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Howard M Kravitz,1 Kristine Ruppert,2 Pam Lian,2 Genevieve Neal-Perry,3 Leslie M Swanson4 1Department of Psychiatry and Behavioral Sciences, and Department of Family and Preventive Medicine, Rush University Medical Center, Chicago, IL, USA; 2Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA; 3Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA; 4Department of Psychiatry, University of Michigan, Ann Arbor, MI, USACorrespondence: Howard M Kravitz, Rush University Medical Center, Department of Psychiatry and Behavioral Sciences, Rush West Campus, 2150 West Harrison Street, Room 278, Chicago, IL, 60612, USA, Tel +1 312 942 4161, Email hkravitz@rush.eduPurpose: To investigate the associations between anxiety symptoms in midlife women and sleep features later in life, the aim is to test the hypothesis that poor sleep, as measured by each of six individual dimensions (4 objective actigraphy measures, 2 self-reports) of sleep health, is associated with higher levels of anxiety symptoms in midlife women.Participants and Methods: The participants in this longitudinal analysis included women from the SWAN Sleep I Study, a subcohort of the community-dwelling midlife women participating in the core Study of Women’s Health Across the Nation (SWAN), which was initiated in 1996. Of the 370 participants enrolled in the Sleep Study, 270 were included in the analytic sample, and 100 who did not meet the inclusion criteria were excluded. Baseline measures of six dimensions of multidimensional sleep health (actigraphy measures: efficiency, duration, mid-sleep timing, regularity; self-report measures: alertness, satisfaction) were obtained between 2003 and 2005, corresponding to SWAN core annual/biennial assessments 5– 8. Associations of each dimension with self-reported anxiety symptoms (Generalized Anxiety Disorder – 7-item scale; GAD-7), collected during visits 12 (2009– 2011), 13 (2011– 2013), and 15 (2015– 2017), were examined using mixed models. The GAD-7 outcome was measured both continuously and as a categorical variable due to its skewed distribution.Results: No statistically significant associations were found between any of the six baseline sleep health dimensions and the GAD-7 score after adjustment for covariates.Conclusion: The reasons for the lack of support for our hypothesis, despite previous evidence supporting an association between sleep and anxiety, are unclear. There is considerable overlap between anxiety and sleep symptoms, which may complicate the interpretation of our the findings. Thus, the failure to identify associations is likely multifactorial, and more studies with shorter follow-up intervals are warranted to better understand these relationships.Keywords: generalized anxiety disorder 7-item scale, GAD-7, longitudinal, mixed model analysis, actigraphy, community study, observational study

PURPOSE: The purpose of this article is (1) to investigate if type 2 diabetes management programs with Latino participants address emotional well-being in addition to the standard diabetes self-care behaviors and (2) to describe the approaches taken to improve psychological and diabetes management outcomes. METHODS: Online article and research databases, Internet searches, and review of article citations were used to identify relevant articles published 1995-2008. Type 2 diabetes management interventions with a psychological (emotion or cognitive) component or outcome measure and Latino sample were selected. Articles were limited to randomized clinical/controlled trials and pre-post comparative studies. RESULTS: Thirteen interventions met the inclusion criteria for this review. Eight studies included emotion outcome measures, and 13 included at least one cognitive outcome measure. One study was specifically designed to improve emotional well-being. This study was not targeted for Latinos but did include Latino participants. A specialized depression case manager and collaborative care model showed significant improvements in depression and mental functioning. Psychological improvements were also found in those studies that assessed cognitive outcomes and were based on cognitive theories. The most frequent cognitive outcomes assessed were diabetes knowledge, problem solving, and self-efficacy. CONCLUSIONS: Few type 2 diabetes interventions address emotional well-being in Latinos. More attention has been directed toward designing culturally sensitive community-based programs for improving behavior and physical outcomes. Because some Latino groups believe that negative emotions cause diabetes and because depression and anxiety are associated with poor self-management, programs should address emotional well-being as an important aspect of diabetes management. [ABSTRACT FROM AUTHOR]

AIMS: We sought to determine if the frequency of reported physical or emotional premenstrual symptoms (PMSx) was associated with (1) dietary intake of phytoestrogens, fiber, fat, or calcium, (2) consumption of alcohol or caffeine, (3) active or passive smoke exposure or lack of physical exercise, and (4) race/ethnicity or socioeconomic status. METHODS: A cross-sectional analysis was conducted of PMSx and demographic and lifestyle factors reported at baseline in the multiethnic sample of 3302 midlife women in the Study of Women's Health Across the Nation (SWAN). Stepwise multiple logistic regression analyses were performed for the overall sample and for each racial/ethnic group for each of five PMSx groupings. RESULTS: Most dietary factors were not related to PMSx. Fat intake was negatively associated with craving and bloating (adjusted odds ratio [AOR] = 0.56, p = 0.024), and fiber intake was positively associated with breast pain (AOR = 1.39, p = 0.037). Alcohol intake was negatively associated with anxiety and mood changes (AOR = 0.63, p = 0.045) and headaches (AOR = 0.50, p = 0.009). Current smoking (AOR = 1.60, p = 0.028) and passive smoke exposure (AOR = 1.56, p = 0.050) were positively associated with cramps and back pain. Symptom reporting differed significantly by race/ethnicity. PMSx were also associated with comorbidities, early perimenopausal status, depressive symptoms, and symptom sensitivity. CONCLUSION: We found little evidence to support a role for diet in PMSx reporting. However, alcohol intake was positively associated with premenstrual anxiety and mood changes, and active and passive smoke exposure was associated with a number of PMSx. Ethnic differences in symptom reporting and associations of comorbidities, early perimenopausal status, depressive symptoms, and symptom sensitivity with reported PMSx were also observed. [ABSTRACT FROM AUTHOR]

Background. Treatment of fibromyalgia syndrome (FMS) remains a clinical challenge. Pain, somatic and cognitive symptoms may be due to neurosensitization involving CNS-activated autonomic and musculoskeletal reactions, associated with EEG abnormalities that may respond to brainwave-based stimulation biofeedback. This study's objective was to examine the efficacy and safety of a novel EEG neurobiofeedback treatment, the Flexyx Neurotherapy System (FNS), and electrophysiological responses in persons with fibromyalgia. Methods. A randomized, double-blind, placebo-controlled clinical trial was conducted in two private practices: a free-standing neurobiofeedback center and a rheumatologist's office at an academic medical center. Sixty-four participants with FMS (American College of Rheumatology criteria; Wolfe et al., 1990) for at least three years and symptoms for at least 48 months with no recent remission were randomized to treatment. A total of 22 treatment sessions were administered over at least 11 weeks of active (n = 33) or sham (n = 31) FNS therapy. Primary efficacy measures were the Clinical Global Impressions improvement scores, Clinician (CGI-I) and Participant (PGI-I) versions. Secondary outcomes included dolorimetry and tender point count, questionnaires (fibromyalgia symptom scales, CNS Dysfunction Questionnaire, Fibromyalgia Impact Questionnaire, Symptom Checklist-90-R), and EEG activity (delta, alpha, total amplitude). Results. More participants treated with active FNS than with sham improved partially or fully on the CGI-I at session 22 (p = .01) and follow-up (p = .04). The active FNS group had a higher CGI-I full response rate at session 22 (p < .05) but not at one-week post-treatment (p = .07). Significant active versus sham PGI-I responses were not detected (p>.10). There was no significant treatment effect on any secondary outcome measure and no specific symptom improved preferentially with active compared with sham FNS. The most commonly reported side effect was fatigue/tiredness. Pre-treatment delta/alpha EEG amplitude ratio > 1 was associated with PGI-I (but not CGI-I) response independent of treatment group assignment. Conclusion. FNS monotherapy is insufficient for treating chronic, nonremitting FMS. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We examined racial/ethnic differences in significant depressive symptoms among middle-aged women before and after adjustment for socioeconomic, health-related, and psychosocial characteristics. METHODS: Racial/ethnic differences in unadjusted and adjusted prevalence of significant depressive symptoms (score >/= 16 on the Center for Epidemiologic Studies Depression [CES-D] Scale) were assessed with univariate and multiple logistic regressions. RESULTS: Twenty-four percent of the sample had a CES-D score of 16 or higher. Unadjusted prevalence varied by race/ethnicity (P <.0001). After adjustment for covariates, racial/ethnic differences overall were no longer significant. CONCLUSIONS: Hispanic and African American women had the highest odds, and Chinese and Japanese women had the lowest odds, for a CES-D score of 16 or higher. This variation is in part because of health-related and psychosocial factors that are linked to socioeconomic status. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study examined the association between psychologic distress and natural menopause in a community sample of African American, White, Chinese, Hispanic, and Japanese women participating in a national women's health study. METHODS: A cohort of 16,065 women aged 40 to 55 years provided information on menstrual regularity in the previous year, psychosocial factors, health, and somatic-psychologic symptoms. Psychologic distress was defined as feeling tense, depressed, and irritable in the previous 2 weeks. RESULTS: Rates of psychologic distress were highest in early perimenopause (28.9%) and lowest in premenopause (20.9%) and postmenopause (22%). In comparison with premenopausal women, early perimenopausal women were at a greater risk of distress, with and without adjustment for vasomotor and sleep symptoms and covariates. Odds of distress were significantly higher for Whites than for the other racial/ethnic groups. CONCLUSIONS: Psychologic distress is associated with irregular menses in midlife. It is important to determine whether distress is linked to alterations in hormone levels and to what extent a mood-hormone relationship may be influenced by socioeconomic and cultural factors. [ABSTRACT FROM AUTHOR]

