes were associated with 20% (95%: 0.69 - 0.93) and 16% (95%: 0.69 - 1.02) reduced risks of postpartum obesity, but the association was weakened by adjusting for pre-pregnancy BMI. Women with higher levels of activity and higher yogurt intakes had a 39% (95%: 0.50 - 0.74) lower risk of obesity. Higher Alternative Healthy Eating Index 2010 (AHEI) scores alone were associated with a statistically significantly lower obesity risk. Results from our fracture analyses found that women who consumed more than 2 s/d of total dairy had a 19% (95% CI: 0.67 - 0.98) lower fracture risk than those who consumed less than 1 s/w. In terms of individual dairy products, 2 s/d of milk were associated with a 14% (95% CI: 0.77 - 0.95) reduction in fracture risk compared with lower milk consumption (

Obesity, defined by BMI, is an escalating health concern. Selenium is an essential trace mineral involved in many metabolic activities, including the production of antioxidant enzymes, fat accumulation, and the conversion of inactive thyroid- T4 to the active form- T3, all of which impact BMI. However, little is known about the relationship between selenium and BMI. Furthermore, the impact of menopause, T3, and physical activity on this relationship has not been evaluated. This study aimed to 1) map the currently available evidence on the selenium level and BMI using Arksey and O’Malley’s scoping review framework, 2) investigate the relationship between serum selenium, BMI, and the menopausal status in 2,130 women who participated in the National Health and Nutrition Examination Survey (NHANES 2011-2012), and 3) analyze mediating effects of T3 and physical activity in the selenium and BMI relationship in 1,341 NHANES (2011-2012) adult participants. This cross-sectional study applied descriptive statistics, t-test, multiple linear regression models, and multilevel structural equation modeling for analysis. The scoping review identified conflicting findings, ranging from an inverse association between selenium to BMI to the positive association of low selenium with overweight and obesity. Adjusted for demographic factors, no statistically significant relationship between selenium and BMI, menopause, T3, or physical activity was found in our analysis. Postmenopausal women in our study had a significantly higher prevalence of obesity than premenopausal women while consuming significantly fewer calories per day. Men in our study had lower BMI, higher selenium and T3 levels, higheriv daily caloric intake, and lower activity levels than women participants. Future studies need to 1) identify and evaluate other metabolically important factors as potential mediating variables, 2) employ a longitudinal study design to capture changes in selenium, T3, and PA over time, and 3) include populations with selenium deficiency and selenium-replete participants to capture a broader range of serum levels and their effects on BMI values.

Abstract: Menopause not only marks the end of a woman’s reproductive years but is a significant transition from a biological and psychosocial standpoint. The majority of women will experience menopause symptoms including vasomotor symptoms, genitourinary symptoms, sleep disturbances, mood changes, depression, anxiety, muscle or joint pain, weight gain and decreased libido. There are many approaches women may take in managing these symptoms involving a combination of prescription medications, complementary and alternative medicines, or lifestyle changes. Since the legalization of cannabis in Canada, the use of cannabis for medical and recreational purposes has increased, especially within the midlife population. There is growing interest in using cannabis for symptoms that overlap with menopause. Following a two- phase, mixed methods research design, the purpose of this thesis was to explore the experiences and perspectives of midlife women using cannabis for medical purposes coinciding with menopause symptoms. The first project of this thesis was the quantitative phase of the mixed methods research. A cross-sectional, web-based survey in midlife women living in Alberta was completed to characterize cannabis use patterns and perceptions, as well as their menopause stage and symptoms. These findings showed over one-third (34%) of midlife women surveyed were current users of cannabis, and 65% indicated ever using cannabis. Of the current users, 75% of these women are using for medical purposes, with the most common reasons that overlapped with menopause being sleep issues, anxiety, muscle/joint achiness, irritability, and depression. Most women accessed cannabis from non-medical sources and used an assortment of cannabis forms at varying frequencies of use. In addition, current cannabis users were more likely to report experiencing menopause symptoms as compared to non-users. History of smoking and health status were significant independent predictors of current cannabis use. Women commonly used the internet or their family or friends for information on cannabis, but desired to get information from healthcare providers. The second project of this thesis was the qualitative phase of the mixed methods research aimed to explore the experiences and perceptions of midlife women using cannabis for medical purposes. Women were recruited from the initial survey sample to take part in one-on-one interviews. Menopause was described as a unique, complex experience and cannabis was a therapeutic agent that provided symptom relief and maintained their quality of life. Women self- managed their use of cannabis, accessed cannabis from a variety of medical and non-medical sources, and relied on experimentation. Similarities in a lack of information available, limited role of healthcare providers, feelings of stigmatization and emphasis on self-educating were reported in women’s experiences with menopause and with using cannabis for medical purposes. The findings from this thesis established that midlife women are using cannabis to manage their symptoms coinciding with menopause. Future research is required to better understand the effect cannabis has on menopause symptoms and aid in the development of clinical resources and education to support midlife women in managing their symptoms with cannabis. By going directly to women, this thesis highlighted the opportunities healthcare providers have to improve the care of midlife women during menopause.

