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Menstrual Cycle Patterns and Their Determinants During the Menopausal Transition Among a Multiethnic Cohort of Women

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Menstrual Cycle Patterns and Their Determinants During the Menopausal Transition Among a Multiethnic Cohort of Women Menstrual Cycle Patterns and Their Determinants during the Menopausal Transition among a Multiethnic Cohort of Women by Pangaja Paramsothy A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy (Epidemiological Science) in The University of Michigan 2012 Doctoral Committee: Professor Siobán D. Harlow, Chair Professor John F. Randolph Jr. Associate Professor Michael R. Elliott Associate Professor Lynda D. Lisabeth © Pangaja Paramsothy 2012 ACKNOWLEDGEMENTS I first like to thank my academic advisor and dissertation committee chair, Dr. Harlow for her mentorship, encouragement, and support during my time here at the University of Michigan. I would also like to thank my dissertation committee: Dr. Randolph, Dr. Elliott, and Dr. Lisabeth for their support, guidance, and feedback. Their involvement strengthened this work. I would like to thank Matheos Yosef for sharing his statistical expertise with quantile regression. His patience and kindness is very much appreciated. I would also like to thank Nancy Vander Kuyl for her administrative support and most importantly her moral support and her cheerleading throughout my time here. I would like to thank my SWAN site coauthors: Dr. Crawford, Dr. Gold, and Dr. Greendale for their timely feedback and suggestions. I am indebted to the SWAN staff at all study sites for their years of hard work. I would also like to express my gratitude to the SWAN participants. Their steadfast dedication in filling out the SWAN Menstrual Calendar made this research possible. I gratefully acknowledge funding support from the Rackham Graduate School of University of Michigan as well as the Department of Epidemiology, University of Michigan School of Public Health. Their financial support made it possible for me to achieve my degree. ii On a personal note, I would like to thank my fellow doctoral students for their friendship and support. I would especially like to acknowledge Sandra Albrecht, Kristin King Sznajder, and Mariana Rosenthal for sharing their wisdom and helping me navigate through the doctoral program. Finally, I would like to thank my family for their love and support, especially my mother for her many sacrifices. I would not have achieved my dreams without her support. iii TABLE OF CONTENTS ACKNOWLEDGEMENTS ................................................................................................ ii LIST OF FIGURES .......................................................................................................... vii LIST OF TABLES ........................................................................................................... viii LIST of APPENDICIES .................................................................................................... ix ABSTRACT ........................................................................................................................ x CHAPTER I ........................................................................................................................ 1 Introduction ............................................................................................................. 1 Dissertation Aims.................................................................................................... 5 Background ............................................................................................................. 6 Questionnaires vs. Menstrual Diaries ................................................................... 15 Factors that Influence Menstrual Cycle Characteristics ....................................... 17 Summary and Chapter Overview .......................................................................... 24 References ............................................................................................................. 26 CHAPTER II ..................................................................................................................... 37 Poor Agreement Found Between Staging the Menopausal Transition Using Annual Interview Questions or Annual Follicle-Stimulating Hormone Measures and Menstrual Calendars....................................................................................... 37 Introduction ........................................................................................................... 37 Methods................................................................................................................. 38 Results ................................................................................................................... 44 iv Discussion ............................................................................................................. 50 References ............................................................................................................. 61 CHAPTER III ................................................................................................................... 63 Quantile Regression Models of Factors Associated with Menstrual Cycle Length During the Menopausal Transition ....................................................................... 63 Introduction ........................................................................................................... 63 Methods................................................................................................................. 64 Results ................................................................................................................... 70 Discussion ............................................................................................................. 73 References ............................................................................................................. 85 CHAPTER IV ................................................................................................................... 89 Abnormal Uterine Bleeding Common during the Menopausal Transition ........... 89 Introduction ........................................................................................................... 89 Methods................................................................................................................. 91 Results ................................................................................................................... 97 Discussion ........................................................................................................... 101 References ........................................................................................................... 113 CHAPTER V .................................................................................................................. 117 Summary of Findings .......................................................................................... 117 Strength and Limitations ..................................................................................... 121 Future Research .................................................................................................. 123 v Clinical Implications ........................................................................................... 126 Conclusions ......................................................................................................... 127 References ........................................................................................................... 129 APPENDICIES ............................................................................................................... 133 Appendix A ......................................................................................................... 133 Appendix B ......................................................................................................... 135 vi LIST OF FIGURES 2.1 An Example of the Comparison Between the Annual Interviews (Baseline and Visits) to the Menstrual Calendar. ..............................................................................55 2.2 The 2 by 2 Table for Calculation of Cohen’s Kappa Statistic ....................................56 3.1 Kernel Density Plot of Menstrual Cycle Length.........................................................77 3.2 Estimated Cycle Length by Time since the Start of Transition from Multivariate Quantile Regressions for Four Percentiles: 25th, 50th, 75th and 90th. .................................. 78 3.3 Estimated Cycle Length by Time until FMP from Multivariable Quantile Regressions for Four Percentiles: 25th, 50th, 75th and 90th. ..................................................................... 79 4.1 Venn Diagram of Potential Abnormal Bleeding Events ........................................................ 106 vii LIST OF TABLES 2.1a Baseline Demographics of Women Participating in the SWAN Menstrual Calendar Study .................................................................................................................................... 57 2.1b Baseline Demographics of Women Participating in the SWAN Menstrual Calendar Study with at least 10 Consecutive Untreated Non-Missing Cycles Observed by FMP Status .......................................................................................................................... 58 2.2 Menopausal Transition (MT) Stage by Menstrual Calendar Compared to MT Stage by Annual Interview among Those with Observed FMP in the Menstrual Calendar .......... 59 2.3 MT Stage by Menstrual Calendar Compared to MT Stage by FSH Level among Those
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