This study examined the associations between ambient air pollution exposure, including fine particulate matter (PM 2.5 ), nitrogen dioxide (NO 2 ), and ozone (O 3 ), with serum levels of high molecular weight (HMW) adiponectin, leptin, and soluble leptin receptors (sOB-R) in midlife women. The analysis included 1551 participants from the Study of Women's Health Across the Nation (median age = 52.3 years) with adipokine data from 2002 to 2003. Annual air pollution exposures were assigned by linking residential addresses with high-resolution machine learning models at a 1-km 2 resolution. Multivariable linear regression and Bayesian kernel machine regression (BKMR) were used to evaluate the associations for individual pollutants and pollutant mixtures. After adjusting for confounders in linear regression models, an interquartile range increase in PM 2.5 (2.5 μg/m 3 ) was associated with a 4.6 % lower HMW adiponectin level (95 % CI: -8.8 %, -0.3 %). Exposure to air pollutant mixtures showed negative associations with HMW adiponectin and positive associations with leptin levels in BKMR models. These findings suggest that exposures to PM 2.5 , NO 2 , and O 3 are associated with adverse levels of adipokines, which may contribute to obesity-related outcomes. Further research is needed to confirm these findings and explore the underlying biological mechanisms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Women may be vulnerable to elevated depressive symptoms during the menopause transition (MT). Studies generally have not considered premenopausal depressive symptom history or examined symptoms in relation to the final menstrual period (FMP)., Objective: To identify specific time points in relation to the FMP when depressive symptoms increase or decrease., Methods: Participants were 1582 multiracial/ethnic women from the longitudinal Study of Women's Health Across the Nation (SWAN). Biological, psychosocial, and depressive symptom data were collected approximately annually. Depressive symptoms were measured by the Center for Epidemiological Studies-Depression (CESD) scale., Results: Women with high baseline depressive symptoms (CES-D ≥ 16) declined in symptoms (M = -1.04/yr., 95 % CI = -1.58, -0.50) until 4 years before the FMP, followed by a smaller decrease (M = -0.50/yr., 95 % CI = -0.72, -0.28) until 18 months after the FMP. Depressive symptoms increased (M = 0.21/yr., 95 % CI = 0.11, 0.30) in those with low baseline symptoms until 1 year before the FMP, and decreased (M = -0.06/yr., 95 % CI = -0.11, -0.008) going forward. Greater social support, higher levels of follicle stimulating hormone and estradiol, and less sleep disturbance contributed to greater decline in depressive symptoms among those with high baseline depressive symptoms. Anxiety, experiencing stressful life events, lower body mass index, and poor role-physical function contributed to an increase in depressive symptoms among those with low baseline symptoms., Limitations: Excluded women had higher baseline CES-D scores. Lacked pre-MT depression for pre/early perimenopausal women at baseline., Conclusion: Accounting for baseline depressive symptom level and focusing on the FMP more precisely characterize depressive symptom change over the MT., Competing Interests: Declaration of competing interest Dr. Joffe is a consultant/advisory board member for Bayer, Merck, and Hello Therapeutics, and has grant/research support from Merck, Sage, and Pfizer., (Copyright © 2024 Elsevier B.V. All rights reserved.)

The harmful effects of perceived discrimination for physical and mental health are well documented. Evidence identifies how dimensions of religious/spiritual (R/S) involvement may reduce these harmful effects. This study examined how R/S experiences are associated with the effects of discrimination on perceived stress. With data from the Study of Women's Health Across the Nation (SWAN), we examined the offsetting and buffering effects of daily spiritual experiences on the relationship between everyday discrimination and perceived stress among 2,221 US midlife women from 5 racial/ethnic groups. Regression analysis identified a positive association between perceived discrimination and perceived stress (p < .001). Daily spiritual experiences were inversely associated with perceived stress (p < .001) for the whole sample and in the subsample of Black women. For this subsample, there was an inverse association between daily spiritual experiences and discrimination. R/S experiences may be one of the ways that R/S reduce the harmful effects of discrimination on health., Competing Interests: Ethical approval. Clinical Centers: University of Michigan, Ann Arbor—Carrie Karvonen-Gutierrez, PI 2021–present; Siobán Harlow, PI 2011–2021, MaryFran Sowers, PI 1994–2011; Massachusetts General Hospital, Boston, MA—Sherri‐Ann Burnett‐Bowie, PI 2020–present; Joel Finkelstein, PI 1999–2020; Robert Neer, PI 1994–1999; Rush University, Rush University Medical Center, Chicago, IL—Imke Janssen, PI 2020–present; Howard Kravitz, PI 2009–2020; Lynda Powell, PI 1994–2009; University of California, Davis/Kaiser—Elaine Waetjen and Monique Hedderson, PIs 2020–present; Ellen Gold, PI 1994–2020; University of California, Los Angeles—Arun Karlamangla, PI 2020–present; Gail Greendale, PI 1994–2020; Albert Einstein College of Medicine, Bronx, NY—Carol Derby, PI 2011–present, Rachel Wildman, PI 2010–2011; Nanette Santoro, PI 2004–2010; University of Medicine and Dentistry—New Jersey Medical School, Newark—Gerson Weiss, PI 1994–2004; and the University of Pittsburgh, Pittsburgh, PA—Rebecca Thurston, PI 2020–present; Karen Matthews, PI 1994–2020. NIH Program Office: National Institute on Aging, Bethesda, MD—Rosaly Correa-de-Araujo 2020–present; Chhanda Dutta 2016–present; Chhanda Dutta 2016–present; Winifred Rossi 2012–2016; Sherry Sherman 1994–2012; Marcia Ory 1994–2001; National Institute of Nursing Research, Bethesda, MD—Program Officers. Central Laboratory: University of Michigan, Ann Arbor—Daniel McConnell (Central Ligand Assay Satellite Services). Coordinating Center: University of Pittsburgh, Pittsburgh, PA—Maria Mori Brooks, PI 2012–present; Kim Sutton-Tyrrell, PI 2001–2012; New England Research Institutes, Watertown, MA—Sonja McKinlay, PI 1995–2001. Steering Committee: Susan Johnson, Current Chair; Chris Gallagher, Former Chair. We thank the study staff at each site and all the women who participated in SWAN., (© 2024. The Author(s).)