Inherent in this artistic project is the question of why menopause is not defined in Western society as a natural process of transformation that has the potential to result in empowerment for the individual woman. The project Performing the Transformative speaks of this potential as it might be depicted in performance art through a series of videos and live performances that actively contemplate and represent the process of change in identity at the menopause. This is undertaken through the use of heuristic methodology that embraces a process of an internal search to discover the nature and meaning of experiences, resulting in growing self-knowledge. In the project, videos are intuitively performed and recorded employing the tripartite process of separation, transition and incorporation evident in a rite of passage. My hybridised theoretical framework draws upon gerontology, feminist psychoanalysis, performativity and gender theory. These theories provide a framework for my research and facilitate in addressing both the creative outcomes and the exegesis for Performing the Transformative. Because the primary vehicle in the expression of my research is performance as a rite of passage, it is important to critically engage with masque, masquerade, and performativity in relation to the question of transformation and empowerment. Gerontology studies and feminist studies on transformation at menopause inform the reflection on this practice. The key terms of masque, masquerade and performativity are defined, as well as studies on the absence of ritual and rites of passage as means of transformation in contemporary society are addressed.

Aging cohort studies recruit participants at an age before most of the population will experience the study outcome to document its natural history and related risk factors. Usually assumptions regarding “normative” aging, including average age at onset, are based on data on White populations. However, evidence suggests that Black and Hispanic populations experience “weathering” or accelerated health declines compared to Whites due to cumulative experience of social, economic, and political marginalization. When population subgroups have a differential probability of inclusion, selection bias, i.e., a distortion caused by differential selection into or out of a study, will likely misinform understanding of aging in these populations. By accounting for left truncation and left and right censoring in the Study of Women’s Health Across the Nation (SWAN), this dissertation addresses the main forms of selection bias in cohort studies and calculates their effects on estimates of racial/ethnic differences in reproductive aging and onset of cardio-metabolic risk. SWAN, a 25-year longitudinal cohort of midlife women, utilized a cross-sectional screener to recruit a cohort of Black, Chinese, Hispanic, Japanese, and White women. Aim 1 created a framework for examining selection bias at study commencement and quantified how selection mechanisms from the cross-sectional screening study into the cohort biased estimates of racial/ethnic differences. Two main mechanisms were identified, eligibility and participation. Black and Hispanic women had the lowest eligibility rates stemming from high rates of surgical menopause. Their eligibility rates decreased with increasing age at a higher rate than in White women. Lower education was associated with lower eligibility for White women only. Participation was associated with demographic characteristics with no evidence of a “healthy volunteer” bias. Failure to account for selection at study commencement may underestimate racial/ethnic disparities in health, especially for Black and Hispanic women. Aim 2 assessed the effects of selection bias on estimates of racial/ethnic differences in age at the final menstrual period (FMP). Results suggest that previous analyses that did not fully account for selection bias via left truncation and right censoring overestimated average age of FMP in Black and Hispanic women. In Black women, age of natural FMP was overestimated by an average of 1.1 years. Adjusting for selection bias, Black and Hispanic women had earlier natural and surgical FMPs compared to White women independent of socioeconomic factors and health behaviors. Aim 3 assessed the effects of selection bias on estimates of racial/ethnic differences in the timing of cardio-metabolic outcomes including hypertension, isolated systolic hypertension, insulin resistance and diabetes. Selection at study commencement had greater effects on outcomes with earlier age at onset (hypertension), whereas selection via loss to follow up had greater effects on outcomes with later onsets (insulin resistance, diabetes). Addressing selection bias via left truncation, left and right censoring led to an average 20-year decrease in predicted median age of onset in cardio-metabolic outcomes but decreased the predicted difference in age at onset for Black and Hispanic women compared to White women. However, Black and Hispanic women still had significantly earlier onset of each outcome. By providing a framework to account for and methods to mitigate selection bias, this dissertation documented accelerated health declines in Black and Hispanic women in SWAN across multiple reproductive and cardio-metabolic outcomes – highlighting the need for new and continued research/interventions aimed at the structural causes of racial disparities in health.

Abstract: Midlife women experience physiological changes. These changes are mainly related to the pre-, peri-, and postmenopausal symptoms that have an impact on their physical and psychological well-being and their general quality of life. Midlife women from diverse cultures differ in behaviours, values, and beliefs related to their life experiences and in ways to manage menopausal symptoms. Along with accessing contemporary healthcare services, urban Pakistani women commonly use natural/traditional/home remedies comprised of ingredients such as honey, garlic, and ginger and practice mind and body therapies such as yoga, aerobics, meditation, and other exercises to manage their menopausal symptoms. A combination of modern medicine and self-care practices tend to be used to promote health and prevent disease. There is limited research in the Pakistani context (Anwar, Green, Norris, & Bukhari, 2015) of midlife women and their menopausal symptoms and strategies used to manage those symptoms (Baig & Karim, 2006; Nisar & Sohoo, 2010). My doctoral research explores urban Pakistani Muslim midlife women’s experiences of menopause to acquire a deeper understanding of menopause and associated management strategies. A focused ethnography research methodology was used for this study. It guided and informed an understanding of the experiential knowledge of midlife women in a specific cultural context. Recruitment of 20 Pakistan Muslim women residing in urban Karachi was facilitated through women who were socially active at their workplaces or within their communities. Further recruitment used the snowball approach. Study data were gathered between December 2017 and March 2018. I conducted in-depth, semi-structured interviews with 20 women to develop a deeper understanding of the experiences related to the management of menopausal symptoms, the use of biomedical interventions, and self-care practices. Mandatory ethical considerations were followed in the study. The data were managed using Quirkos qualitative data management software and I analyzed the data using qualitative content analysis to interpret and describe the women’s experiences of menopause. The demographic characteristics of the participants indicated that the age of the study participants ranged between 40 and 59 years. All the participants were Muslim but belonged to different faith practices of Islam. Participants of the study were educated working women. Three main themes developed: perception of menopause, strategies for symptom management, and influencing factors. Cultural and religious understanding and practices were interconnected with women’s overall perception and experience of menopause. The findings of this study have offered a novel perspective regarding providing a deeper cultural understanding of menopause and associated management strategies in the study population. In addition, it revealed the factors that contribute to shaping women’s decisions and menopause-related experiences. The information acquired through this study are valuable for nurses and other health care professionals to provide culturally appropriate interventions to midlife Pakistani women. This study has generated significant information to direct further research in the context of Pakistani midlife women experiencing menopause.

