CE: M.S.

; MENO-D-17-00351; Total nos of Pages: 7;

MENO-D-17-00351

Menopause: The Journal of The North American Menopause Society

Vol. 25, No. 8, pp. 000-000
DOI: 10.1097/GME.0000000000001091
ß 2018 by The North American Menopause Society

Climacteric-related symptoms in menopause transition and beyond:

a prospective 19-year follow-up study on previously
hysterectomized women
Riina Katainen, MD,1 Janne R. Engblom, DSc, Msc,2 and Päivi Polo-Kantola, MD, PhD 1

Abstract
Objective: Only a few extended follow-up studies have investigated the natural progress of climacteric-related
symptoms. The results have been conflicting. Thus, our aim was to evaluate, through a 19-year longitudinal study,
whether these symptoms decrease or disappear as time elapses after menopause.
Methods: Our study was a prospective follow-up survey of 65 hysterectomized peri or postmenopausal women.
The women were interviewed at the baseline, and at 6 and 19 years thereafter. Changes in various climacteric-related
symptoms were evaluated by repeated-measures analysis of variance with time as the independent variable. The
analyses were adjusted for baseline age, body mass index, employment, and use of hormone therapy. Climacteric-
related symptoms were evaluated with the Women’s Health Questionnaire, of which we included seven symptom
domains (vasomotor, sleep, depressive, anxiety/fears, cognitive, sexual, and somatic).
Results: Vasomotor symptoms decreased remarkably during the follow-up period. In addition, a statistically
significant decrease was found in sleep problems and cognitive difficulties. However, the decrease was minor, and
thus probably clinically insignificant.
Conclusions: The only symptom with notable decrease was vasomotor symptoms. The etiology of other
symptoms, commonly connected to menopause transition, is probably multifactorial and not substantially dependent
on the climacteric.
Key Words: Aging – Climacteric symptoms – Menopausal symptoms – Middle age – Midlife – Quality of
life.

I
n midlife, many women suffer from some symptoms,
like hot flashes and night sweats, that are considered
characteristic for the climacteric,1,2 and also other symp-
toms, like sleep problems,3 mood changes,1 sexual com-
plaints,1,4 and problems with memory and concentration1
that presumably stem from multiple origins. Although up
to four of five women are estimated to experience hot flashes
or night sweats to some degree during the climacteric,5,6 the
duration of vasomotor symptoms (VMS) is not consistently
Received November 14, 2017; revised and accepted February 1, 2018.
From the 1Department of Obstetrics and Gynaecology, Turku University
Hospital and University of Turku, Turku, Finland; and 2Department of
Mathematics and Statistics, University of Turku, Turku, Finland.
Funding/support: The Finnish Menopause Society, Turku University
Hospital (the Special Government Funding), University of Turku Grad-
uate School (UTUGS), the Finnish Medical Foundation, the Finnish
Medical Society Duodecim, Åland Culture Foundation, and Orion
Research Foundation sr have granted the project.
Financial disclosure/conflicts of interest: RK was funded by The Finnish
Menopause Society, Turku University Hospital (the Special Government
Funding), University of Turku Graduate School (UTUGS), the Finnish
Medical Foundation, the Finnish Medical Society Duodecim, Åland
Culture Foundation, and Orion Research Foundation sr. PP-K was
funded by Turku University Hospital Government grant. For JE, none
reported.
Address correspondence to: Riina Katainen, MD, Department of
Obstetrics and Gynaecology, Turku University Hospital, Turku, Finland.
E-mail: riina.katainen@utu.fi
documented. In previous longitudinal studies, the average
duration of hot flashes has varied from 3 to 12 years.2,7-10 A
median duration of 7.4 years was found in a large multiethnic
17-year follow-up study of 1,449 women.2 Climacteric is also
a risk factor for sleep problems,11 especially if accompanied
by VMS.11,12 However, as aging per se impairs general sleep
quality13,14 and predisposes to difficulty falling asleep13 and
maintaining sleep,13,14 it is challenging to determine the
actual duration of climacteric-related sleep problems. Few
follow-up studies investigate subjective sleep problems of
postmenopausal women. An American longitudinal study of
115 women, aged 55 years or older at the baseline, found that
sleep problems had increased by the 10-year follow-up.15
Climacteric women frequently experience depressive symp-
toms.16-18 Yet, previous studies have found the relationship
between depressive symptoms, climacteric, and aging to be
complex.17-22 In the 20-year follow-up to an Australian study
that began with women who were all premenopausal, negative
mood and depressive symptoms decreased with age,20,21 hav-
ing been highest during the menopause transition and lowest in
late postmenopause,21 decreasing even as the women aged
from 60 to 70 years.20 On the contrary, a Finnish 15-year
follow-up study on participants of both sexes found that
depressive symptoms increased with age.22 The findings on
the association between climacteric and cognitive difficulties