Background: Cognitive decline may progress for decades before dementia onset. Better cardiovascular health (CVH) has been related to less cognitive decline, but it is unclear whether this begins early, for all racial subgroups, and all domains of cognitive function. The purpose of this study was to determine the impact of CVH on decline in the 2 domains of cognition that decline first in White and Black women at midlife., Methods and Results: Subjects were 363 Black and 402 White women, similar in baseline age (mean±SD, 46.6±3.0 years) and education (15.7±2.0 years), from the Chicago site of the Study of Women's Health Across the Nation. Cognition, measured as processing speed and working memory, was assessed annually or biennially over a maximum of 20 years (mean±SD, 9.8±6.7 years). CVH was measured as Life's Essential 8 (blood pressure, body mass index, glucose, non-high-density lipoprotein cholesterol, smoking, physical activity, diet, sleep). Hierarchical linear mixed models identified predictors of cognitive decline with progressive levels of adjustment. There was a decline in processing speed that was explained by race, age, and the 3-way interaction of race, CVH, and time ( F 1,4308 =8.8, P =0.003). CVH was unrelated to decline in White women but in Black women poorer CVH was associated with greater decline. Working memory did not decline in the total cohort, by race, or by CVH., Conclusions: In midlife Black women, CVH promotion may be a target for preventing the beginnings of cognitive decline, thereby enhancing independent living with aging.

Menopause is a significant milestone in a woman's life, characterized by decreasing estradiol (E2) and increasing follicle-stimulating hormone (FSH) levels. Growing evidence suggests that air pollution may affect reproductive health and disrupt hormone profiles, yet the associations in women undergoing menopausal transition (MT) remains underexplored. We examined the associations between annual air pollutant exposures and repeated measures of E2 and FSH in 1365 women with known final menstrual period (FMP) date from the Study of Women's Health Across the Nation. Air pollution was calculated as the annual averages of 24-h average PM 2.5 levels, daily one-hour maximum NO 2 levels, and daily 8-h maximum O 3 levels. Linear mixed models with piece-wise linear splines were used to model non-linear trajectories of E2 and FSH in three distinct time periods: up to 2 years before the FMP (early MT), within 2 years before and 2 years after FMP (transmenopause), and >2 years post-FMP (postmenopause). In the transmenopausal period, an interquartile (5 μg/m3) increase in PM 2.5 was associated with a significant decrease in E2 levels (-15.7 %, 95 % CI: -23.7, -6.8), and a 10 ppb increase in NO 2 was associated with a significant decrease in E2 levels (-9.2 %, 95 % CI: -16.2, -1.7). A higher PM 2.5 was also associated with an accelerated rate of decline in E2. Regarding FSH, a 10 ppb increase in NO 2 was associated with decline in FSH levels (-11.7 %, 95 % CI: -21.8, -0.1) in the early MT and accelerated rates of decline in the postmenopause (-1.1 % per year, 95 % CI: -2.1, -0.1). Additionally, inverse associations between O 3 and FSH were observed in the transmenopause and postmenopause. Our study suggests that increases in PM 2.5 , NO 2 , and O 3 exposures are linked to significant declines in E2 and FSH levels across menopausal stages, suggesting the detrimental impact of air pollutants on women's reproductive hormones., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier B.V.)

Objectives: To determine whether physical function (PF) before menopause is related to cardiovascular disease (CVD) risk., Methods: Participants were N = 2950 pre-/early peri-menopausal women (median age 46, (25th-75th percentile: 43-48 years). Physical function was assessed at baseline using the Physical Function subscale of the SF-36 and scores were trichotomized (no, some, or substantial limitations). Clinical CVD events were ascertained at annual/biennial clinical assessments through the 15th follow-up visit. Risk of CVD was determined with Cox proportional hazards models. Results: Women were followed for a median of 19.1 years, during which 220 women had a CVD event. In fully adjusted models, women with substantial limitations at baseline had higher CVD risk compared to women with no limitations (hazards ratio [HR] = 1.55, 95% confidence interval [CI]: 1.12-2.33). Discussion: Substantial PF limitations in pre- and early peri-menopausal women are associated with higher risk of clinical CVD events, consistent with literature in older adults.

Sleep disturbances are common and may impact fracture risk directly by influencing bone turnover or indirectly through shared risk factors or mediators. To investigate the association between self-reported sleep disturbances across the menopausal transition (MT) and fractures, we prospectively studied 3101 women enrolled in the Study of Women's Health Across the Nation (SWAN). At each of 14 study visits spaced approximately 18 months apart, a standardized validated scale ascertained trouble falling asleep, waking up several times during the night, and waking up earlier than planned. Two time-varying exposures were modeled: presence of any of the three disturbances at least three times per week and waking up several times during the night at least three times per week. Base models adjusted for fixed (race/ethnicity, study site) and time-varying characteristics (age, body mass index, and MT stage). Fully adjusted models also included time-varying bone beneficial and detrimental medications, smoking, alcohol, physical activity, diabetes, depression and sleep medications, and depressive symptoms. Women who experienced a fracture were more likely to report a greater frequency of having trouble falling asleep, waking up several times, and/or waking up earlier: 35% versus 30% at baseline, p  = 0.02. In the base models, women who had any of the three sleep disturbances at least three times per week had a higher risk of any fracture, odds ratio (OR) = 1.23 (95% confidence intervals, 1.02, 1.48) and nontraumatic fracture, OR = 1.36 (1.03, 1.80). These associations were largely attenuated to nonsignificance in the fully adjusted model. Sensitivity analyses limiting our sample to 2315 SWAN women enrolled in the bone mineral density (BMD) centers yielded similar results. Additional adjustment for femoral neck BMD had no effect on our results. In conclusion, self-reported sleep disturbances were associated with an increased risk of fractures, but these associations likely reflect shared risk factors or factors in the causal pathway. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research., Competing Interests: JAC, HMK, KR, YL, MH, SDH, JSF, and have no conflicts., (© 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.)

Objectives: To examine the associations of actigraphy-assessed sleep timing and regularity with psychological health in early late life women, whose circadian rhythms may be impacted by aging., Design: Cross-sectional., Participants: A racially/ethnically diverse sample of 1197 community-dwelling women (mean age 65 years) enrolled in the Study of Women's Health Across the Nation., Measures: Actigraphy-assessed sleep measures included timing (mean midpoint from sleep onset to wake-up) and regularity (standard deviation of midpoint in hours). Psychological health measures included a composite well-being score, the Center for Epidemiological Studies Depression Scale, and the Generalized Anxiety Disorder-7 Scale. Linear and logistic regression models, adjusted for covariates (including sleep duration), tested associations between sleep and psychological health measures., Results: After covariate adjustment, a sleep midpoint outside of 2:00-4: 00 AM was significantly associated with depressive symptoms (β = 0.88, 95% CI = 0.06, 1.70) and scoring above the cut-point for clinically significant depressive symptoms (OR = 1.72, 95% CI = 1.15, 2.57). Sleep irregularity was significantly associated with lower psychological well-being (β = -0.18, 95% CI = -0.33, -0.03), depressive (β = 1.36, 95% CI = 0.29, 2.44) and anxiety (β = 0.93, 95% CI = 0.40, 1.46) symptoms, and scoring above the cut-point for clinically significant depressive (OR = 1.68, 95% CI = 1.01, 2.79) and anxiety (OR = 1.62, 95% CI = 1.07, 2.43) symptoms., Conclusion: Above and beyond sleep duration, a sleep midpoint outside of 2:00-4:00 AM was associated with depressive symptoms while sleep irregularity was associated with multiple psychological health domains in late life women., Competing Interests: Declaration of conflicts of interest The authors have declared no conflicts of interest., (Copyright © 2022 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Research has shown a link between childhood sexual abuse (CSA) and lower urinary tract and sexual disorders in clinical settings. We examined whether CSA was associated with two specific aspects of high tone, elevated resting tension pelvic floor dysfunction (PFD) in community-dwelling women. Materials and Methods: Data were from 2068 participants (25.5% Black, 9.6% Chinese, 10.8% Japanese, 5.0% Hispanic, and 49.1% Non-Hispanic White) in the Study of Women's Health Across the Nation (SWAN), a multirace/multiethnic longitudinal observational study of women's midlife health. At baseline, enrolled women were 42-52 years old and premenopausal or early perimenopausal. Annual or biennial assessments conducted over 20 years (1996 through 2017) included single-item queries about urgency urinary incontinence and pain with sexual activity used to assess PFD outcomes. The 12th follow-up visit conducted in 2009-2011 assessed the primary exposure, history of CSA, using a single-item response. Multivariate logistic regression models tested study objectives. Results: The prevalence of CSA was 15%, self-reported in 313/2068 women. CSA and PFD, both pain with sexual activity (odds ratio [OR] = 1.56 confidence interval [95% CI = 1.12-2.18]) and urgency urinary incontinence (OR = 1.87 [95% CI = 1.29-2.71]), were significantly associated in unadjusted models. The final adjusted model that included sociodemographic variables and physical and behavioral risk factors was significant for pain with sexual activity (OR = 1.48 [95% CI = 1.08-2.02]), but not for urgency urinary incontinence (OR = 1.38 [95% CI = 0.96-1.98]). Conclusions: In midlife women, pain with sex, but not urgency urinary incontinence, was associated with a history of CSA. A multidisciplinary diagnostic and therapeutic approach to PFD is key, inclusive of CSA screening.