Breast cancer is the second leading cause of death in women in the U.S. The CDC estimates that between 2010 and 2020, there will be an increase in breast cancer in women in the United States by 21%, or greater 900,000 new cases per year. (CDC) Women are at increased risk for breast cancer due to the fact that some breast cancers have cells which are responsive to the hormone estrogen. Further, the risk of developing cancer increases as women age. Women who experience menopause after age 55 have an increased risk of developing breast cancer. (Surakasula et al., 2014) Phytoestrogens, which include isoflavones, are compounds found in plants and processed foods, which structurally and functionally mimic the hormone estrogen. Soy is frequently found in processed foods regularly consumed in the average American diet and is a source of isoflavones, including genistein, daidzein, and daidzein’s metabolite, equol. Phytoestrogens can bind to the estrogen receptor and change the expression of genes that respond to estrogen, such as the oncogene c-Fos, a protein in breast cancer cells which can suppress breast cancer cell growth when it is mutated (Lu et al., 2005). Phytoestrogens have been shown to reduce the severity and frequency of some of the symptoms of menopause, including a reduction in hot flashes and other estrogen deficiency-related symptoms of menopause. (Chen et al., 2015). Phytoestrogens have been used therapeutically in menopausal women, as they can compensate for lower levels of estrogen in the body. There is, however, limited research regarding the consumption of soy and increased risk for cancer in postmenopausal women. The objective of this study was to determine whether increasing levels of urinary phytoestrogen are correlated with a decreased risk of postmenopausal breast cancer. The analysis observes 2,439 postmenopausal female subjects equal to or greater than 45 years of age who had urinary phytoestrogen and reproductive health data in the 1999-2010 National Health and Nutrition Examination Survey database. The dietary data was obtained from the U.S. Department of Agriculture’s Agricultural Research Service database. Logistic regression models constructed using SAS were used to assess the change in the relative risk for cancer across low, medium, and high levels of urinary daidzein, genistein, and equol. Variables of interest, including demographic, body measures, dietary patterns, and lab measures, were compared to a base model, which adjusts for age only. It was found that the relative risk for postmenopausal breast cancer was not significantly different in the tertiles and quintiles of urinary phytoestrogens. The greatest increase in the likelihood of postmenopausal breast cancer was found to be 1.53 times in the second tertile of daidzein, increasing the risk by 53%. There was no significant protective effect of increasing levels of urinary phytoestrogens against postmenopausal breast cancer.

Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are ubiquitous environmental toxicants used in consumer products and industry, such as non-stick cookware, food packaging materials, personal care products, and aqueous fire-fighting foams. PFAS have received unprecedented attention recently due to nationwide drinking water contamination that impacts up to 110 million residents in the United States. Due to the widespread use and chemical stability of these compounds, more than 98% of the general population in the United States likely has at least one PFAS detectable in their blood. Growing evidence suggests that ovaries may be a potential target for PFAS toxicity. The ovary is a primary regulator of reproductive and endocrine function in females. Menopause marks the cessation of ovarian function, and its timing has physiologic impacts beyond the reproductive system. As age at the final menstrual period reflects a woman’s overall health, investigation of the role of potential endocrine-disrupting chemicals in ovarian aging is warranted. The overall goal of my dissertation was to explore the impact of PFAS on ovarian aging and timing of natural menopause. The following specific aims were tested using a community-based, longitudinal cohort of midlife women, the Study of Women’s Health Across the Nation (SWAN). Aim 1 examined temporal variations in serum concentrations of PFAS and determined assessed whether the time trends differed by race/ethnicity, menstruation status and parity to better understand longitudinal changes in PFAS across the menopausal transition. We observed longitudinal declines in serum concentrations of legacy PFAS including perfluorooctanoic acid (PFOA), perfluorooctane sulfonic acid (PFOS) and their precursors but increases in other PFAS compounds such as perfluorononanoic acid (PFNA) from 1999 to 2011. Menstruating women had consistently lower concentrations than non-menstruating women. Temporal trends in PFAS concentrations were not uniform across race/ethnicity and parity groups. Previous epidemiologic studies of PFAS and menopausal timing conducted in cross-sectional settings were limited by reverse causation bias because PFAS serum concentrations increase after cessation of menstrual bleeding. Aim 2 examined the associations between PFAS exposure and incident natural menopause among 1120 midlife women aged 45-56 years at baseline from 1999 to 2017. Higher serum concentrations of PFOA and PFOS were associated with earlier onset of natural menopause, a risk factor for adverse health outcomes in later life. Women were classified into four clusters based on their overall PFAS concentrations as mixtures: low, low-medium, medium-high, and high. Compared to the low cluster, the high cluster had a HR of 1.66 (95% CI: 1.17-2.36), which is interpreted as 1.8 years earlier experience of natural menopause which is equivalent to the impact of smoking tobacco. Aim 3 explored the mediating role of follicle-stimulating hormone (FSH) in the associations between PFAS exposure and incident natural menopause to understand potential underlying mechanisms. The proportion of the effect mediated through FSH was 26.9% (95% CI: 15.6%, 38.4%) for linear PFOA and 13.2% (95% CI: 0.0%, 24.5%) for branched PFOS. The effect of PFAS on natural menopause may be partially explained by their association with variations in FSH concentrations. Overall this dissertation provides evidence that PFAS exposure may accelerate ovarian aging, possibly through endocrinologic mechanisms associated with changing serum concentrations of FSH. Future studies that can confirm these findings and steps to limit exposure to these chemicals appear warranted.

