Association of menopause symptoms with depressive symptom severity in a diverse community-based sample

Abstract

The Dallas Heart Study dataset was used to examine relationships between menopausal symptoms and depressive symptom severity in 384 women (37-73 years old) self-reporting as menopausal. Self-reported menopausal symptoms were grouped based on the Menopause-specific Quality of Life Questionnaire (MENQOL). Depressive symptom severity was assessed using the Quick Inventory of Depressive Symptomatology – Self-Report (QIDS-SR). The relationship between menopause symptom groups, ethnicity and QIDS-SR was evaluated using multiple linear regression. Endorsement of sexual symptoms was positively associated with QIDS-SR score (β = .12, p = .031), suggesting that sexual dysfunction during menopause may be a predictor of underlying depressive symptoms.

1. Introduction

Studies have shown that women may have an increased risk of new onset depression during their menopausal transition in comparison to the premenopausal period. Symptoms associated with this transition have been linked to increased depression scale scores within several community-based studies, including one by Bromberger and Kravitz looking at data from the Study of Women’s Health Across the Nation (SWAN) [1, 2]. When evaluating clusters of related symptoms, the presence of vasomotor and sleep symptoms tends to display a positive relationship with depression scale scores amongst menopausal women. Sexual symptoms resulting in an overall decline in sexual health are equally prevalent, yet poorly understood in the context of reproductive health and changes during menopausal transition. A limited number of studies have evaluated the decline in sexual health during menopause and found sexual symptoms to be significantly linked to depression within Turkish and Hispanic communities [3, 4]. In the current report, menopausal symptoms and their impact on depressive symptoms were examined in a racially diverse, community-based sample.

2. Methods

Data were utilized from the second phase of the Dallas Heart Study (DHS-2), a multiethnic community-based study identifying risk factors for cardiovascular disease and other health issues [5]. Female participants who self-endorsed being in menopause at the time of the study were included in the current sample (n = 384). Menopause symptoms were grouped into vasomotor, psychosocial, physical, and sexual categories as used in the Menopause-specific Quality of Life Questionnaire (MENQOL) (see supplemental Table 1 for categorical definitions). Depression was measured using the total score on the Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR).

Multiple linear regression was performed with QIDS-SR as the dependent variable, and menopause symptom clusters as independent variables. Ethnicity, age, smoking status, annual family income, and history of hormone replacement therapy were included as covariates. Categorical covariates were dummy coded prior to being included in the analyses using the following reference categories: Non-Hispanic Black (race/ethnicity), never smoker (smoking status), and no history of hormone replacement therapy/estrogen use. The interaction terms were created by multiplying together the variables of interest.

3. Results

Within the sample, 64.06% were non-Hispanic Black, 26.82% were non-Hispanic White, and 9.11% were Hispanic. Mean age was 56.24 (SD = 6.82) years and 81.51% of the women endorsed experiencing vasomotor symptoms during menopause, 77.86% psychosocial, 84.38% physical, and 47.14% sexual. QIDS-SR scores had a mean of 7.16 (SD = 4.74, range 0-25).

The overall regression model was statistically significant, F(10, 304) = 5.59, p < .001, R² = .16, with predictors accounting for 16% of variance in total QIDS-SR scores (Table 1). After factoring in covariates, endorsement of sexual symptoms during menopause was a statistically significant positive predictor of QIDS-SR (β = .12, p = .031). This relationship remained significant (β = .13, p=.043) upon excluding women taking antidepressants. There was a positive trend between psychosocial symptoms and QIDS-SR (β = .11, p = .077). Vasomotor and physical symptoms did not demonstrate any statistically significant relationship with QIDS-SR. Ethnicity was not a significant predictor of QIDS-SR scores during menopause. None of the interaction terms between ethnicity and symptom clusters were statistically significant in relation to QIDS-SR.

Table 1.