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MENO-D-17-00351
KATAINEN ET AL
diverge as well.23,24 Women often report experiencing cogni-
tive difficulties during the climacteric,23-27 but findings on the
relationship between climacteric and objectively measured
cognitive performance are inconsistent.25-27 In a longitudinal
study of 2,124 American women—the Study of Women’s
Health Across the Nation (SWAN)—objectively measured
cognitive performance declined during a 6.5-year follow-up
among midlife women.28 However, it is difficult to distinguish
natural age-dependent cognitive decline from dementing
illnesses, especially when preclinical.29
Recently, there has been a growing interest in sexual
functioning among climacteric women, but longitudinal stud-
ies extending the follow-up to late postmenopause are sparse.
In an Australian study, involvement in sexual activities
decreased remarkably from early to late postmenopause,
but no change was found in pain related to sexual intercourse
or in satisfaction with sexual life,30 even though impaired
sexual functioning during the climacteric is typically con-
nected to distress related to vaginal dryness or atrophy caused
by estrogen deficit.4 In the SWAN study, the importance of
sex, sexual desire, arousal, emotional satisfaction, and physi-
cal pleasure decreased during a 6-year follow-up, but no
change was found in pelvic pain.4
Longer follow-up studies investigating the natural progress
of climacteric-related symptoms are few, and the results are
rather conflicting. Therefore, to evaluate whether these symp-
toms continue after the climacteric period, we used the
Women’s Health Questionnaire (WHQ)—a validated31,32
and widely used32 instrument—to evaluate women’s experi-
ence of these symptoms during a 19-year follow-up.
METHODS
Design and participants
The study included three interviews: a baseline interview, a
6-year follow-up, and a 19-year follow-up. The participants
were originally recruited through announcements in local
newspapers for a survey studying the effects of hormone
therapy (HT) on sleep and cognition.33 Only peri and post-
menopausal women who had previously had a hysterectomy
for benign indications and who were not using systemic HT at
the time of the study were included. Furthermore, women with
malignancy or severe neurological, cardiovascular, endo-
crinological, or mental diseases were excluded, as were
women who used central nervous system medications (includ-
ing sleep medications) or who abused alcohol or drugs. To
ensure that the women were peri or postmenopausal, a serum
follicle-stimulating hormone level (FSH) 30 IU/L was
required. Two women were accepted with lower FSH levels
(28 and 29 IU/L), because of their ages, which were 56 and
62 years, respectively. Blood hemoglobin, leucocytes, sedi-
mentation rate, serum thyrotropin, free thyroxin, vitamin B12,
creatinine, glucose, and cholesterol levels were investigated
before the study to ensure that they fell within the normal
ranges. Altogether, 71 women were accepted into the study.
The Joint Ethics Committee of the University of Turku and
Turku University Hospital approved the study. Written
2 Menopause, Vol. 25, No. 8, 2018
Copyright ß 2018 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
informed consent was obtained from all participants after
they received oral and written information about the study.
The original study was a prospective, randomized, placebo-
controlled crossover study with two 3-month treatment peri-
ods (HT and placebo). Five women interrupted the study, and
one began antidepressant use and was excluded. Thus, the
baseline study population consisted of 65 women. Of these
women, one (1.5%) declined to participate at the 6-year
follow-up. At the time of the 19-year follow-up, three
(4.6%) women were not able to participate because of
severe dementia, and five (7.7%) women were deceased.
The remaining 57 women (including the one who declined
at the 6-year follow-up) completed the 19-year follow-up.
After the baseline study, the women were free to use both
systemic and local HT, and this use was recorded separately
for both types as ‘‘no,’’ ‘‘yes,’’ or ‘‘previously.’’
At the baseline and at the 6-year follow-up, the women
completed the questionnaires in the presence of a researcher.
At the 19-year follow-up, the women were contacted by phone
and allowed to choose between a personal and a postal
interview; a personal interview was selected by 28 women
and a postal questionnaire by 29 women. In the case of
missing answers, the participants were re-contacted by phone
to complete the questionnaire. Body mass index (BMI, kg/m2)
was calculated at the baseline and at the 6-year follow-up;
weights were measured by a researcher, and heights recorded
as reported by the participants. At each interview, marital and
employment status, smoking habits, existing diseases, and use
of medications were recorded.
Measurements
To measure climacteric-related symptoms, we used the
WHQ, that contains 36 items.31,32 According to the user
manual of the questionnaire,32 the items are grouped into
symptom domains, of which we included seven: VMS (two
items), sleep problems (three items), depressive symptoms
(seven items), anxiety/fears (four items), cognitive difficulties
(three items), sexual functioning (three items), and somatic
symptoms (seven items). The participants rated each item on a
4-point scale (yes, definitely; yes, sometimes; no, not much;
no, not at all). The scoring was reversed for certain items
because some of the items were expressed positively and
some negatively.32 To obtain major factor scale scores for the
domains, the scores were summated and divided by the
number of the items in each domain.32 A higher number
indicated more symptoms. Missing data were handled as
disclosed in the user manual of the WHQ.32 Regarding sexual
functioning, only sexually active women were instructed to
reply to two of the items. Because only one missing answer
was accepted,32 the domain of sexual functioning included
only sexually active women. The women with two missing
answers were considered as sexually inactive. At the baseline,
apart from the items of sexual functioning, there was one
woman with one missing answer in depressive symptoms and
two women with one missing answer in somatic symptoms.
Two missing answers are accepted in these two symptom
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CLIMACTERIC-RELATED SYMPTOMS IN OLDER AGE

