Study of Women Veterans In Menopause by Patricia Anne Rouen A dissertation submitted in ...

342 Pages·2009·1.07 MB·English

Study of Women Veterans In Menopause

by

Patricia Anne Rouen

A dissertation submitted in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
(Nursing)
in The University of Michigan
2009

Doctoral Committee

Professor Joyce E. Roberts, Co-Chair
Professor Emeritus Nancy E. Reame, Co-Chair
Professor Robert M. Anderson
Professor Carolyn M. Sampselle
Assistant Professor Sarah L. Krein
© Patricia Anne Rouen

2009
Dedication
In memory of Joseph Edward Rouen (1926 – 1968) and
in honor of Doreen Sharkey Rouen

ii
Acknowledgements
With sincere appreciation, I would like to thank the members of my dissertation
committee. Dr. Nancy Reame, co-chair and mentor who has seen me through this entire
program from Michigan to New York and has provided that perfect balance of faith,
challenge and guidance; Dr. Joyce Roberts, co-chair and mentor who graciously took this
project on and provided ongoing support and encouragement; Dr. Carolyn Sampselle,
who provided menopause expertise and words of wisdom; Dr. Robert Anderson, for his
diabetes expertise and sense of humor, and Dr. Sarah Krein, who championed this
research within the Veteran's Affairs healthcare system and provided statistical
consultation and negotiated systems issues on a regular basis.
Most of all, heartfelt thanks to Eileen & Jack, Jim & Anne, Sean, Katie, Brenna
and Kelly who didn't bat an eye when I said I was going back to school and never
wavered in their support of this goal.
Funding for this dissertation research was provided by the Department of
Veterans Affairs, Veterans Health Admnistration, Health Services Research and
Development Service Quality Enhancement Research Initiative Program RRP 07-354,
Sigma Theta Tau - Lamba Zeta Chapter, the Dean's Intramural Funding at the University
of Detroit Mercy and the University of Michigan School of Nursing

iii
Table of Contents

Dedication ii
Acknowledgements iii
List of Tables vi
List of Figures viii
Abstract ix
Chapter
1. Introduction 1
Menopause Research 6
Nursing Science and Menopause Research 8
Purpose 10
2. Review of the Literature 18
Physiologic Features of Menopause 18
Metabolic Consequences of Menopause 23
Factors Affecting Age at Menopause 32
Sociocultural and Developmental Challenges of the Menopause 38
Symptoms of the Menopause 44
Diabetes Mellitus (DM) 85
The Intersection of Diabetes and Menopause 102

iv
Theoretical Framework 117
3. Methods 134
Sample 134
Measurement 137
Human Subjects 142
Data Management and Analysis 142
4. Results 148
Study Participants 148
Menopause Characteristics 150
Main Findings: Menopause Symptom Prevalence and Severity 153
Menopause Symptoms: Perceived Prevalence 153
Menopause Symptoms: Perceived Severity 153
Main Findings: Factors Associated with Menopause Symptoms 155
Correlates of Menopause Symptom Severity 155
Menopause Symptom Severity: Multivariate Analysis 156
Correlates of Menopause Symptom Severity: Factor scores 156
Menopause Symptom Severity Factor Scores: Multivariate Analysis 157
Other Covariates 158
Diabetes Symptoms 160
Health Status 161
5. Discussion 203
Appendix A 236
References 263
v
List of Tables

Table

1.1 Menopause Research and Nursing Science 12

2.1 Prevalence Patterns of Menopause Symptoms 124

2.2 Prevalence Patterns of Menopause Symptoms by Race/Ethnicity 127

2.3 Factors Associated with Menopause Symptoms 130

2.4 Risk Factors for Type 2 Diabetes 132

2.5 Diabetes and Reproductive Functions 133

3.1. Study of Women veterans In Menopause: Sample Selection 147
Process

4.1 Clinical Characteristics by Diabetes Groups 168

4.2 Comorbid Medical Conditions by Diabetes Groups 170

4.3 Demographic Characteristics by Diabetes Groups 171

4.4 Lifestyle Behaviors by Diabetes Groups 172

4.5 Characteristics of Women with Diabetes Mellitus 173

4.6 Diabetes Self Care Management Behaviors 174

4.7 Type of Menopause by Diabetes Groups 175

4.8 Type of Menopause: Women with Diabetes Pre or Postmenopause 176

4.9 Age of Menopause by Diabetes Groups 177

4.10 Years Postmenopause by Diabetes Groups 178

4.11 Menopause Difficulty 179

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4.12 Menopause Symptom Prevalence: Women with/without Diabetes 180