Background: Daily 24-h sleep-wake cycles have important implications for health, however researcher preferences in choice and location of wearable devices for behavior measurement can make 24-h cycles difficult to estimate. Further, missing data due to device malfunction, improper initialization, and/or the participant forgetting to wear one or both devices can complicate construction of daily behavioral compositions. The Method for Activity Sleep Harmonization (MASH) is a process that harmonizes data from two different devices using data from women who concurrently wore hip (waking) and wrist (sleep) devices for ≥ 4 days., Methods: MASH was developed using data from 1285 older community-dwelling women (ages: 60-72 years) who concurrently wore a hip-worn ActiGraph GT3X + accelerometer (waking activity) and a wrist-worn Actiwatch 2 device (sleep) for ≥ 4 days (N = 10,123 days) at the same time. MASH is a two-tiered process using (1) scored sleep data (from Actiwatch) or (2) one-dimensional convolutional neural networks (1D CNN) to create predicted wake intervals, reconcile sleep and activity data disagreement, and create day-level night-day-night pairings. MASH chooses between two different 1D CNN models based on data availability (ActiGraph + Actiwatch or ActiGraph-only). MASH was evaluated using Receiver Operating Characteristic (ROC) and Precision-Recall curves and sleep-wake intervals are compared before (pre-harmonization) and after MASH application., Results: MASH 1D CNNs had excellent performance (ActiGraph + Actiwatch ROC-AUC = 0.991 and ActiGraph-only ROC-AUC = 0.983). After exclusions (partial wear [n = 1285], missing sleep data proceeding activity data [n = 269], and < 60 min sleep [n = 9]), 8560 days were used to show the utility of MASH. Of the 8560 days, 46.0% had ≥ 1-min disagreement between the devices or used the 1D CNN for sleep estimates. The MASH waking intervals were corrected (median minutes [IQR]: -27.0 [-115.0, 8.0]) relative to their pre-harmonization estimates. Most correction (-18.0 [-93.0, 2.0] minutes) was due to reducing sedentary behavior. The other waking behaviors were reduced a median (IQR) of -1.0 (-4.0, 1.0) minutes., Conclusions: Implementing MASH to harmonize concurrently worn hip and wrist devices can minimizes data loss and correct for disagreement between devices, ultimately improving accuracy of 24-h compositions necessary for time-use epidemiology.

Objective: We hypothesized that, among midlife women with vasomotor and/or genitourinary symptoms of menopause, (1) hormone therapy (HT) compared with complementary alternative medicine (CAM) will be associated with higher quality of life (QoL), and (2) race/ethnicity would modify associations of HT and CAM with QoL., Methods: Cross-sectional and longitudinal analyses of QoL in the Study of Women's Health Across the Nation participants using HT, CAM, or both. Women ( n = 2,514) completed a CAM use questionnaire and QoL assessments at baseline and every 1 to 2 years from 2002 to 2013. Associations between QoL and treatment, adjusted for covariates, and race/ethnicity-by-treatment interactions were analyzed using linear and mixed effects regression models., Results: During 7.8 (SD, 2.9) years of follow-up, 732 women (29%) reported HT of 2.4 (SD, 1.7) years, and 798 women (32%) reported CAM use of 2.1 (SD, 1.4) years. Overall, neither HT nor CAM was associated with QoL. However, the treatment-by-race/ethnicity interaction was significant for self-reported QoL ( P = 0.034 at baseline, P = 0.044 longitudinal). Among White women, self-reported QoL was higher in HT-only users than in those who used neither ( P = 0.030; d = 0.11; 95% confidence interval, 0.01-0.21). In contrast, Black women using HT only had lower self-reported QoL compared with Black women using neither ( P = 0.027; d = -0.21; 95% confidence interval, -0.40 to -0.02)., Conclusion: Comparisons between treatment type within each racial/ethnic group yielded significant differences in self-reported QoL. Clinicians should be aware of racial/ethnic differences in treatment preferences when counseling patients on treatment options for menopausal symptoms to provide optimal care., Video Summary: http://links.lww.com/MENO/B33 ., Competing Interests: Financial disclosure/conflicts of interest: Christmas reports Board of Trustees for The North American Menopause Society (NAMS), NAMS Scientific Program Committee, NAMS Editorial Board, Steering Committee for Core OutcoMes in MenopAuse (COMMA), Speaker Alliance Chicago and FDA Bone, Reproductive and Urologic Division (BRUDAC) Committee. Joffe receives grant support from the National Institutes of Health, Merck, and Pfizer. She serves/has served as a consultant to Bayer, Jazz, and Eisai. Her institution received funding from NeRRE/KaNDy and Que Oncology. Her spouse is an employee at Arsenal Biosciences and has equity in Merck. Santoro reports advisory board member for Astellas, Que Oncology, Amazon (Ember), and Menogenix Inc; consultant for Ansh Labs; NAMS Program Committee; past president Society for Reproductive Investigation; and nominating committee Endocrine Society. The other authors have nothing to disclose., (Copyright © 2022 by The North American Menopause Society.)

Purpose: This study examined whether employment status during mid-life and older adulthood is associated with physical function impairment., Methods: Participants were 2700 women in the multiracial/multiethnic Study of Women's Health Across the Nation. Time-varying, lagged, and cumulative exposure analyses modeled associations between self-reported employment status and the likelihood of severe physical function impairment across 19 years of follow-up., Results: Independent of demographic variables, women who were not working (OR = 1.58, 95% CI = 1.22, 2.04) or employed part-time (OR = 1.29, 95% CI = 1.04, 1.61) were more likely to report severe physical function impairments than women employed full-time. This same pattern was seen in lagged analyses predicting risk of physical function impairment from employment status at the prior assessment (not working vs. full-time: OR = 1.53, 95% CI = 1.08, 2.18; part-time vs. full-time: OR = 1.53, 95% CI = 1.17, 2.00). The likelihood of severe physical function impairment increased by 20% for every additional 10% of follow-up spent not working (OR = 1.02, 95% CI: 1.01, 1.03). Associations were robust to adjustment for health-related variables, body mass index, and physical activity., Conclusions: Women with lower levels of employment from mid-life to older adulthood were more likely to experience severe impairment in physical function. However, the underlying mechanisms, and the timescales over which associations unfold, require further study., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The menopausal transition (MT) poses an increased risk for major depression (MD), but not for all women. Current and past stress are toxic risk factors for depression throughout life. The MT may be a time of increased sensitivity to stress, especially among women with a lifetime history of major depressive disorder (MDD). We evaluated whether women who experienced childhood maltreatment (CM) or current stressful events or ongoing problems were at increased risk for MD during the MT., Methods: At the Pittsburgh site of the Study of Women's Health Across the Nation, 333 midlife women were interviewed approximately annually over 15 years with the Structured Clinical Interview for the Diagnosis of DSM-IV Axis I Disorders and provided health and psychosocial data including the Childhood Trauma Questionnaire. Repeated measures logistic regression analyses were conducted separately for women with and without lifetime MDD at study entry., Results: Among women with lifetime MDD, CM, but not current stress, interacted with menopausal status to increase the risk for MD during postmenopause (ORs ranged from 2.71 to 8.04). All stressors were associated with increased odds of MD. Among women without lifetime MDD, current stress was related to risk for MD, but the effect did not vary by menopausal status., Conclusions: Women with MDD prior to midlife and who experienced CM were at greatest risk for MD after the MT. Women without prior MDD were at increased risk for MD during peri- and postmenopause. Healthcare providers should monitor women at risk for MD even after the MT.

