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Nocturia and health in women aged 40–64 years
Maturitas 35 (2000) 143 – 148 www.elsevier.com/locate/maturitas
Nocturia and health in women aged 40–64 years Ragnar Asplund a,b,*, Hans Edvard A, berg b b
a Family Medicine Stockholm, Karolinska Institutet, SE-141 57 Huddinge, Stockholm, Sweden Center for studies in Health and Quality of Life (CSL), Mid Sweden Uni6ersity, SE-831 25, O8 stersund, Sweden
Received 17 June 1999; accepted 17 February 2000
Abstract To analyse the relationship between nocturnal micturition and health in 40- to 64-year-old women. A questionnaire study was carried out in 3669 randomly selected women (out of 6000 invited) in the County of Ja¨mtland, Sweden. Questions were asked about the general health status of health, health development during the last 5 years, nocturnal micturition, parity, menstrual status, menopausal symptoms, hormone replacement therapy, cardiac diseases, diabetes and snoring. Poor health was reported by 10.4%. In 24.1% of the women health development had been unfavourable in the last 5 years. Poor health was reported by 4.7% of women without nocturnal micturition, and by 11.2, 20.1 and 39.0% (PB0.0001) of women with one, two, and three or more nocturnal voiding episodes, respectively. In a multiple logistic regression analysis significant independent correlates of health were: one versus no nocturnal micturitions (odds ratio [OR] 2.2; confidence interval [CI] 1.5–3.3), two versus none (OR 3.2; 1.9 – 5.3), and three or more versus none (OR 6.5; 3.5–11.9), spasmodic chest pain (OR 6.6; CI 3.0 – 14.5), irregular heart beats (OR 3.0; CI 2.1 – 4.3), diabetes (OR 5.1; CI 2.8–9.4), leg oedema ]6 days/month versus B 6 days/month (OR 23; CI 1.6 – 3.3), snoring:53 times/week versus never (OR 1.4; CI 1.0–2.0), snoring 4 – 7 times/week versus never (OR 1.6; CI 1.1 – 2.2), beingB5 years after versus being before the menopause (OR 1.6; 95% CI 1.0 – 2.5), 5 – 9 years after versus before the menopause (OR 1.7; CI 1.0–2.9), ]10 years after versus before the menopause (OR 2.2; CI 1.3 – 3.7), diuretic treatment (OR 2.8; CI 1.7–4.6). The perceived state of health in 40- to 64- year-old women is profoundly affected by nocturia, independently of heart diseases, diabetes, snoring, age and menopausal status. © 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Health; Hormone replacement therapy; Menopause; Nocturia; Parity; Snoring; Woman
1. Introduction
* Corresponding author. Present address: Tallva¨gen 3, S-833 34 Stro¨msund, Sweden. Tel.: + 46-670-10007; fax: + 46-63165626. E-mail address: [email protected] (R. Asplund)
Urogenital diseases and symptoms are common in adult women. The frequency of urogenital symptoms is increasing at ages around the menopause [1]. In an earlier study of women aged 40–64 years we found that frequent nocturnal micturition was
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associated with poor sleep, daytime sleepiness and impaired well-being [2]. With increasing numbers of nocturnal voiding episodes the women were also more prone to experience poor appetite, unhappiness and lack of confidence in the future [2]. In addition they paid more visits to doctors and received more medical treatment. The number of days on the sick list was five times higher in women with three or more voiding episodes than in those without nocturnal voiding [2]. Besides nocturia, there is an increase in the frequency of several symptoms, such as vasomotor symptoms, sleep disturbances and, to some extent, depression during the peri- and postmenopausal period [3]. The increased occurrence of nocturia in women at perimenopausal ages may be partly due to atrophy of the genital mucosal membranes due to oestrogen deficiency [4]. Nocturia may also occur in association with cardiac diseases, diabetes or snoring [5–7]. The relationship between nocturia and health may therefore reflect the impact of certain somatic diseases, rather than a connection between nocturnal micturition per se and health. The mechanism of the negative influence of nocturia on health is obscure. We considered it important to elucidate the question of whether this relationship could be attributed to some disease, or whether the increase in reports on health deterioration in women with nocturia could be reflect an age-related or menopause-related phenomenon, or whether both nocturia and poor health could be attributable to certain somatic diseases or symptoms, such as cardiovascular diseases, diabetes or snoring. The present study was therefore undertaken to investigate the nature of the previously observed relationship between nocturia and health among 40- to 64-year-old women [2].
