Kapoor, Ekta

The goal in selecting these recent articles was to help identify literature that may change the clinical practice of women’s health for practitioners in the primary care setting. Articles were identified by reviewing the high-impact medical and women’s health journals, national guidelines, ACP JournalWise, and NEJM Journal Watch. In this Clinical Update, we selected recent publications relevant to the cardiovascular health of women.

Objectives: To investigate the association between hormone therapy use and severe outcomes due to COVID-19 in perimenopausal and postmenopausal women. Methods: Using the Rochester Epidemiology Project, we retrospectively searched for the records of women aged 40-65 years who had a documented case of COVID-19 between March 12 and September 29, 2020. We further identified those who were perimenopausal or postmenopausal. The rates of emergency department visits, hospitalizations, and deaths were compared by hormone therapy use. Logistic regression models were used to assess the odds of the combined outcome based on hormone therapy use. Results: Among the 689 patients included in this study, the median age was 56 years, and 77.5% were White. Compared with patients currently using hormone therapy, those with past/never use of hormone therapy were significantly older, had more risk factors for severe COVID-19, and had a higher incidence of diabetes. A total of 102 emergency department visits/hospitalizations/deaths occurred among both groups. Participants with current hormone therapy use had similar rates and risk of emergency department/hospitalization/death outcomes as those without hormone therapy, even after adjusting for age and severe COVID-19 risk factors. Conclusions: Severe COVID-19 outcomes were not significantly different between women with current versus past/never use of hormone therapy. Our study adds to the data suggesting no harm with hormone therapy use in women with severe symptoms of COVID-19.

Abstract Introduction Female sexual dysfunctions (FSDs) are prevalent yet underrecognized concerns among menopausal women, particularly those aged 65 and older. Age- and menopause-related sexual health issues often go unaddressed due to societal stigma and misconceptions, leading many women to attribute their symptoms to a normal part of aging. This perception limits diagnosis and treatment of conditions like hypoactive sexual desire disorder and genitourinary syndrome of menopause. Objective This study aims to compare sexual function and distress between women aged 50-64 and those aged 65 and older, with a focus on addressing critical knowledge gaps in sexual function among older women. Methods This cross-sectional study included women aged 50 and above who visited Mayo Clinic Women’s Health Clinics in Rochester, MN; Scottsdale, AZ; and Jacksonville, FL between, May 1, 2015, and August 31, 2022. Participants completed the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale (FSDS-R), along with assessments of chief sexual health complaints, mood (PHQ-9), and anxiety (GAD-7) included in the Data Registry on Experiences of Aging, Menopause, and Sexuality (DREAMS). Results Among 4900 women included in the analysis, the median number of sexual health complaints was 2.0 in midlife (50-64 yrs) and 1.0 in older (65+ yrs) age groups (p = 0.004). Chief complaints of loss of sexual desire (47.6% vs. 33.4%; p < 0.001) and reduced genital sensation (16.9% vs. 13.0%; p = 0.024) were more common in the midlife age group. No significant differences were found in rates of complaints of vaginal dryness (51.2% vs. 52.5%; p = 0.57), painful intercourse (32.6% vs 30.7%; p = 0.38), or of difficulties with arousal or orgasm (24.0% vs 20.8%; p = 0.09). Midlife age women were also more likely to report pelvic pain (6.7% vs. 4.5%; p = 0.050), while older women reported more genital pain (8.1% vs. 5.8%; p = 0.038). FSFI scores indicated age-related differences in desire (2.4 vs. 3.0; p < 0.001), lubrication (3.9 vs. 3.6; p < 0.001), and pain (4.8 vs. 4.0; p < 0.001), aligning with the chief complaints, while arousal (3.6, p = 0.890), orgasm (4.0, p = 0.926), and satisfaction (4.4, p = 0.346) scores were similar between groups. Total FSFI scores showed no significant difference between the age groups (total = 22.2 vs 21.2, p = 0.109). Median FSDS-R scores indicated higher distress in the midlife group (15.0 vs. 13.0; p = 0.015), while overall FSD prevalence (FSFI ≤26.55 and FSDS ≥11) was similar between groups (56.2% vs 51.8%; p = 0.056). Conclusions Midlife and older women were equally likely to experience FSD in women presenting to women’s health clinics, but older women reported less distress. These results are strikingly similar to previous research indicating that while older women have FSD, there is less distress associated with it. Raising awareness and promoting open dialogue can help older women recognize that their sexual health concerns are both valid and treatable, ultimately improving quality of life. Disclosure No.