Objective: To examine depressive symptoms during postmenopause and the contribution of depressive symptom trajectories before the final menstrual period (FMP) and psychosocial/health factors to postmenopause depressive symptoms., Methods: Longitudinal analysis of depressive symptoms (Center for Epidemiologic Studies-Depression scale) collected every 1 to 2 years from 1996 to 2017 from 1,551 midlife women in the Study of Women's Health Across the Nation for a median follow-up of 19.0 years. Latent class growth analysis identified depression trajectories from baseline to FMP. Multivariable random effects (woman as random effect) linear or logistic regression models were conducted., Results: Women had higher odds of reporting high depressive symptom score (≥16) during postmenopause than when they were premenopausal (OR = 1.49, 95% CI, 1.09-2.04), but not when perimenopausal. Three pre-FMP trajectories were identified: Group 1 (47.7%), consistently low scores, Group 2 (39.9%), moderate scores below the high depressive symptom threshold, and Group 3 (12.4%), consistently high scores. Both the moderate (OR = 2.62, 95% CI, 1.89-3.66) and high score (OR = 6.88, 95% CI, 4.72-10.02) groups, compared with the consistently low group, had significantly higher postmenopausal depressive symptom scores. Other pre-FMP variables associated with high postmenopausal depressive symptoms were: higher odds of childhood trauma/maltreatment, poor role physical, high anxiety symptoms, sleep problems, high vasomotor symptoms, and lower odds for chronological aging and lower social support., Conclusions: Compared with premenopause, postmenopause remains a period of increased risk for higher depressive symptoms, especially for women with pre-FMP depressive symptoms. Pre-FMP depressive symptom trajectories are highly predictive of postmenopause depressive symptoms independent of health and psychosocial factors., Competing Interests: Financial disclosure/conflicts of interest: H.M.K. (NIA), H.J. (NIA, NCI), J.T.B. (NIA, NIMH), and N.E.A. (NIA, NCI) report grants from NIH during the period of the study. H.J. reports the following additional disclosures: Grants: Merck, Pfizer; Consulting: NeRRe/KaNDy, Eisai, Jazz, Bayer; Spouse: Arsenal Biosciences employee; Merck Research Labs equity; Tango equity. A.B.C. and Y.C. declared no conflicts of interest or financial involvement (including employment, fees, share ownership) or affiliation with any organization whose financial interests may be affected by material in the manuscript, or any other conflicts of interest which might potentially bias it., (Copyright © 2022 by The North American Menopause Society.)

Study Objectives: Polysomnography (PSG) is considered the "gold standard" for assessing sleep, but cost and burden limit its use. Although wrist actigraphy and self-report diaries are feasible alternatives to PSG, few studies have compared all three modalities concurrently across multiple nights in the home to assess their relative validity across multiple sleep outcomes. This study compared sleep duration and continuity measured by PSG, actigraphy, and sleep diaries and examined moderation by race/ethnicity., Methods: Participants from the Study of Women's Health Across the Nation (SWAN) Sleep Study included 323 White ( n = 147), African American ( n = 120), and Chinese ( n = 56) middle-aged community-dwelling women (mean age: 51 years, range: 48-57). PSG, wrist actigraphy (AW-64; Philips Respironics, McMurray, PA), and sleep diaries were collected concurrently in participants' homes over three consecutive nights. Multivariable repeated-measures linear models compared time in bed (TIB), total sleep time (TST), sleep efficiency (SE), sleep latency (SL), and wake after sleep onset (WASO) across modalities., Results: Actigraphy and PSG produced similar estimates of sleep duration and efficiency. Diaries yielded higher estimates of TIB, TST, and SE versus PSG and actigraphy, and lower estimates of SL and WASO versus PSG. Diary SL was shorter than PSG SL only among White women, and diary WASO was lower than PSG and actigraphy WASO among African American versus White women., Conclusions: Given concordance with PSG, actigraphy may be preferred as an alternative to PSG for measuring sleep in the home. Future research should consider racial/ethnic differences in diary-reported sleep continuity., (© The Author(s) 2022. Published by Oxford University Press on behalf of Sleep Research Society.)

Study Objectives: To evaluate how change in menopausal status related to spectral analysis and polysomnographic measures of sleep characteristics., Methods: The Study of Women's Health Across the Nation (SWAN) Ancillary Sleep Study evaluated sleep characteristics of 159 women who were initially pre- or early perimenopausal and repeated the assessment about 3½ years later when 38 were pre- or early perimenopausal, 31 late perimenopausal, and 90 postmenopausal. Participants underwent in-home ambulatory polysomnography for two to three nights. Average EEG power in the delta and beta frequency bands was calculated during NREM and REM sleep, and sleep duration, wake after sleep onset (WASO), and apnea hypopnea index (AHI) were based on visually-scored sleep., Results: The women who transitioned to postmenopause had increased beta NREM EEG power at the second assessment, compared to women who remained pre-or early premenopausal; no other sleep measures varied by change in menopausal status. In multivariate models the associations remained; statistical controls for self-reported hot flashes did not explain findings. In secondary analysis, NREM beta power at the second assessment was greater among women who transitioned into the postmenopause after adjustments for initial NREM beta power., Conclusions: Sleep duration and WASO did not vary by menopause transition group across assessments. Consistent with prior cross-sectional analysis, elevated beta EEG power in NREM sleep was apparent among women who transitioned to postmenopause, suggesting that independent of self-reported hot flashes, the menopausal transition is associated with physiological hyperarousal during sleep., (© Sleep Research Society 2021. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Graduate medical education (GME) training commonly requires residents and fellows to engage in night float shift work. This review aims to assess the effectiveness of interventions for trainees when preparing for, completing, and recovering from working night float shifts. We reviewed all available studies published prior to September 2019 using PubMed, Scopus, CINAHL, the Cochrane library, PsycINFO, and Google Scholar databases. We included all original, primary research articles assessing either non-pharmacological or pharmacological interventions on the chronobiological and physiological effects of night float shift work among GME trainees. Five studies (n = 179 patients) met inclusion criteria. Interventions included melatonin in the morning before sleep after night float shifts, napping during night float shifts, modafinil after a night of sleep deprivation, and caffeinated energy drinks after 6 consecutive night float shifts. Melatonin improved one measure of attention. A 2-hr nap was associated with improved speed related to task switching. Modafinil improved performance in tests of cognition. Caffeinated energy drinks led to improvement in select driving performance variables and reaction time. Effect sizes for outcome variables were calculated. Heterogeneity among the studies precluded combining the data in a meta-analysis. According to GRADE criteria, the quality of the evidence in these studies was low or very low. Our findings suggest GME trainees may benefit from utilising a limited number of interventions when preparing for or recovering from night float shift work. More investigation is needed to identify interventions that could help GME trainees adapt to and recover from working night float shifts., (© 2020 European Sleep Research Society.)