4.13 Menopause Symptom Prevalence by Diabetes Study Groups 181

4.14 Menopause Symptom Severity: Women with and without Diabetes 182

4.15 Menopause Symptom Severity by Diabetes Study Groups 183

4.16 Correlation Matrix: Menopause Symptom Severity Score 184

4.17 Correlation Matrix: Menopause Symptom Severity Score/Diabetes 186

4.18 Multivariate Analysis: Menopause Symptom Severity Score 187

4.19 Correlation Matrix: MSL Factor Severity Score and Diabetes 188

4.20 Multivariate Analysis: Factor 1 Psychological Severity Score 190

4.21 Multivariate Analysis: Factor 2 Somatic Severity Score 191

4.22 Multivariate Analysis: Factor 3 Vasomotor Severity Score 193

4.23 Diabetes Symptoms: Women with and Without Diabetes 195

4.24 Diabetes Symptoms by Diabetes Study Groups 196

4.25 Correlation Matrix: DSC-R Global Scores & Menopause 197

4.26 DSC-R Global Scores and Clinical/Demographic Variables 198

4.27 Health Status Measures by Diabetes Groups 199

4.28 Correlation Matrix: Short Form 12 Composite Scores 200

4.29 Multivariate Analysis: Physical Health Composite Score 201

4.30 Multivariate Analysis: Mental Health Composite Score 202

5.1 Postmenopause Symptom Prevalence: Comparisons with 231
Longitudinal Investigations

5.2 Mental and Physical Health Composite Scores: Women Veterans and 233
National Norms

5.3 Menopause Symptom Prevalence: Comparisons in Chronic Illness 234

vii
List of Figures

Figure

2.1 The Theory of Unpleasant Symptoms 122

2.2 Theory of Unpleasant Symptoms: SWIM Study Model 123

3.1 Stages of Reproductive Aging Workshop (STRAW) criteria 145

3.2 Measurement of Major Variables 146

4.1 Menopause Symptom Severity by Diabetes Groups 164

4.2 Menopause Symptom Severity: Women with Controlled and Poorly 165
Controlled Diabetes

4.3 Diabetes Symptoms Global Scores by Diabetes Groups 166

4.4 Self-Reported General Health by Diabetes Groups 167

5.1 Theory of Unpleasant Symptoms: SWIM Study Findings 230

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Abstract
In healthy women, menopause symptoms have been associated with decreased
quality of life, limitations in physical functioning and perceived declines in health status.
Most menopause research is limited to the study of healthy women and little is known as
to how menopause symptoms manifest themselves in women with type 2 diabetes. This
study employed a comparative group design to examine the menopause symptom
experience of three groups of women veterans receiving care in the Veteran Affairs
Healthcare system: women without diabetes (n = 90), women with controlled diabetes
(hemoglobin A1c [HbA1c] < 7%; n = 135) and women with poorly controlled diabetes
(HbA1c > 7%; n = 102). Participants were recruited from an ethnically diverse
postmenopausal sample (n = 536) who responded to a national mailed survey (n = 900)
and consented to clinical data access. As a group, the women were obese, of low income
with more than one chronic illness. On average, menopause symptom prevalence rates
were higher compared to those observed in previous community-based investigations of
ethnically diverse non-veteran cohorts. However, despite higher BMI and increased
disease-related co-morbidities, diabetic participants experienced menopause at the same
age and reported similar menopause symptoms as the non-diabetic cohort.
Among respondents with diabetes, glucose control was an important clinical
correlate of menopause symptom severity, independent of obesity, surgical menopause,
and non-European ethnicity. With the exception of vasomotor symptoms, women
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