domains,32 and thus, all women were included in these
domains. At the follow-ups, with the exception of sexual
functioning, there were no missing answers.
Statistical analysis
Data on the symptom domains and on basic characteristics
were submitted first to a descriptive analysis. Data on the
symptom domains were defined by means and standard devia-
tions (SDs), and data on the basic characteristics were defined as
means (SDs) or as numbers and percentages. Repeated-measures
analysis of variance (ANOVA) with time as the independent
variable was used to investigate changes in the WHQ symptom
domains (dependent variable) between the three stages of the
study (baseline, 6-year follow-up, and 19-year follow-up). The
changes between the three points in time were quantified using
the differences in means with SDs. The analyses were adjusted
for baseline age, baseline BMI, baseline employment, and use of
HT at the 6-year follow-up (HT use was not allowed at the
baseline and at the 19-year follow-up it was used only by four
[7.0%] women). For the adjustment, the employment was
classified as ‘‘working’’ or ‘‘not-working’’ (unemployed or
retired) and the use of systemic HT as ‘‘yes’’ or ‘‘no’’ according
to current use. Tukey’s multiple comparison test was used to
identify significant differences. To investigate inter and intra-
subject variations of the symptom domains, random-effect
variance tests for the baseline and for the time effects were
performed. As to ‘‘Results’’ section, only statistically significant
changes are described. To assess the internal consistency in the
symptom domains at the baseline, Cronbach’s a coefficient was
used. The values ranged from 0.67 to 0.84 for other domains,
except for the sleep symptoms domain, where it was 0.56.
Differences in age and in the symptom domain means between
women who were interviewed personally and women who were
interviewed by a postal questionnaire at the 19-year follow-up
were tested with an independent-samples t test. Statistical
analyses were carried out using SAS system for Windows,
release 9.4. P values less than 0.05 were considered significant.
RESULTS
The mean time interval between the baseline and the first
follow-up was 5.8 years (SD 0.5, range 5.0-6.6 years), and the
interval between the baseline and the second follow-up was
19.2 years (SD 0.4, range 18.5-19.8 years). The follow-up
rates were 98.5% and 87.7%, respectively. The basic char-
acteristics at each time point, including the details of HT use
and previous oophorectomy, are shown in Table 1, and the