Background: Depressive symptoms and sleep disturbances disproportionately affect midlife women. While there may be a bidirectional association, few studies have examined whether depressive symptoms are longitudinally associated with subsequent sleep. Sleep is typically considered unidimensional, despite emerging evidence that multidimensional sleep health provides novel information on the sleep-health link., Purpose: The current study examined whether higher depressive symptoms were longitudinally associated with poorer multidimensional sleep health., Method: Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale across six to nine annual assessments in 302 midlife women from the Study of Women's Health Across the Nation. Six months after their last assessment, actigraphy (mean ± standard deviation = 29.3 ± 6.9 days) and self-report were used to assess sleep health components: efficiency, duration, mid-sleep timing, regularity, alertness, and satisfaction, which were dichotomized and summed to create a composite multidimensional sleep health score. Mixed-effects models were used to evaluate the longitudinal associations between depressive symptoms and multidimensional sleep health, as well as individual sleep health components, adjusting for covariates. Exploratory analyses stratified models by race/ethnicity., Results: Higher depressive symptoms were associated with subsequent poorer multidimensional sleep health (p < .0.001) and lower alertness (p < .0001) and satisfaction with sleep (p < .0001)., Conclusions: Our finding that higher average depressive symptoms were associated longitudinally with actigraphy-measured poorer sleep health in midlife women is novel and converges with the larger body of evidence that these two common symptoms are strongly associated. The bidirectional relationship between these two prevalent symptoms needs to be studied in prospective longitudinal studies., (© Society of Behavioral Medicine 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To examine the effects of prescription sleep medications on patient-reported sleep disturbances., Design: Retrospective cohort., Setting: Longitudinal cohort of community-dwelling women in the USA., Participants: Racially and ethnically diverse middle-aged women who reported a sleep disturbance., Interventions: New users of prescription sleep medications propensity score matched to women not starting sleep medications., Main Outcomes and Measures: Self-reported sleep disturbance during the previous 2 weeks-difficulty initiating sleep, waking frequently and early morning awakening-using a 5-point Likert scale, ranging from no difficulty on any night (rating 1) to difficulty on 5 or more nights a week (rating 5). Sleep disturbances were compared at 1 year (primary outcome) and 2 years of follow-up., Results: 238 women who started sleep medications were matched with 447 non-users. Participants had a mean age of 49.5 years and approximately half were white. At baseline, sleep disturbance ratings were similar: medication users had a mean score for difficulty initiating sleep of 2.7 (95% CI 2.5 to 2.9), waking frequently 3.8 (95% CI 3.6 to 3.9) and early morning awakening 2.8 (95% CI 2.6 to 3.0); non-users ratings were 2.6 (95% CI 2.5 to 2.7), 3.7 (95% CI 3.6 to 3.9) and 2.7 (95% CI 2.6 to 2.8), respectively. After 1 year, ratings for medication users were 2.6 (95% CI 2.4 to 2.8) for initiating sleep, 3.6 (95% CI 3.4 to 3.8) for waking frequently and 2.8 (95% CI 2.6 to 3.0) for early morning awakening; for non-users, the mean ratings were 2.3 (95% CI 2.2 to 2.5), 3.5 (95% CI 3.3 to 3.6) and 2.5 (95% CI 2.3 to 2.6), respectively. None of the 1 year changes were statistically significant nor were they different between medication users and non-users. Two-year follow-up results were consistent, without statistically significant reductions in sleep disturbance in medication users compared with non-users., Conclusions: These analyses suggest that women who initiated sleep medications rated their sleep disturbances similar after 1 and 2 years. The effectiveness of long-term sleep medication use should be re-examined., Competing Interests: Competing interests: DHS also receives support from NIH-P30-AR072577. He has received salary support from research grants to Brigham and Women’s Hospital for unrelated work from AbbVie, Amgen, Corrona, Genentech and Pfizer., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The menopausal transition is characterized by progressive changes in ovarian function and increasing circulating levels of gonadotropins, with some women having irregular menstrual cycles well before their final menstrual period. These observations indicate a progressive breakdown of the hypothalamic-pituitary-ovarian axis often associated with an increase in menopausal symptoms. Relationships between vasomotor symptoms (VMS) and depressed mood and sleep as well as a bidirectional association between VMS and depressed mood in mid-life women have been reported, but the endocrine foundations and hormone profiles associated with these symptoms have not been well described. Our objective was to determine the relationship between daily urinary hormone profiles and daily logs of affect and VMS during the early perimenopausal transition., Study Design: SWAN, the Study of Women's Health Across the Nation, is a large, mutli-ethnic, multisite cohort study of 3302 women aged 42-52 at baseline, designed to examine predictors of health and disease in women as they traversed the menopause. Inclusion criteria were: an intact uterus and at least one ovary present, at least one menstrual period in the previous three months, no use of sex steroid hormones in the previous three months, and not pregnant or lactating. A subset (n = 849) of women aged 43-53 years from all study sites in the first Daily Hormone Study collection were evaluated for this substudy., Outcome Measures: We measured daily VMS, and urinary hormones: follicle stimulating hormone (FSH), luteinizing hormone (LH), pregnanediol glucuronide (PdG) and estradiol (estrone conjugate, E1C)., Results: A variable pattern of LH and negative LH feedback were the hormone patterns most strongly associated with increased VMS. In contrast, no hormone pattern was significantly related to negative mood., Conclusion: Fluctuations of LH associated with low progesterone production were associated with VMS but not negative mood, suggesting different endocrine patterns may be related to increased negative mood than to the occurrence of VMS., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Study Objectives: To determine whether actigraphy-assessed indices of sleep are associated with cognitive performance in women, and explore whether these associations vary by race/ethnicity., Methods: Participants were 1,126 postmenopausal community-dwelling females (mean age 65 years) from the observational Study of Women's Health Across the Nation (SWAN); 25% were black, 46% white, 13% Chinese, 11% Japanese, and 5% Hispanic. Actigraphy-assessed sleep measures included total sleep time, wake after sleep onset (WASO), and fragmentation. Cognitive measures included immediate and delayed verbal memory, working memory, and information processing speed. All measures were assessed in conjunction with SWAN annual visit 15., Results: Across the sample, after covariate adjustment, greater WASO and fragmentation were concurrently associated with slower information processing speed. Black participants had significantly worse sleep relative to other race/ethnic groups. Significant race/sleep interactions were observed; in black, but not white, participants, greater fragmentation was concurrently associated with worse verbal memory and slower information processing speed, and greater WASO was concurrently associated with slower information processing speed. Sleep-cognitive performance associations were not different in Chinese and Japanese participants relative to white participants., Conclusions: Greater wakefulness and fragmentation during sleep are concurrently associated with slower information processing. Sleep continuity impacted concurrent cognitive performance in black, but not white, women. This effect may not have been detected in white women because their sleep was largely within the normal range. Future longitudinal studies in diverse samples are critical to further understand whether race/ethnicity moderates the influence of sleep on cognitive performance., (© Sleep Research Society 2020. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please e-mail journals.permissions@oup.com.)