Obesity is a national health concern, and obese menopausal women are at greater risk for diabetes and cardiovascular disease than their male counterparts. Notably, obesity is comorbid with anxiety and depression, particularly in women, suggesting shared hormonal or brain networks linking mood and metabolic disorders. Estrogens, particularly 17β-estradiol (E2), maintain energy and metabolic homeostasis by offsetting excess weight gain and obesity-related consequences in women. E2 is circulated through the bloodstream to various organs including the brain, e.g. hypothalamus and medial amygdala (MeA) which regulate mood and metabolism. Unfortunately, being obese may disrupt the protective actions of E2 and ultimately dampen the brain’s ability to effectively regulate energy homeostasis. Thus, it is important to understand how obesity impacts brain function in females and whether these potential effects are reversible or permanent.This research includes a series of experiments conducted in adult female rats in order to (1) determine the impact of high fat diet (HFD) on metabolic and reproductive function, and estrogen receptor (ER&alpha) expression in metabolic-regulatory brain regions in ovarian-intact rats, to mimic a pre-menopausal state; (2) determine whether peripheral E2 reverses obesity and obesity-related consequences in adult-HFD ovariectomized (OVX) female rats, designed to mimic a menopausal state; (3) determine whether central E2 administration in the MeA via stereotaxic surgery, prevents obesity and obesity-related consequences in “menopausal” rats. Lastly, we determined the impact of E2 in the MeA on neuronal activity in stress and metabolic-regulatory brain regions.High-fat diet increased body weight and body fat, decreased muscle mass, impaired glucose tolerance, and induced irregular estrous cycles in young adult ovarian-intact female rats. These findings suggest that diet-induced obesity produces a metabolic and reproductive profile that is akin to aged females. Despite marked changes in metabolic function, HFD did not alter ERα expression in brain regions involved in energy balance. Obese OVX rats fed a HFD had increased body weight and fat mass, decreased energy expenditure, and higher glucose levels, compared with low-fat fed females. However, E2 treatment in obese OVX-HFD females did not improve glucose tolerance or decrease abdominal fat. This suggests that some benefits of E2 lessen with obesity or following a significant time after E2 loss. E2 in the MeA also prevented excess food intake and body weight gain, increased visceral adiposity, and glucose intolerance that is typically seen in OVX rats. Finally, we found that E2 in the MeA decreased anxiety-like and depression-like behaviors in OVX rats, which may be due to its ability to modulate neuronal activity in mood and stress-regulatory brain regions.Our findings reveal that obesity induces an accelerated aging phenotype on body composition and reproductive function in young rats. Though E2 is typically beneficial in women, obesity and or a significant time after E2 loss (e.g. menopause) may weaken the metabolic and reproductive benefits of E2. Most importantly, we demonstrate that the MeA mediates estrogenic effects on mood and energy homeostasis in females; which makes it a target region for treating the comorbidity of obesity, depression and or anxiety, particularly in women.

Using menopausal hormone therapy (HT) for more than five years puts women at increased risk for breast, ovarian, and endometrial cancer, cardiovascular disease (CVD), gallbladder disease, incontinence, and dementia. For this reason, HT is not recommended beyond this therapeutic window, except in rare circumstances. Nevertheless, data on filled prescriptions indicate that over a third of HT prescriptions are written for women over age 60. These alarming facts raised the research questions: "What factors influence older women to use HT beyond the menopause transition?" and "How do older women weigh the risks and benefits of HT?"Conventional grounded theory methods were used to interview 30 long-term users of systemic HT, code transcripts, and analyze data. Results showed that long-term users perceived that HT gave them control of numerous symptoms they attributed to menopause, enabled them to maintain attributes associated with youth and femininity, and helped them avoid diseases associated with aging, such as dementia and CVD. Risk was rarely mentioned in interviews; it was generally disregarded; and most participants did not know that age and length of HT use increase the risk of breast cancer. Users were observed to be the primary drivers of long-term HT, although gynecology specialty providers played a major role by giving reassurance about risk and continuing to prescribe HT.Arguing that the science behind the quantification of HT risk is faulty, some hormone manufacturers promote HT for long-term use. This promotion is largely directed at gynecology specialists through strategies such as ghostwriting, and, as a consequence, many of them remain skeptical of prescribing guidelines that recommend limiting duration of use. Key concepts from the literature on decision making that help explain disregard of risk information were identified.Study findings are applicable to any clinical encounter that involves weighing benefit and risk. Recommendations to providers: Learn to distinguish science from marketing. Help patients understand that positive feelings about treatment may be based on unrealistic expectations for efficacy and underestimation of risk. Discuss judgment biases and cite base rates when providing risk statistics in clinical encounters. Such interventions could potentially strengthen joint decision making and improve patient outcomes.