1200 women in every 5-year age interval received a questionnaire during the first 3 months of 1993. One more questionnaire was sent to those who did not respond within 1 month. In relation to information obtained in this way on health, two statements were analysed: ‘I am essentially healthy’, with the alternative answers ‘yes’ or ‘no’ (y/n), referred to in the following as ‘health’, and ‘My health is poorer than 5 years ago’ (y/n), referred to in the following as ‘health development’. The questionnaire included a question on the number of nocturnal voiding episodes. If the number was reported as an interval, e.g. 0–1, 1–2 etc., the woman was allocated to the group with the lower number. There were also two statements on heart diseases, namely ‘I suffer from spasmodic chest pain’ (y/n), and ‘I suffer from irregular heart beats’ (y/n) and a statement ‘I suffer from diabetes’ (y/n). Snoring was reported as ‘never’, ‘no more than three times a week’ or ‘four or more times a week’. Leg oedema (six or more days per month) and treatment with diuretics (y/n) were reported. There were also questions on the menopausal status, menopausal symptoms, and hormone replacement therapy (HRT). The questionnaire was approved by the committee on ethics of the Faculty of Medicine, University of Umea˚, Sweden.
2. Material and methods
3. Results
The study was carried out in the County of Ja¨mtland in northern Sweden, a county which at the beginning of 1993 had a total population of 135 910. There were 19 639 women of ages 40 – 64 years. Of these, a stratified, random selection of
3.1. General results
2.1. Statistical methods Standard methods were used for calculating mean values and standard deviations (SD). Group comparisons of non-numerical data were made with the x 2-test. For simultaneous evaluation of the influence of more than one independent variable on health, logistic regression analysis (StatView 5.0 for Macintosh) was performed.
The questionnaire was initially answered by 3019 of the 6000 women. After a reminder, 650 further responses were received. The response rate
R. Asplund, H.E. A, berg / Maturitas 35 (2000) 143–148
was thus 61.2% and decreased to some extent with increasing age. In the whole group, poor health was reported by 10.4%. The proportion of women who had experienced an unfavourable health development during the last 5 years was 24.1%.
3.2. Age and menopausal status, parity and hormone replacement therapy Both the percentage of women reporting poor health and the percentage reporting an unfavourable health development increased with every 5-year age group (Fig. 1). Of the whole group, 6.6% reported poor health, and of the premenopausal women 19.6% reported an unfavourable health development. The frequencies of both poor health and an unfavourable health development increased during the first 5 years after the menopause in comparison with the premenopausal frequencies, and there was a further increase in the following 5-year periods. The women had given birth to 2.3 91.1 (mean 9SD) children. HRT was being used by 18.1% of the healthy women and 25.4%, of the women in poor health (P B0.001). The corresponding frequencies in women without and with an unfavourable health development were 17.2 and 24.6%, respectively (P B 0.0001). Of the women with no nocturnal micturition, 13.1% were
145
receiving HRT, and the corresponding frequencies in women with one, two, and three or more nocturnal voiding episodes were 21.3, 23.5 and 27.6%, respectively (PB 0.0001).