TABLE 1. The basic characteristics

Baseline (N ¼ 65) 6-y follow-up (N ¼ 64) 19-y follow-up (N ¼ 57)
Median (SD, range) Median (SD, range) Median (SD, range)
Age, y 56.2 (4.4, 47-65) 61.9 (4.3, 53-71) 74.9 (4.5, 66-85)
Body mass index, kg/m2 26.9 (4.0, 19.8-39.0) 27.3 (4.0, 19.8-37.6) NA

N (%) N (%) N (%)

Marital status
Single 4 (6.2) 4 (6.3) 3 (5.3)
Married/cohabiting 44 (67.7) 40 (62.5) 31 (54.4)
Divorced 10 (15.4) 10 (15.6) 7 (12.3)
Widowed 7 (10.8) 10 (15.6) 16 (28.1)
Employment
Employed 31 (47.7) 14 (21.9)a 2 (3.5)b
Unemployed 6 (9.2) 1 (1.6) 2 (3.5)
Retired 28 (43.1) 58 (90.6) 55 (96.5)
Smoking
No 59 (90.8) 60 (93.8) 54 (94.7)
Yes 6 (9.2) 4 (6.3) 3 (5.3)
Hysterectomized 65 (100) 64 (100) 57 (100)
One side oophorectomized 9 (13.8) 11 (17.2)
Both side oophorectomized 16 (24.6) 17 (26.6)
Systemic HT usec
No 17 (26.2) 6 (9.4)d 5 (8.8)d
Yes 0 32 (50.0) 4 (7.0)
Previously 48 (73.8) 26 (40.6) 48 (84.2)
Local HT use
No 54 (83.1) 45 (70.3) 26 (45.6)
Yes 1 (1.5) 10 (15.6) 16 (28.1)
Previously 10 (15.4) 9 (14.1) 15 (26.3)
Median (SD, range)
Age of the HT users, ye 60.9 (4.3, 53-71)
Age of the non-HT users, ye 63.0 (4.2, 53-71)
HT, hormone therapy; NA, not available.
a
Nine women were employed and retired.
b
Two women were employed and retired.
c
The women were not allowed to use systemic HT at the inclusion.
d
All women used estrogen for three months in the baseline study (see: ‘‘Methods’’ section). The answer was recorded as ‘‘no,’’ if this was the only
systemic HT use reported.
e
The age between the women using and not using systemic HT did not differ (P ¼ 0.055).