Purpose: Sleep disturbances are common, particularly in middle aged women. Prescription medications for this indication are increasingly used, despite uncertain safety. This study assessed prescription medication use for sleep among a cohort of women with and without sleep disturbances., Methods: We examined reports of sleep disturbance and sleep medication use among pre- and early peri-menopausal womenassessed annually or biennially since 1996. Women self-reported medications at visits, and we identified medications that have been used primarily for sleep disturbances. They reported on difficulties falling and staying asleep, and early morning wakening. Sleep medication use across 20 years of follow-up was examined for all women and by race/ethnicity. Women who reported data for both sleep disturbance and sleep medication use were included in the analyses.., Results: Among participants in a cohort of 3302 women who were enrolled prior to their menopause transition, 3082 women were included in the analytic sample and 2531 (82%) reported sleep disturbances. They were more likely to endorse higher anxiety and pain scores and more comorbid conditions than women without sleep disturbances. Baseline characteristics were similar among women who did and did not use sleep medications. Among women reporting a sleep disturbance at baseline, 2.5% reported sleep medication use, increasing to 8% over 20 years. However, the proportion of women reporting sleep medication use who did not report a sleep disturbance remained low, approximately 1% to 2% over the entire follow-up. Increases in sleep medication use was observed across women of all race/ethnicities., Conclusions: The use of sleep medications among women reporting sleep disturbance grew over the last 20 years. Growth was observed across women of all race/ethnicities., (© 2020 John Wiley & Sons Ltd.)

Objectives: The association between sleep and adiposity (indexed by body mass index or waist-to-hip ratio) has typically been evaluated using a single dimension of self-reported sleep. However, other dimensions and behavioral measures of sleep may also be associated with adiposity. This study evaluated whether multidimensional sleep health calculated from actigraphy and self-report was longitudinally associated with adiposity in a sample of midlife women who have a high prevalence of sleep disturbances and adiposity., Design: Longitudinal study with 11-14 years of follow-up time between the sleep health assessment and body mass index / waist-to-hip ratio measurements., Participants: Two hundred and twenty-one midlife women enrolled in the Study of Women's Health Across the Nation Sleep Study., Measurements: Multidimensional sleep health was quantified using actigraphy (M[SD] = 29.1[7.2] nights) measures of sleep efficiency, midpoint, duration, regularity, and self-report measures of alertness and satisfaction. Each component was dichotomized and summed; higher values indicated better sleep health. Height, body weight, and waist and hip circumference were measured at the sleep study and at follow-up. Linear regression models were used to assess associations between sleep health and adiposity, adjusting for demographic and menopausal covariates., Results: There was no substantial within-person change in adiposity over time. Better sleep health was cross-sectionally and longitudinally associated with lower adiposity in unadjusted, but not in adjusted, models. Individual sleep health components were not associated with adiposity after adjustment., Conclusion: We did not observe cross-sectional or longitudinal associations between multidimensional sleep health and adiposity. The sleep-adiposity link may be weaker in midlife adults than in other age groups., (Copyright © 2020 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To identify groups of women who share levels and patterns of change in follicle-stimulating hormone (FSH), self-reported sleep maintenance problems, and frequent vasomotor symptoms (VMS) up to 10 years before and after their final menstrual period and to evaluate their premenopausal characteristics., Method: Group-based multi-trajectory modeling grouped 1,407 women from the Study of Women's Health Across the Nation who had an observed natural menopause and did not use hormone therapy, based on repeated measures of FSH, sleep maintenance problems, and frequent VMS relative to final menstrual period. Multivariable analyses assessed race/ethnicity, body mass index, smoking, and depressive symptoms as predictors of group membership., Results: Women formed five distinct groups: (1) low symptoms (low VMS/sleep problems)/high FSH rise (N = 552; 39.2%); (2) moderate VMS and sleep problems/low FSH rise (N = 169; 12.0%); (3) dominant sleep problems (lower VMS/high sleep problems)/high FSH rise (N = 203; 14.4%); (4) dominant VMS (high VMS/lower sleep problems)/high FSH rise (N = 297; 21.1%)); and (5) high symptoms (high VMS/high sleep problems)/intermediate FSH rise (N = 186; 13.2%)). Multivariate analyses showed that race/ethnicity, premenopausal body mass index and depressive symptoms, and increasing depressive symptoms during the early phase of the transition predicted group membership., Conclusions: Women can be classified based on shared levels and patterns of FSH, sleep maintenance problems, and frequent VMS across the menopause transition. Either VMS or sleep maintenance problems can be dominant in the face of high FSH. Experiencing one menopause-related symptom or hormone profile does not automatically imply that another is also being experienced., Competing Interests: Financial disclosure/conflicts of interest: MMB: DSMB member: Cerus Corporation. HJ: Consultant/Advisory Board: NeRRe/KaNDy, Sojournix, Eisai, Jazz; Grant/Research Support: NIH, Merck, NeRRe/KaNDy, Pfizer, QUE Oncology; Spouse: Merck Research Lab—employee; Arsenal Biosciences—consulting and equity; Tango—equity. RCT: Consultant: Astellas, Virtue Health, Procter and Gamble, and Pfizer. All other authors have no conflicts., (Copyright © 2020 by The North American Menopause Society.)

Background: Body composition strongly influences physical function in older adults. Bioelectrical impedance analysis (BIA) differentiates fat mass from skeletal muscle mass, and may be more useful than body mass index (BMI) for classifying women on their likelihood of physical function impairment., Aims: This study tested whether BIA-derived estimates of percentage body fat (%BF) and height-normalized skeletal muscle mass (skeletal muscle mass index; SMI) enhance classification of physical function impairment relative to BMI., Method: Black, White, Chinese, and Japanese midlife women (N = 1482) in the Study of Women's Health Across the Nation (SWAN) completed performance-based measures of physical function. BMI (kg/m 2 ) was calculated. %BF and SMI were derived through BIA. Receiver-operating characteristic (ROC) curve analysis, conducted in the overall sample and stratified by racial group, evaluated optimal cutpoints of BMI, %BF, and SMI for classifying women on moderate-severe physical function impairment., Results: In the overall sample, a BMI cutpoint of ≥ 30.1 kg/m 2 correctly classified 71.1% of women on physical function impairment, and optimal cutpoints for %BF (≥ 43.4%) and SMI (≥ 8.1 kg/m 2 ) correctly classified 69% and 62% of women, respectively. SMI did not meaningfully enhanced classification relative to BMI (change in area under the ROC curve = 0.002; net reclassification improvement = 0.021; integrated discrimination improvement = - 0.003). Optimal cutpoints for BMI, %BF, and SMI varied substantially across race. Among Black women, a %BF cutpoint of 43.9% performed somewhat better than BMI (change in area under the ROC curve = 0.017; sensitivity = 0.69, specificity = 0.64)., Conclusion: Some race-specific BMI and %BF cutpoints have moderate utility for identifying impaired physical function among midlife women.

Background: Chronic conditions are associated with worse physical function and commonly develop during midlife. We tested whether the presence of 8 chronic conditions, or the development of these conditions, is associated with declines in physical function among midlife women as they transition into early late life., Methods: Participants ( N  = 2283) were from the Study of Women's Health Across the Nation. Physical function was assessed at 8 visits starting at the study's fourth clinic visit in 2000/2001 through follow-up visit 15 (2015/2017) using the Short Form-36 Physical Function subscale. Chronic conditions included diabetes, hypertension, osteoarthritis, osteoporosis, stroke, heart disease, cancer, and depressive symptoms. Repeated-measures Poisson regression modeled associations between 1) prevalent chronic conditions at analytic baseline (visit 4) and longitudinal physical function, and 2) change in physical function associated with developing a new condition. Models were adjusted with the total number of other chronic conditions at visit 4., Results: In separate fully-adjusted longitudinal models, prevalent heart disease and osteoporosis were associated with 18% (IRR = 0.815, 95% confidence interval [CI]: 0.755-0.876) and 12% (IRR = 0.876, 95% CI: 0.825-0.927) worse initial physical function, respectively. Prevalent osteoarthritis was associated with approximately 6% (IRR = 0.936, 95% CI: 0.913-0.958) worse initial physical function, and a slight additional worsening over time (IRR = 0.995, 95% CI: 0.994-0.996). A 12% (IRR = 0.878, 95% CI: 0.813-0.950) decrease in physical function concurrent with stroke development was evident, as was accelerated decline in physical function concurrent with heart disease development (IRR = 0.991, 95% CI: 0.988-0.995)., Conclusions: Initial prevalent conditions related to the musculoskeletal system were associated with worse initial physical function, with some evidence of accelerated decline in physical function with osteoarthritis. Stroke and heart disease are less common than osteoarthritis in this age group, but the severe effects of these conditions on physical function shows the need for a greater focus on cardiovascular health during midlife. Women who develop chronic conditions during midlife may be at particular risk for poor physical function as they age, warranting disability prevention efforts focused on this population., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