Regression Analysis Summary for Menopausal Symptoms Predicting QIDS-SR Scores

Predictor	b	95% CI	β	p
Vasomotor Symptom	−0.27	[−1.66, 1.12]	−.02	.700
Psychosocial Symptoms	1.24	[−0.13, 2.62]	.11	.077
Physical Symptoms	0.73	[−0.85, 2.34]	.06	.362
Sexual Symptoms	1.13	[−0.10, 2.16]	.12	.031*
Smoking History	−0.72	[−1.71, 0.27]	−.08	.155
Age	−0.13	[−0.21, −0.05]	−.19	.002*
Annual Family Income	−0.39	[−0.56, −0.23]	−.28	< .001*
History of Hormone Replacement Therapy	−0.37	[−1.47, 0.74]	−.04	.513
Ethnicity: Black vs. White	−0.98	[−2.17, 0.22]	−.10	.108
Ethnicity: Hispanic vs. Black	1.00	[−0.69, 2.69]	.06	.246
Ethnicity: Hispanic vs. White	0.03	[−1.84, 1.89]	.00	.979

Note. R² = . 16. CI = confidence interval for b.

^*p < .05.

Vasomotor symptoms consist of hot flashes. Psychosocial symptoms include depression, irritability, moodiness, forgetfulness. Physical symptoms are fatigue, sleep disturbances, headache, digestive problems, abnormal hair growth. Sexual symptoms are vaginal dryness and low sex drive.

4. Discussion

Previous studies have described a positive relationship between endorsement of menopausal symptoms and depression scale scoring within limited patient populations [3, 4]. The current study evaluated this relationship across racial/ethnic groups. This allowed for further analysis of whether race significantly impacts the relationship between menopausal symptoms and depression.

The presence of hot flashes was not a significant predictor of QIDS-SR scores. Although hot flashes have been associated with depression in previous studies, it has been proposed that depression actually precedes hot flashes rather than being caused by them [1]. Surprisingly, psychosocial symptoms also did not reach significance. This result may be due to the wide range of symptoms considered (irritability, moodiness, forgetfulness). In exploring sexual symptoms of menopause, we found a significant positive association with QIDS-SR scores. This finding is in line with previous studies performed showing a similar link in decreased sexual functioning with depression, although in a different population [3, 4]. The finding remained statistically significant after excluding participants on antidepressants. This suggests that sexual symptoms may indicate underlying depressive symptoms which are not clinically apparent. There appeared to be no impact of racial/ethnic background on this relationship. Persistence of this finding in a diverse sample suggests that it may also apply to the population at large. In looking at race/ethnicity and its potential impact on depression scale scoring, we found no statistically significant differences between Black, White, and Hispanic populations. This finding is in line with a previous study, wherein when controlling for socioeconomic status, there was no significant difference in scores between these racial/ethnic groups [2].

This study was limited by its sample size and self-reported menopausal status of its respondents. However, participants were largely within the appropriate age range for menopause and endorsed attributed symptoms. Although a diverse sample was used, the DHS dataset was purposefully oversampled for Non-Hispanic Black women, and the number of Hispanic women was modest. However, the large Non-Hispanic Black population was also a strength of the study given information pertaining to menopausal symptoms and depression within the black community is needed. Additionally, sexual symptoms were limited to low libido and vaginal dryness and only one vasomotor symptom (hot flashes) was surveyed. Further research with a larger, more representative, diverse population, and confirmed peri-menopausal status may help further clarify this relationship. Future studies should also incorporate screening tools that assess sexual symptoms including decreased lubrication, dyspareunia, decreased arousal, and urinary symptoms.

The findings of this study suggest that sexual symptoms in menopause may be indicative of underlying depressive symptoms. Physicians should be aware of the contribution of sexual health to mental health. While screening menopausal women for depression is routine, those who endorse sexual symptoms may warrant a more thorough investigation.

Highlights.

• Sexual symptoms in menopause may be predictive of depression.

• Other menopausal symptoms were not significantly associated with depression.

• Race and ethnicity were not significant predictors of depression in menopause.