Female midlife coincides with the menopausal transition, a normative part of reproductive aging marked by menstrual changes and a host of commonly experienced symptoms such as vasomotor symptoms and sleep disturbance. Research on sleep quality during midlife has sought to determine the factors implicated in women’s heightened vulnerability to sleep disturbance during this time, including hormonal changes, vasomotor symptoms, health status, lifestyle behaviors, negative affect, socioeconomic status, and race/ethnicity. No research to date has analyzed these factors along with potentially meaningful variables including mindfulness, acceptance, and positive affect. The present study collected surveys from 301 women in online support groups. No differences were found between menopause status groups (i.e., premenopause, perimenopause, and postmenopause) in subjective sleep quality, daytime functioning, or menopause symptom severity. Menopause symptom severity was a significant predictor across all analyses, whereas mindfulness failed to reach significance on any analyses. Menopause symptom acceptance and positive affect were significant predictors of daytime functioning. This study provides initial support for the role of positive affect and acceptance in the daytime functioning of midlife women. Future studies may further explore the role of these variables in daytime functioning within different samples of midlife women and ultimately as treatment targets to improve women’s functioning despite ongoing menopausal symptoms.

Introduction: Lymphangioleiomyomatosis (LAM) is a rare, female-predominant, low-grade metastasizing neoplasm characterized by proliferation of abnormal smooth muscle cells and progressive destruction of lung parenchyma. Improved understanding of the natural history of LAM and identification of prognostic biomarkers can help guide management decisions in this patient population. Methods: Over a three-year period (1998–2001), 246 patients with LAM were enrolled into a National Heart, Lung, and Blood Institute (NHLBI) funded registry at six sites across the United States. Longitudinal data was collected at every 6-12 month intervals until 2003. The data collected included quality of life questionnaires, computed tomography (CT) scan findings, pulmonary function test (PFT) measurements, and serum specimens. These data and samples were subsequently de-identified and stored at the National Disease Research Interchange (NDRI) - an agency that contracts with the NHLBI to store and distribute samples. We obtained the de-identified data and serum specimens collected as part of this registry from the NDRI. In addition, we queried the National Death Index and the United Network for Organ Sharing databases to determine the patients who had either deceased or undergone lung transplantation after enrolling in this registry. A linear mixed effects model was employed to compute the rate of lung function decline and to correlate it with various clinical characteristics and biomarkers such as serum vascular endothelial growth factor-D (VEGF-D). Prognostic variables associated with progression to death/lung transplantation were identified using a Cox proportional hazard model. Results: After excluding patients with unclear diagnosis (n=17) and the patients who had undergone lung transplantation prior to study enrollment (n=12), we analyzed the data from the remaining 217 patients. The average rate of decline of forced expiratory volume in 1-second (FEV1) and forced vital capacity (FVC) was 89±17 mls/year and 71±57 mls/year, respectively. Rate of decline of FEV1 was significantly negatively impacted by the baseline FEV1 (p

Prior to and following breast cancer treatment women experience multiple co-occurring menopausal-related symptoms. The purposes of this dissertation research were: to evaluate for the differences in multiple dimensions of menopausal-related symptoms between pre- and postmenopausal women prior to and at 12 months following breast cancer surgery; to evaluate for differences in the number and types of menopausal-related symptom clusters at both time points using ratings of occurrence and severity; and to evaluate for changes in these symptom clusters over time. Menopausal-related symptoms were evaluated using the Menopausal Symptoms Scale (MSS). Of the 312 women enrolled prior to surgery, 37.4% were premenopausal and 62.6% were postmenopausal. In the multivariate analysis, premenopausal patients reported higher occurrence rates for urinary frequency (p=.006) and reported lower occurrence rates for joint pain/stiffness (p=.011), difficulty falling asleep (p=.025), and vaginal dryness (p=.002). A significant interaction was found between age and menopausal status for hot flashes (p=.002), wake during the night (p=.025), and headache (.040). Of the 327 women with breast cancer who completed the 12-month assessment, 35.2% were premenopausal and 64.8% were postmenopausal prior to surgery. In the conditional models that evaluated seven symptoms (i.e., hot flashes, night sweats, depression, daytime sweats, joint pain or stiffness, wake during the night, numbness or tingling), for which significant interactions were found between age and menopausal status, the differences in symptom occurrence rates between pre- and postmenopausal patients depended on their age. Of the 398 women evaluated for symptom clusters, the mean number of symptoms was 13.2 ± 8.5 at enrollment and 10.9 ± 8.2 at 12 months after surgery. Using exploratory factor analysis, eight distinct symptom clusters were identified prior to and at 12 months following surgery using occurrence and severity. Only two symptom clusters (i.e., pain/discomfort and hormonal) were relatively stable across both dimensions and time points and two symptom clusters were relatively stable across both dimensions either prior to surgery (i.e., sleep/psychological/cognitive) or at 12 months after surgery (i.e., sleep). The other four clusters (i.e., irritability, psychological/cognitive, cognitive, psychological) were identified at one time point using a single dimension.

Menopause causes declines in ovarian hormones such as estrogens and progesterone. During the menopausal transition, women may experience adverse symptoms such as anxiety, depression and lack of desire to interact. However, since the publication of the Women’s Health Initiative (WHI) many women have been left asking questions about whether, when, and how long to take hormone treatments for menopausal symptoms. This dissertation focuses on the effects of timing and duration of estradiol (E2) relative to loss of ovarian hormones (OVX) on the social brain and behavior in mature adult (MAT) and aging (AG) female rats. The results from these studies illustrated that in MAT rats, 3-months of E2 given immediately following OVX decreased communications and social interactions between cagemates, as assessed in a test quantifying the number of ultrasonic vocalizations emitted, as well as time spent interacting with one another. I interpret this result to mean that the E2 animals had improved social memory. In MAT rats gene expression of the neuropeptides (Oxt, Avp, Oxtr, Avpr1a) involved in regulating social behavior were also greater in the BNST, MeA, and SON of rats treated with estradiol compared to vehicle. Because menopause typically happens at middle age, I conducted a similar experiment in middle-aged rats to assess the influence of estradiol deprivation or replacement in aging rats. Aging animals were behaviorally characterized twice (at 3 and 6-months), groups were given different timing and duration of estradiol or vehicle treatments as a model for the WHI. Similar to the MAT animals, the estradiol-treated AG rats called less than their vehicle counterparts during an ultrasonic vocalization test conducted at the 3-month testing period. However, at the 6-month testing period no differences were observed, which could be the result of aging. Oxt, Oxtr, Avp and Avpr1a showed unique gene expression patterns that were dependent upon the timing and duration of estradiol in a region-specific manner in the AG rats. Most genes were up-regulated by estradiol treatment, irrespective of timing or duration. Overall this work may benefit the field of women’s health through new knowledge on consequences of age, and the timing and duration of estrogen treatment, on the social brain and behavior.