Background: Chronic medical conditions (CMCs) often emerge and accumulate during the transition from mid- to late-life, and the resulting multimorbidity can greatly impact physical function. We assessed the association of CMC presence and incidence on trajectories of physical function from mid- to early late-life in the Study of Women's Health Across the Nation., Methods: Physical function was assessed at eight clinic visits (average 14 years follow-up) using the physical function subscale of the Short Form-36. CMCs included osteoarthritis, diabetes, stroke, hypertension, heart disease, cancer, osteoporosis, and depressive symptomatology, and were considered cumulatively. Repeated-measures Poisson models estimated longitudinal change (expressed as percent difference) in physical function by chronic CMCs. Change-points assessed physical function change coincident with the development of a new condition., Results: Women (N = 2,283) followed from age 50.0 ± 2.7 to 64.0 ± 3.7 years; 7.3% had zero CMCs through follow-up, 22.5% (N = 513) had no baseline CMCs but developed ≥1, 22.7% women had ≥1 baseline CMC but never developed another, and 47.6% had ≥1 baseline CMC and developed ≥1 more. Each additional baseline CMC was associated with 4.0% worse baseline physical function and annual decline of 0.20%/year. Women with more baseline CMCs had greater decline in physical function with a new CMC (-1.90% per condition); and annual decline when developing a new condition accelerated by -0.33%/year per condition., Conclusions: Self-reported physical function changes are evident from mid- to early late-life with the development of CMCs. Preventing or delaying CMCs may delay declines in physical function, and these potential pathways to disability warrant further research., (© The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Our study objectives were to evaluate the age-related changes in actigraphy measures of sleep duration, continuity, and timing across 12 years in midlife women as they traversed the menopause, and to take into account factors affecting women's sleep that also change with age. Black, white, and Chinese women were recruited from the Study of Women's Health Across the Nation (SWAN) to participate in an ancillary sleep study on two occasions over 3 years apart and a third assessment 12 years after the first (N = 300, mean ages, 52, 55, and 64 at the three assessments). Women had at least four consecutive nights of actigraphy (95% with 7 nights) and sleep diaries, and self-reported sleep complaints measured at each time point. Partial correlations adjusted for time between assessments across the 12 years were significant and moderate in size (r's = .33-.58). PROC MIXED/GLIMMIX multivariate models showed that sleep duration increased over time; wake after sleep onset (WASO) declined, midpoint of sleep interval increased, and sleep latency and number of sleep complaints did not change between the first and third assessments. Blacks and whites had a greater increase in sleep duration than Chinese. Taken together, the results of this longitudinal study suggest that sleep may not worsen, in general, in midlife women. Perhaps, the expected negative effect of aging in midlife into early old age on sleep is overstated., (© Sleep Research Society 2019. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please e-mail journals.permissions@oup.com.)

Context: Metabolic syndrome (MetS) affects cognitive function in late life, particularly in women. But longitudinal research is scarce on associations of MetS with cognitive function during midlife., Objective: To determine associations between MetS exposure and cognitive function trajectories in midlife women., Design and Setting: This is a 17-year prospective, longitudinal study of multiracial/ethnic women in 7 US communities, with annual/biennial assessments., Participants: Participants were 2149 US women traversing menopause., Exposure: Exposure consisted of MetS assessments (median 4 assessments over 4 years)., Main Outcome Measures: Main outcome measures were assessments of cognitive function in 3 domains: perceptual speed (symbol digit modalities test, SDMT), episodic memory (East Boston Memory Test, EBMT), and working memory (Digit Span Backward Test, DSB)., Results: By their first cognitive assessment (age 50.7 ± 2.9 years), 29.5% met the criteria for MetS. Women completed a median (interquartile range [IQR]) of 6 (IQR 4-7) follow-up cognitive assessments over 11.2 (IQR 9.2-11.5) years. Women with MetS, compared with those without, had a larger 10-year decline in SDMT z-score (estimate -0.087, 95% confidence interval, -0.150 to -0.024; P = 0.007), after adjustment for cognitive testing practice effects, sociodemographics, lifestyle, mood, and menopause factors. As such, MetS accelerated the 10-year loss of perceptual speed by 24%. MetS did not differentially affect the rate of decline in either immediate (P = 0.534) or delayed (P = 0.740) episodic memory or in working memory (P = 0.584)., Conclusions: In midlife women MetS exposure was associated with accelerated decline in perceptual speed, but not episodic or working memory., (© Endocrine Society 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Investigate temporal patterns of sleep maintenance problems in women who became surgically menopausal (hysterectomy with bilateral oophorectomy) before their final menstrual period and examine whether presurgery trajectories of sleep maintenance problems are related to problems staying asleep postsurgery., Methods: Longitudinal analysis of sleep self-reports collected every 1 to 2 years from 1996 to 2013 from 176 surgically menopausal women in the Study of Women's Health Across the Nation, a seven-site community-based, multiethnic/multiracial, cohort study. Median follow-up was 15.3 years (4.2 years presurgery, 10.2 years postsurgery). Group-based trajectory modeling was used to identify patterns of problems staying asleep, and the presurgery trajectories were used to predict similar postsurgery sleep problems., Results: Four trajectory patterns of sleep maintenance problems were identified: low (33.5% of women), moderate (33.0%), increasing during presurgery (19.9%), and high (13.6%). One-fifth of women reported a presurgery increase in these problems. Postsurgically, problems staying asleep remained associated with similar levels of presurgical problems, even after adjusting for postsurgical early morning awakening, frequent vasomotor symptoms, and bodily pain score (βlow = -1.716, βmoderate = -1.144, βincreasing = -0.957, βhigh = -1.021; all P values <0.01)., Conclusions: Sleep maintenance problems were relatively stable across time postsurgery. These data are remarkably consistent with our trajectory results across the natural menopause, suggesting that presurgical assessment of sleep concerns could help guide women's expectations postsurgically. Although reassuring that sleep complaints do not worsen postsurgically for most surgically menopausal women, referral to a sleep specialist should be considered if sleep symptoms persist or worsen after surgery.

Study Objectives: To describe racial/ethnic differences in sleep duration, continuity, and perceived sleep quality in postmenopausal women and to identify statistical mediators of differences in sleep characteristics., Methods: Recruited from the observational Study of Women's Health Across the Nation (SWAN), 1,203 (548 white, 303 black, 147 Chinese, 132 Japanese, and 73 Hispanic; mean age 65 years, 97% postmenopausal) women participated in a week-long actigraphy and daily diary study in 2013-2015. Actigraphic measures of sleep duration and wake after sleep onset (WASO), and diary-rated sleep quality were averaged across the week. Candidate mediators included health-related variables; stress; and emotional well-being assessed up to 13 times across 18 years from baseline to sleep study., Results: Whites slept longer than other groups; the significant mediators were concurrent financial hardship and increasing number of stressors for Hispanics or Japanese versus whites. Whites had less WASO than blacks and Hispanics; significant mediators were concurrent number of health problems, physical inactivity, waist circumference, vasomotor symptoms, number of life stressors, and financial hardship, and increasing number of health problems from baseline to sleep study. Whites reported better sleep quality than blacks, Chinese, and Japanese; significant mediators were concurrent physical inactivity, vasomotor symptoms, positive affect, and depressive symptoms., Conclusions: Sleep differences between blacks or Hispanics versus whites were mediated by health problems, number of stressors, and financial hardship, whereas sleep differences between Chinese or Japanese versus whites were mediated by emotional well-being. This is the first study using formal mediational approaches., (© Sleep Research Society 2019. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please e-mail journals.permissions@oup.com.)