Abstract Objective To assess the association of systolic and diastolic blood pressure (SBP and DBP) in recently menopausal women with white matter hyperintensity (WMH) volume later in life and determine whether short-term menopausal hormone therapy (mHT) modifies these associations. Methods Kronos Early Estrogen Prevention Study (KEEPS) was a multicenter, randomized, double-blinded, placebo-controlled 4-year mHT trial (oral conjugated equine estrogens or transdermal 17β-estradiol). KEEPS continuation was an observational follow-up of the participants 10 years after the end of mHT. The associations between KEEPS baseline blood pressure (BP) with KEEPS continuation WMH volume were examined adjusting for covariates in model 1 (age, total intracranial volume, study site, mHT type) and model 2 (additionally conventional CVD risk factors). Interaction terms (BP × mHT type) were added into the linear regression models. Results The mean ± SD ages of participants were 53 (±2) years at KEEPS baseline and 67 (±2) years at KEEPS continuation. Elevated BP at KEEPS baseline was associated with greater WMH volume measured 14 years later (model 1: SBP: β = 0.01 [95% CI, 0.001‐0.01] and DBP: β = 0.01 [95% CI, 0.003‐0.03]) and after additionally adjusting for CVD risk factors (model 2). We did not find any evidence that mHT versus placebo modified these associations. Topographically, higher BP was associated with greater periventricular WMH in the frontal and parietal lobes. Conclusion Our findings suggest the importance of maintaining normal BP in recently postmenopausal women with low CVD risk, irrespective of short-term mHT usage, to potentially reduce the risk of WMH later in life.

Abstract INTRODUCTION Premenopausal bilateral oophorectomy (PBO) before the age of 46 years is associated with an increased risk of dementia. We investigated the long‐term effects of PBO performed before age 50 years on amyloid beta (Aβ), tau, and neurodegeneration imaging biomarkers of Alzheimer's disease (AD). METHODS Mayo Clinic Cohort Study of Oophorectomy and Aging‐2 participants were divided into early PBO (< 46 years; n = 61), and late PBO (46–49 years; n = 51) groups and were compared to referent women who did not undergo PBO ( n = 119). RESULTS Early PBO was associated with thinner entorhinal cortex ( p = 0.014), higher tau load at higher levels of Aβ load ( Pp = 0.005), higher Aβ load ( p = 0.026), and smaller temporal lobe cortical thickness ( p = 0.022), only at older ages compared to the referent group. DISCUSSION PBO before the age of 46 years is associated with entorhinal cortex thinning, elevated tau at higher Aβ levels, along with an AD‐like pattern of atrophy at older ages. CLINICAL TRIALS REGISTRATION NCT03821857 sex‐specific effects of endocrine disruption on aging and AD. Highlights Premenopausal bilateral oophorectomy (PBO) before the ages of 46 (early PBO) years and ages 46 to 49 (late PBO) years was studied. Early PBO was associated with reduced entorhinal cortex thickness later in life. Early PBO was associated with greater amyloid beta (Aβ) load at older ages. Early PBO was associated with greater Alzheimer's disease pattern of atrophy at older ages. Early PBO was associated with higher tau load at higher Aβ levels.