Background: In the United States, the aging population is rapidly growing. By 2060, it is expected that 12 million women will be ages 85 years and older. However, determinants of longevity and healthy aging in women are not fully understood. This dissertation had three objectives: 1) Determine whether ages at menarche and menopause and reproductive lifespan were associated with survival to age 90, termed “exceptional longevity;” 2) Determine whether genetic factors associated with longevity in prior studies among populations of European descent were associated with survival to ages 85 and 90 and healthy aging in white, African-American, and Hispanic women; and 3) Determine whether accelerometer-measured and self-reported sedentary time were associated with leukocyte telomere length (LTL), a purported biomarker of aging, among older women. Methods: Three studies were conducted among participants from the Women’s Health Initiative, a longitudinal study investigating major determinants of chronic diseases in postmenopausal women. Study one was a prospective study among 16,251 women who had potential to survive to age 90 as of August 29, 2014. Study two was a prospective study among 11,154 women who could survive to age 85 as of August 29, 2014 and used genetic data from multiple genome-wide association studies. Study three was a cross-sectional study among 1,481 women with information on either accelerometer-measured or self-reported sedentary time. All studies consisted of racially diverse samples.Results: In study one, the odds of exceptional longevity were elevated among women with later menarche, later menopause, and longer reproductive lifespan. In study two, three variants at APOE were associated with survival to age 90 and healthy aging in white women, and seven variants at a novel locus were associated with survival to age 85 in Hispanic women. In study three, among women at or below the median level of moderate-to-vigorous intensity physical activity (MVPA), higher accelerometer-measured sedentary time was associated with shorter LTL. Among women with higher MVPA levels, sedentary time was not associated with LTL. Conclusions: Findings suggest that reproductive and genetic factors may be associated with late-age survival and that a high level of inactivity may be associated with short LTL.

Menopausal loss of ovarian function associates with changes in body composition, increasing the risk of developing central obesity, metabolic syndrome, and other chronic diseases. Breast cancer is the second leading cause of cancer deaths in women, with the majority occurring in postmenopausal women. Obesity is associated with increased risk of postmenopausal breast cancer and the underlying mechanism(s) likely involves obesity-related metabolic dysregulation. Therefore, improvement of metabolic status may be a useful approach to decrease the risk of breast cancer. Naringenin is a flavonone found in citrus fruits and tomatoes. It possesses anti-tumor properties as well as ameliorates obesity-associated metabolic dysregulation. Therefore, we hypothesized that naringenin ameliorates metabolic disturbances not only resulting from loss of ovarian function but also that associated with postmenopausal obesity. Furthermore, we hypothesized that naringenin inhibits mammary tumor growth induced by postmenopausal obesity. To determine the effect of naringenin on metabolic changes resulting from loss of ovarian function, ovariectomized C57BL/6J female mice were fed a control diet (10% kcal fat) for 11 weeks. Half of the mice were supplemented with 3% naringenin for the next 11 weeks. Ovariectomized mice exhibited hyperglycemia and increased adiposity. Naringenin supplementation decreased plasma leptin and leptin mRNA in adipose depots as well as adipose tissue inflammation. Naringenin-supplemented mice also had reduced hepatic lipid accumulation with corresponding alterations of hepatic gene expression associated with de novo lipogenesis and gluconeogenesis. Thus, dietary naringenin attenuated many of the metabolic disturbances associated with ovariectomy in female mice. Then, the effect of naringenin on metabolic disturbances in a mouse model of postmenopausal obesity was examined. Ovariectomized mice were fed a high-fat diet (60% kcal fat) for 11 weeks to induce obesity and half of the mice were then supplemented with 3% naringenin for another 11 weeks. Naringenin-fed mice had decreased weight gain, hyperglycemia, and intra-abdominal adiposity. Mice supplemented with naringenin also exhibited elevated locomotor activity, maintained muscle mass, reduced muscle diacylglycerol content and decreased muscle mRNA level for genes involved in de novo lipogenesis, lipolysis, and triglyceride synthesis/storage. Thus, naringenin supplementation attenuated metabolic dysregulation in obese ovariectomized mice.To determine the effect of naringenin on breast tumors growth in a mouse model of postmenopausal obesity, ovariectomized mice were fed a high-fat diet for 3 weeks to induce obesity and then supplemented with 1% or 3 % naringenin, or metformin, a glucose-lowering drug. After 2 weeks of experimental diets, E0771 murine breast cancer cells were inoculated into one mammary fat pad and the tumor size was monitored daily. Decreased body weight, adipose depot mass, and mRNA expression of inflammatory cytokines in both mammary and perigonadal adipose tissues were observed in naringenin-fed mice. Naringenin supplementation suppressed early tumor growth but not final tumor weight. Metformin reduced tumor growth and final weight, without affecting body weight, tissue weights, and adipose tissue inflammation. Collectively, our data demonstrated that naringenin and metformin alter mammary tumorigenesis via different mechanisms. Overall, these experiments suggest that naringenin supplementation may correct metabolic dysregulation induced by excess caloric consumption and/or loss of ovarian function.