Menopause, Vol. 25, No. 8, 2018 3

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KATAINEN ET AL
TABLE 2. Prevalence of the diseases

Baseline (N ¼ 65) 6-y follow-up (N ¼ 64) 19-y follow-up (N ¼ 57)

Disease Total N (%) Medicated n (%) Total N (%) Medicated n (%) Total N (%) Medicated n (%)
Cardiovascular disease 9 (13.8) 8 (12.3) 15 (23.1) 15 (23.1) 49 (86.0) 37(64.9)
Diabetes 0 0 1 (1.6) 0 9 (15.8) 9(15.8)
Neurological disease 5 (7.7) 1 (1.5) 5 (7.8) 2 (3.1) 2 (3.5) 1(1.8)
Bronchopulmonary disease 3 (4.6) 2 (3.1) 5 (7.8) 2 (3.1) 13 (22.8) 6(10.5)
Musculoskeletal disease 22 (33.8) 5 (7.7) 7 (10.9) 2 (3.1) 18 (31.6) 13(22.8)
Gastrointestinal disease 4 (6.2) 1 (1.5) 2 (3.1) 0 3 (5.3) 0
Thyroid disease 0 0 3 (4.7) 3 (4.7) 11 (19.3) 8 (14.0)
Dermatological disease 2 (3.1) 2 (3.1) 1 (1.6) 1 (1.6) 0 0
Cancer 0 0 0 0 9 (15.8) 1 (1.8)
Mental disease 0 0 0 0 2 (3.5) 1 (1.8)

occurrence of the diseases is shown in Table 2. The WHQ
symptom domain means (SDs) are shown in Table 3. The use
of sleep medication was not allowed at the baseline, and none
of the participants used it at the 6-year follow-up. At the
19-year follow-up, however, 10 women (17.5%) used sleep
medication (five [8.8%] used hypnotics, three [5.3%] used
melatonin, and two [3.5%] used both). Additionally, two
(3.5%) women used benzodiazepine; one had depression
and the other pulmonary cancer. At the baseline, 73.8% of
the women were sexually active, and at the 6 and 19-year
follow-ups, the percentages were 54.7% and 33.3%, respec-
tively. Of the sexually active women, at the baseline, 85.4%
were married/cohabiting. At the 6 and 19-year follow-ups, the
percentages were 82.6% and 89.5%, respectively.
At the 19-year follow-up, women interviewed personally
and women interviewed by a postal questionnaire did not
differ by age (P ¼ 0.813). Four (7.0%) women in the study
used systemic HT, and all of these women chose to be
interviewed by a postal questionnaire. Of climacteric-related
symptoms, women interviewed by a postal questionnaire
had more somatic (P ¼ 0.040) and depressive symptoms
(P ¼ 0.003), and anxiety/fears (P ¼ 0.003) than women
interviewed personally.
Vasomotor symptoms decreased during the follow-up
period between all the interviews (P < 0.001; baseline vs
6-year follow-up: d ¼ 0.83 [SD 0.17], baseline vs 19-year
follow-up: d ¼ 1.40 [SD 0.17], and 6-year follow-up vs
19-year follow-up: d ¼ 0.57 [SD 0.17]). Sleep problems
and cognitive difficulties decreased from the baseline to the
19-year follow-up (sleep problems: P ¼ 0.029, d ¼ 0.36 [SD
0.13]; cognitive difficulties: P ¼ 0.007, d ¼ 0.40 [SD 0.12]).
No change was found in other symptoms.
There was intersubject variation in all the symptoms at
baseline (in every symptom P < 0.01). In relation to time, the
intersubject variation was found in anxiety/fears (P ¼ 0.007),
in cognitive difficulties (P ¼ 0.006), and in sexual functioning
(P ¼ 0.029). In VMS, there was not enough variation in the
response to attribute any variation to the random effect,
controlling for everything else in the model. As to the intra-
subject variation, in all symptom domains, a part of the total
variation of the dependent variable was explained by the
unexplained variance of the dependent variable (P < 0.001).
DISCUSSION
The follow-up time in our study was long—almost 20 years.
As could be expected, VMS, widely recognized as the most
typical symptoms of the climacteric, decreased. In sleep prob-
lems and cognitive difficulties, the decreases were minor and
thus possibly clinically insignificant. Nevertheless, our finding
opposed the general assumption that problems in sleep and
memory worsen throughout the aging process. Although cli-
macteric women frequently report various somatic symptoms
and depressive/anxious feelings, these symptoms remained
unchanged over time. Thus, their etiology is obviously multi-
factorial and their duration not remarkably dependent on the
time that has passed after menopause.