Abstract Objectives The aims of the study were to identify conditions diagnosed in at least 10% of midlife women living in the US upper midwest and to assess prevalence by age, race, ethnicity, and sociodemographic status. Methods The Rochester Epidemiology Project was used to conduct a cross-sectional prevalence study of 86,946 women between 40 and 59 years residing in a 27-county region of the United States on January 1, 2020. Diagnostic billing codes were extracted and grouped into broader condition categories using the Clinical Classification System Refined. The prevalence of 424 conditions was calculated by age, race, ethnicity, and area deprivation index quartiles. Logistic regression was used to examine associations between participant characteristics and conditions that affected 10% or more of the study population. Results Twenty-eight conditions affected ≥10% of women, and eight conditions increased by ≥45% between the ages of 40 and 59 (disorders of lipid metabolism, hypertension, sleep/wake disorders, thyroid disorders, esophageal disorders, osteoarthritis, tendon and synovial disorders, and menopausal disorders; all test for trend P < 0.01). Black women had a significantly higher prevalence of hypertension and esophageal disorders at all ages (adjusted P values <0.05). Women living in more deprived areas had a significantly higher prevalence of hyperlipidemia, hypertension, sleep/wake disorders, and esophageal disorders (adjusted P values <0.05). Women living in less deprived areas had a significantly higher prevalence of thyroid disorders at age 40 to 44 and menopausal disorders at ages 50 to 59 (adjusted P values <0.05). Conclusions These data suggest that additional attention should focus on Black women and women with a lower socioeconomic status to ensure that common midlife conditions are diagnosed and treated.

Abstract Objective Metabolic dysfunction–associated steatotic liver disease (MASLD) and vasomotor symptoms (VMS) are associated with increased cardiovascular disease risk. Although visceral adiposity has been linked to MASLD and VMS independently, this study aimed to evaluate associations between the two in midlife women. Methods A cross-sectional study of women aged 45-60 years receiving primary care at one of four sites was conducted from March 1 through June 30, 2021. MASLD diagnosis was obtained utilizing the International Classification of Diseases , Ninth Revision and Tenth Revision codes. VMS burden was evaluated with the Menopause Rating Scale and categorized as severe/very severe versus none/mild/moderate. Logistic regression models were used to assess the association between VMS and diagnosed MASLD both univariately and after individually adjusting for several risk factors. Results A total of 4,599 women were included in the final analysis, 304 (7%) of whom had an MASLD diagnosis. On univariate analysis, women with an MASLD diagnosis were more likely to have severe/very severe VMS (odds ratio [OR], 1.50; 95% CI, 1.08-2.08; P = 0.015). However, the association between MASLD diagnosis and severe/very severe VMS was no longer statistically significant after individually adjusting for body mass index (adjusted OR, 1.36; 95% CI, 0.97-1.92) and hypertension (adjusted OR, 1.38; 95% CI, 0.99-1.93). Conclusions The relationship between MASLD and VMS appears to be best explained by other variables including BMI and hypertension. Although they do not appear to be directly linked, given the prevalence of bothersome VMS in midlife women, addressing VMS may enable greater adherence to lifestyle modifications as part of MASLD management.

Abstract Disclosure: A.Y. Chang: None. D.Z. Erickson: None. W.F. Young: None. J.C. Andrews: None. E. Kapoor: None. Background: While mild androgen excess is frequently encountered in endocrine practices, severe symptoms, rapid onset or markedly abnormal biochemical testing lead to further evaluation for rare ovarian androgen-producing tumors, ovarian hyperthecosis or androgen-secreting adrenal tumors. Combined ovarian and adrenal vein sampling (COAVS) might be necessary to identify the source of androgen hypersecretion and guide treatment. The utility of COAVS has been studied in limited case series, combining case reports and different centers. There is no consensus regarding the testosterone gradient that localizes the androgen source or the added value of COAVS when a pathologic source of androgen excess is suspected. The additional clinical benefit of adrenal vein sampling (AVS) when combined with ovarian vein sampling (OVS) has also not been examined. Objectives: We sought to determine: a) the optimal total testosterone (TT) gradient for identifying unilateral vs bilateral source of hyperandrogenism and b) the utility of AVS in addition to OVS. Methods: We performed a retrospective chart review of all adult women who had COAVS at Mayo Clinic, Rochester from 1996 to 2023. Pathologic sources of androgen excess were defined as ovarian hyperthecosis (OH) as well as ovarian and adrenal tumors. We calculated the ratio of dominant OV or AV divided by the nondominant OV or AV. Results: 22 COAVS procedures from 7 premenopausal and 15 postmenopausal women were included in the study: 12 (55%) women had adrenal abnormalities seen on computed cross sectional imaging and 5 (23%) had unilateral ovarian imaging abnormalities. Of the 22 participants in the case series, successful 4-vessel catheterization was completed in 20 (1 right ovarian vein could not be cannulated, and 1 had bilateral oophorectomy). Nine (41%) women had unilateral and 10 (45%) bilateral ovarian androgen hypersecretion. Eleven (50%) women had pathologic causes for elevated TT (5 ovarian tumors, 6 cases of OH), 5 lacked follow-up pathology and 5 had benign pathology. AVS did not diagnose an adrenal source of androgen hypersecretion. TT concentrations were significantly greater in patients with unilateral compared to those with bilateral ovarian androgen hypersecretion (median 262.5 ng/dL [245- 401.5 IQR] vs 104 ng/dL [82-190], P = 0.01). In addition, TT concentrations were higher in those women with a pathologic source of TT hypersecretion compared to those with benign ovaries (349 ng/dL [251-538] vs 115 ng/dL [93-195], P = 0.03). All cases of unilateral ovarian disease had a dominant OV gradient of TT ≥ 2.1 compared to the nondominant OV. Conclusion: In a series of successful COAVS in women with androgen hypersecretion, an ovarian side-to-side gradient of ≥ 2.1 diagnosed all sources of unilateral ovarian pathology. AVS did not diagnose any pathologic source of adrenal androgen excess in this patient cohort. Presentation: 6/3/2024