Cardiovascular diseases (CVDs) are the number one killer worldwide, in the United States, and in the state of Hawai’i. Women’s risk for CVDs increases after menopause, partially due to changing cholesterol levels. The Hilo Women’s Health Study seeks to advance knowledge of women going through the menopausal transition in the multiethnic population of Hilo, Hawai’i, including Asian Americans, Native Hawaiians, and Pacific Islanders. The two phase, cross-sectional study obtained information on 189 women from the ages of 45 to 55. Menopausal status was divided into premenopause, perimenopause, and postmenopause, and regressed on total cholesterol, HDL-C, LDL-C, triglycerides, and the triglyceride to HDL-C ratio. After adjusting for potential confounders, menopause status was significantly associated with total cholesterol and LDL-C. However, ethnicity was significantly associated with all of the cholesterol measures. Conversely, age was not found to be associated with any of the measures.

The use of the Daubert Standard in court proceedings has highlighted the need to substantiate scientific findings or claims beyond simply accepting the word of a respected expert. The concept of postmenopausal masculinization of the skull in female crania falls into this category. Dr. Walker references this concept in several articles but there is no research to support this hypothesis. This project examines the theory of postmenopausal masculinization of female crania from several perspectives, using the visual sex estimation method set forth in Standards for Data Collection from Human Skeletal Remains edited by Jane E. Buikstra and Douglas H Ubelaker, photographic seriation of these sex estimation traits, and metric measurements in conjunction with Fordisc 3.1. A sample of 395 crania from the Hamann-Todd Collection at the Cleveland Museum of Natural History was analyzed using all three of these methods to determine if there was a pattern of masculinization in the postmenopausal female sample. The average age for the onset of menopause in the United States is 50, thus there should be an increase in "masculinization" observable through more rugged sex estimation traits, a higher number of females 50 or over being found below the midpoint in photographic seriations of sex estimation traits, and an increase in Fordisc 3.1 sex identification misclassifications in females in this age category. The results of the analyses revealed that there were statistically significant differences between ancestry groups, the sexes, and in some cases, age-groups. The results of this research indicate that though there are some differences between comparison groups, there does not appear to be a cohesive pattern of masculinization in female crania at or after the average age of onset of menopause. Human variation is endless, and even in areas of the skeleton for which it has been established that there is a significant degree of sexual dimorphism, there will be individuals who do not fit neatly into a binary conception of sexual divergence. Though these individuals may be misidentified as the opposite sex using one or all of the methods utilized in this project, this falls short of being classified as a part of the menopausal process in females.

The Impact of Chronic Perceived Stress on Perceived Health Status and Symptom Experience in Pre- and Post-Menopausal WomenHolly J. JonesAbstractChronic stress has been recognized as a precursor to poor health outcomes and health disparity. The purpose of this dissertation research study was to evaluate the impact of chronic perceived stress on perceived health status and symptom experience in women before and after menopause. The theory of allostasis was used as the framework for this study and proposes that chronic perceived stress will result in symptom expression or illness if a person in unable to adapt effectively to a stressor(s). In an effort to fully explore this phenomenon, this study was comprised of two parts: 1) secondary analyses of retrospective data exploring symptom experience in a cohort of midlife women who participated in the UCSF Midlife Women’s Health Study prior to menopause and, 2) mixed-methods analysis of current data exploring perceived stress and its long-term effects using a smaller sample of the women who participated in the parent study and are now post menopause. Bladder and sleep symptoms were found to be prevalent in the sample. Reproductive status was a significant contributor to the variance in experiencing nocturia. Sleep quality and sleep hours were associated with several determinants of adverse health outcomes: perceived stress, body mass index, and race. Mixed methods analysis found perceived stress scores to be consistent over time in the subsample of African American women and six stress-related themes were identified. Finally, multiple physiological, psychosocial, and demographic factors were investigated to determine their unique contributions to the variance in leukocyte telomere length. Telomere length is recognized as a measure of aging and chronic stress. Despite the small sample size, income, age, perceived stress, and diastolic blood pressure were noted to be influential to having shorter telomere length. The combination of data from a cohort of contemporary women before and after menopause provided a better understanding of the stressors endured over time, symptom experience, coping strategies, and associations with genetic biomarkers. Results from this study should be used to identify vulnerable midlife women and formulate individualized care plans in an effort to decrease morbidity and health disparity.