TABLE 3. Symptom domain means

Baseline 6-y follow-up 19-y follow-up 0-6 y 0-19 y 6-19 y
Variable n Mean SD n Mean SD n Mean SD Pa Pa Pa
Vasomotor 65 2.90 0.98 64 1.90 0.97 57 1.64 0.91 <0.001 <0.001 0.136
Sleep 65 2.24 0.78 64 2.02 0.66 57 1.98 0.74 0.021 0.033 0.893
Depressive 65 1.68 0.53 64 1.52 0.43 57 1.54 0.50 0.055 0.199 0.928
Anxiety/fears 65 1.47 0.48 64 1.41 0.49 57 1.45 0.64 0.587 0.927 0.923
Cognitive 65 2.58 0.72 64 2.37 0.65 56 2.20 0.70 0.003 0.004 0.296
Sexual 48 2.40 0.78 35 2.04 0.68 19 2.35 0.90 0.018 0.996 0.230
Somatic 65 2.13 0.57 64 2.05 0.52 57 2.00 0.61 0.375 0.304 0.910
The symptom domains are presented on the 1 to 4 scale.
The scale items are summated and divided by the number of the items in each symptom domain.
A higher number refers to more symptoms.
a
P values from the pair-wise comparisons (repeated-measures analysis of variance with time as independent variable, unadjusted model).