Abstract Objective Menopause symptoms affect quality of life and financial well-being but are often unaddressed in primary care clinics. Therefore, we evaluated the extent of menopause symptom documentation in electronic health records (EHRs) by primary health care professionals. Methods We retrospectively reviewed adult women who reported moderate or higher vasomotor symptoms on a Mayo Clinic survey conducted from March 1, 2021, through June 30, 2021. We then assessed adequacy of menopause symptom documentation in the EHRs of these women who had primary care visits during the survey period. We reviewed the percentage of documented vasomotor symptoms from May 1, 2019, through May 1, 2021. Results In the Mayo Clinic Health System—Northwest Wisconsin Region, 229 women self-reported moderate or higher vasomotor symptoms in the Mayo Clinic survey. Although only 23% of these women had vasomotor symptoms listed in the EHR clinical problem lists, 60% of these women had vasomotor symptoms documented in their clinic notes from the primary care visit. Approximately 6% of women reported hormone therapy use for management of menopause symptoms, and nearly 15% reported use of nonhormone prescription therapies for vasomotor symptoms. Conclusions A greater proportion of women in our study had EHR documentation of bothersome menopause symptoms than those reported in other studies, but vasomotor symptoms remain generally untreated. We need better methods for identifying midlife women with bothersome menopause symptoms in primary care clinics so that appropriate treatment options, including hormone therapy, can be discussed and offered.

Abstract Introduction Obesity is a global health crisis that has been growing over the past few decades. The economic burden associated with obesity is substantial as it is associated with multiple disabling chronic diseases, such as cardiovascular disease, certain cancers, osteoarthritis, chronic pain, and mental illness. Obesity is known to be a risk factor for sexual dysfunction in men, but this association is less well understood in women. Aims To provide a narrative review of the available literature on the relationship between overweight/obesity and female sexual dysfunction, elaborate on the possible mechanisms explaining this association, and discuss the effects of weight loss on sexual function in those with obesity. Methods A search of the medical literature was carried out in PubMed and Medline, focusing on original research and systematic reviews of original research on obesity and sexual function in women. Results The relationship between obesity and female sexual function is not consistent across studies. While women with obesity are more likely to have worse sexual function and avoid sexual activity, many studies have failed to identify these associations. Lifestyle changes resulting in weight loss lead to better sexual function, and bariatric surgery has been shown to improve sexual function in the first couple of years following the procedure; yet, the long-term effects of weight loss and bariatric surgery are still uncertain. Conclusions The evidence on the relationship between obesity and female sexual function is mixed. Nevertheless, weight loss has been shown to improve sexual function in women with obesity. The impact of weight loss medications and the long-term effect of bariatric surgery on female sexual function require further study.