Background: As obesity rates rise, new methods to provide substantial weight loss have become crucial to the healthcare industry. Bariatric surgery has proven to be the most effective treatment for obesity, and the Roux-en-Y Gastric Bypass operation has not only enabled many to lose excess weight, but also has resulted in the resolution of comorbid conditions. To date, research on the effectiveness of the RYGB surgery in postmenopausal women is minimal.Objective: This study was completed to compare excess body weight lost and metabolic syndrome resolution in pre- and postmenopausal Roux-en-Y Gastric Bypass surgery patients, preoperatively to one year postoperatively. Methods: A retrospective chart review was completed for 42 premenopausal and 36 postmenopausal RYGB surgery patients at Wood County Hospital in Bowling Green, Ohio. Surgeries took place between September 2008 and May 2012. Weight data was collected preoperatively, and at 2 week, 2 month, 6 month, and 1 year follow up appointments. To determine diagnosis of metabolic syndrome, preoperative, 6 month, and 1 year data was utilized. Results: At 1 year, percent excess body weight lost was 68.79% for the premenopausal group and 59.44% for the postmenopausal group, which was significant, t(73)= 2.61, p=0.011. To compare the effect time on percent excess body weight lost for those with data at all follow up appointments, a repeated measures analysis of variation was done, which showed a difference between groups as time elapsed, with significance at 1 year F(3,195)=4.71, p=0.0182. Excess percent body weight lost was greater than 50% in 64 of 78 individuals at 1 year. Significance between pre- and postmenopausal groups was also found for preoperative (X2 (1, n=76) p=0.0307) and midway glucose (X2 (1, n=76) p=0.0047), as well as midway (X2 (1, n=69) p=0.0024) and 1 year blood pressure (X2 (1, n=74) p=0.0089). Preoperatively, metabolic syndrome diagnosis was 54 of 78 (22 premenopausal and 32 postmenopausal), midway 37 of 78 (13 premenopausal and 24 postmenopausal), and 17 of 78 (7 premenopausal and 10 postmenopausal) at 1 year. Conclusion: In this retrospective chart review, premenopausal surgery patients lost a significantly greater amount percent excess body weight at 1 year, when compared to the postmenopausal group. Metabolic syndrome incidence was also less in the premenopausal group preoperatively, midway and at 1 year. This study shows that the Roux-en-Y bariatric surgery was able to provide weight loss and resolution of metabolic syndrome in both pre- and postmenopausal women, however postmenopausal women saw less success overall. In the future, a change in bariatric surgery inclusion criteria for those women in the perimenopausal period to include those at a lower BMI may be helpful to more quickly address issues with weight allowing for greater success in the postoperative time period after bariatric surgery.

Menopause is a natural transition heralded by the cessation of menstrual cycles and ovulation, and it occurs in all women at an average of about 50 years of age. While not a disease, menopause is often accompanied by symptoms that interfere with the quality of life and these symptoms are due to the relatively abrupt deprivation of E2 and P4 experienced during reproductive aging. Reproductive aging consists of changes in the synthesis and release of hormones from the hypothalamus, pituitary and gonad, which make up the HPG axis. Because gonadal hormones play critical roles in many systems throughout the body and brain, not just reproduction, treatment of menopausal symptoms to date largely involves hormone replacement therapy (HRT) with E2, P4 or their combination. While not intended to treat other neurobiological symptoms beyond hot flushes, HRT has the potential to exert widespread actions due to the abundance of hormone receptors throughout the nervous system. Thus, a fuller understanding of the neurobiology of menopause is badly needed. Although much of the research into the mechanisms that underlie reproductive aging focuses on ovarian failure and follicular atresia (cell death), there is evidence that there are significant alterations in the function of the neuroendocrine levels - the hypothalamus and pituitary - that also contribute to this process. As the mean age of the population increases, the number of post-menopausal women continues to grow with broad economic, healthcare and social costs. It is increasingly important to understand the complex mechanisms underlying reproductive aging and the effects of HRT. In this dissertation, I focus on the question of how the female non-human primate hypothalamus changes both with aging and in response to steroid hormone treatments.

This qualitative study used a phenomenological approach to understand the experience of 10 later-life mothers who had a first child at age 35 or older and were in the process of raising a teenager. Data were collected with semi-structured interviews and analyzed using thematic coding. Initial findings suggest maternal age contributes to a positive parenting outcome due to life experience, emotional maturity and financial security. Drawbacks include fatigue and reduced fertility that limited family size, as well as competing life stages such as retirement and college. Older mothers felt in the mainstream. Clinical implications are discussed.

During midlife, it is expected that women will progress towards the biological state of menopause; the permanent condition of infertility due to alterations or diminution of reproductive hormones. Typically lasting 5-10 years, the menopausal transition is associated with symptoms including hot flashes, night sweats, interrupted sleep, anxiety, forgetfulness, and inconsistent mood. As these symptoms often hinder a women's successful functioning in everyday life, hormone therapy is commonly prescribed as a means for diminishing symptoms. However, many women are seeking alternative/complementary treatments that can assist in managing menopausal symptoms due to the detrimental health-risks associated with the use of conventional therapies. The purpose of this mixed methods study was (a) to determine the effects of participation in a ten-week yoga intervention on the physiological symptoms experienced by women during menopause; and (b) to determine to what extent a change in symptoms can be attributed to yoga, as opposed to any other form of physical activity. Findings support previous literature indicating there to be a direct relationship between yoga participation and a reduction in the severity and/or frequency of menopausal symptoms. Additional results support an indirect relationship between yoga participation and improved management of menopausal symptoms due to decreased levels of perceived stress.

ABSTRACTObjectives: The purposes of this study were to determine 1) if cone beam computed tomography (CBCT) can determine relative differences in bone mineral density distribution using clinical images of patients’ mandibular bone and 2) if the relative differences can be used to detect the effects of gender and age on bone mineral density distribution. Methods: Sixty six clinical CBCT images from patients (36 females and 30 males) were identified. Three age groups (40, 50, and 60 years) were identified for male and female patients. Alveolar bone (AB) and basal cortical bone regions were digitally isolated. A histogram of gray levels, which are equivalent to degrees of bone mineralization, was obtained from each region of the CBCT images. Mean, standard deviation (SD), coefficient of variation (COV), fifth percentile low (Low5) and high (High5) of gray levels were obtained. Percentage differences of gray level parameters between alveolar and basal cortical bones were computed.Results: The alveolar bone region had significantly higher SD and COV, but significantly lower Mean, Low5 and High5 than the basal cortical bone region for all CBCT images (p