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CLIMACTERIC-RELATED SYMPTOMS IN OLDER AGE
In VMS, a more notable decrease was found between the
baseline and the 6-year follow-up than between the 6-year
follow-up and the 19-year follow-up. Based on the duration of
VMS found in previous studies,2,7-10 our finding was antic-
ipated. Yet, some of the women still experienced VMS at the
19-year follow-up. Climacteric-related VMS may last deca-
des, but other factors, such as weight,34 sleep apnea,35 diabe-
tes,36,37 medications,38 or emotions (emotional flushing),38
may also initiate them. The sleep problems domain of
the WHQ includes three items,31 two of which address
maintenance insomnia and one of which addresses initiation
insomnia. Waking too early, apart from being caused by
climacteric11 or age,13,14 typically results from stress39 or
depression.39 Our research group has previously shown that
postmenopausal women are prone to sleep problems induced
by workdays.40 Thus, during the follow-up period, events like
retirement could have reduced stress or workload, alleviating
the problem of maintaining sleep. It must be noticed that the
occurrence of sleep problems may have been altered by sleep
medication, which was used by roughly one-sixth of the
women at the 19-year follow-up.
Regarding most mental symptoms, the women were quite
asymptomatic at baseline, which might partially explain our
neutral findings. Most previous longitudinal studies on symp-
toms of depression or anxiety have not expanded the follow-
up to later postmenopause, which complicates the comparison
with our findings. However, in an American longitudinal
study examining depressive symptoms from early adulthood
to old age in women, and also in men, depressive symptoms
were most common in young adulthood, decreased across
middle age, and then increased again in later adulthood.19 Our
neutral outcomes, together with the incoherent findings of the
previous literature, allow us to presume that depressive
symptoms are more dependent on other factors than on the
climacteric, even though they are often reported by climac-
teric women.17,18
Climacteric women often report experiencing cognitive
difficulties,23-27 but the relationship between menopause
and objectively measured cognitive performance is more
controversial.26,27 Maki et al41 found that decreased cognitive
performance in relation to the climacteric was a consequence
of night sweats and other sleep problems rather than a direct
cause of menopause. However, despite the decrease in VMS,
we did not find a decrease in cognitive difficulties from
baseline to the 6-year follow-up, which might be explained
by the adjustment for HT use. Although decline in cognitive
performance, and especially in memory, is considered a part
of normal aging,28,29 cognitive difficulties decreased during
the 19-year follow-up period. On one hand, this may indicate
that women indeed suffered from climacteric-related cogni-
tive difficulties, evident in the relatively high mean value at
the baseline (Table 3). But, on the other hand, a decrease
instead of an increase in cognitive difficulties among the
women included in the follow-up could partly be explained by
an increased risk for developing dementia among the women
with cognitive difficulties at baseline,29,42 given that three
Copyright ß 2018 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
(4.6%) women were excluded from the 19-year follow-up
because of severe dementia. Moreover, as the women in the
study aged, they may have considered cognitive difficulties to
be an age-related inconvenience, leading to underestimation.
The majority of the women discontinued having sex, which
is consistent with findings from previous studies.4,30 At the
baseline, three-quarters of the women were sexually active,
compared with one-third at the last follow-up. The decrease in
sexual activities may partially be explained by increased
widowhood or by the fact that older women may have long,
shared histories with their partners, and have lost interest in
sexual activities through habituation and routine.43 However,
dissatisfaction with sexual relationships or distress caused by
vaginal dryness could also have played a role. Because
dissatisfaction and distress may have led women to become
sexually inactive (and thus to skip these two items on the
questionnaire as instructed), it is possible that these symp-
toms, in fact, became more frequent between the follow-ups,
even though we could not find any change.
Somatic symptoms in the WHQ comprise seven completely
diverse physical problems that are considered to be related to
the climacteric.31,32 However, some of them are quite non-
specific, which may explain our neutral outcome. For
instance, even though joint aches are a common complaint
among climacteric women,44,45 their relationship with meno-
pause, and also with aging, is uncertain.44,45
Our study was important because of the long follow-up
period and the high follow-up participation rate. But, because
the study included only three interviews, we were unable to
precisely identify the actual duration of the symptoms. We
could not determine the timing of the hysterectomy and
oophorectomy in relation to the menopausal age, which could
have biased the results. The personal contact at every inter-
view ensured the coherency of the study. At the 19-year
follow-up, to ensure a high response rate, a postal interview
was allowed as some of the women were quite old, and it
might have been too burdensome to participate in the personal
interview. As a result, none of the women who were alive and
not demented neglected to participate. Interestingly, the
women interviewed by a postal questionnaire at the 19-year
follow-up had more symptoms, especially mental symptoms,
than women interviewed personally. It is possible that some
women were unable to attend the interview due to their
symptoms. But, it is also possible that, particularly regarding
mental concerns, the women interviewed by a postal ques-
tionnaire were more honest and took more time to answer,
leading them to recognize even minor symptoms. Because the
women were originally recruited to take part in a study
investigating the effects of HT on sleep problems and cogni-
tive difficulties, the women may have been more symptomatic
in relation to these symptoms at the baseline than average
women of a similar age. To assess climacteric-related symp-
toms, we used only one questionnaire—the WHQ. Our results
could have been strengthened by using several questionnaires.
However, the WHQ is a well-validated31,32 questionnaire that
is widely used in climacteric surveys.32 According to the
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KATAINEN ET AL
WHQ user manual, the item scores should be reduced to a
binary scale (0-1), meaning the scores would range from 0 to 1
in all symptom domains.32 However, the 1 to 4 scale offers
more detailed responses, and we have previously shown that it
is preferable in Finnish populations.46
CONCLUSIONS
Not surprisingly, VMS, the most typical symptoms of the
climacteric, decreased as time passed after menopause. A
slight decrease was found also in sleep problems and cogni-
tive difficulties. These associations might be due to climac-
teric hormonal changes, but they are more likely associated
with VMS. Instead, no changes were found in somatic or
mental symptoms. Thus, these symptoms probably stem from
factors that are not climacteric-related. This is important,
since regarding these symptoms as related only to the climac-
teric may cause a delay in proper diagnosis of an underlying
disease or condition.
Acknowledgments: The English-language proofreading of this
manuscript was performed by Scribendi.
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