3.3. Nocturnal micturition The number of nocturnal micturitions increased with age. No nocturnal micturition was reported by 32.9% of the women and one, two and three or more episodes by 52.4, 10.8 and 3.9%, respectively. Among premenopausal women no nocturnal micturition was reported by 43.9%, and one, two and three or more episodes by 46.9, 7.3 and 2.0%, respectively. The corresponding frequencies among women during the first 5 years after the menopause were 25.9, 58.7, 10.8 and 4.6%, respectively. In the groups of women 5–9 years and ] 10 years after the menopause there was no further change in this frequency distribution. Poor health was reported by 4.7% of the women without nocturnal micturition, and by 11.2, 20.1 and 39.0% (PB0.0001) of the women with one, two, and three or more nocturnal voiding episodes, respectively. The number of such episodes showed no relation to parity.
3.4. Heart diseases and diabetes Of the total group of women, 1.6% suffered from spasmodic chest pain, 8.2% from irregular heart beats and 2.3% from diabetes. The frequency of both cardiac diseases and diabetes increased with age (Table 1). Poor health was 13.5 (7.5–23.8) times more commonly reported by women with spasmodic chest pain. The corresponding figure for irregular heart beats was 3.3 (2.4–4.4) times and for diabetes 8.3 (5.3–13.2) times.
3.5. Snoring
Fig. 1. The occurrence of poor health and an unfavourable health development in relation to age.
Of the total group of women, 57.7% were never troubled by snoring, 24.1% reported that they snored 5 3 nights per week and 18.2% snored 4–7 nights per week. Snoring increased with age, and also increased during the menopausal transition and with each following five-year period.
R. Asplund, H.E. A, berg / Maturitas 35 (2000) 143–148
146
Table 1 Odds ratios (OR) and 95% confidence intervals (CI 95%) for variables included in the logistic model with poor health as the dependent variable OR
CI 95%
Nocturnal 6oiding episodes. No micturition =1.0 One 2.1 Two 2.8 Three or more 4.8
1.4–3.2 1.6–4.7 2.4–9.3
Spasmodic chest pain. No =1.0 Yes 5.1
2.2–11.6
Irregular heart beats. No =1.0 Yes
2.9
2.0–4.3
Diabetes. No =1.0 Yes
4.5
23–8.7
Leg oedema. No 1.0 Yes
2.3
1.6–3.3
Snoring. Ne6er 1.0 53 Times/week 4–7 Times/week
1.4 1.5
1.0–2.0 1.0–2.1
Years after the menopause. Before the menopause =1.0 B5 Years after 1.5 0.9–2.4 5–9 Years after 1.6 1.0–2.8 ]10 Years after 2.1 1.2–3.8 Diuretic therapy. No =1.0 Yes
2.8
1.7–4.6
Snoring 4–7 nights per week was reported by 12.7% of the women without nocturnal micturition, and by 20.4, 31.4 and 34.0% (P B0.0001) of those reporting one, two, or three or more nocturnal voiding episodes, respectively.
3.6. Leg oedema and diuretic treatment Oedema in the legs 6 days per month was reported by 11.4% of the women. Such oedema was reported by 7.2% of the women without nocturnal micturition, and by 11.8, 26.8 and 33.0% (P B 0.0001) of the women with one, two, and three or more nocturnal voiding episodes, respectively. Treatment with diuretics was reported by 4.3% of the women. Of the women with no nocturnal micturition, 1.2% were receiving such treatment, and the corresponding frequencies among women with one, two, and three or more nocturnal voiding episodes were 4.5, 11.9 and 18.1% (P B 0.0001), respectively.
3.7. Logistic regression analysis The logistic regression analysis included health as the dependent variable and the number of nocturnal micturitions, age, menopausal status, spasmodic chest pain, irregular heart beats, diabetes, leg oedema, snoring, diuretics, and HRT as explanatory variables. The analyses revealed that the occurrence of nocturnal micturition was associated with poorer health, and increasing numbers of nocturnal micturitions were associated with increasingly negative reports on health (Table 1). Age and HRT were deleted by the logistic model. The reported health was poorer after the menopause than before, but was not age-related. Spasmodic chest pain, irregular heart beats and diabetes all affected the perceived health. Health was also worse among women who suffered from leg oedema and in those on diuretics. Snoring was associated with an increase in poor health, while the frequency of snoring showed no relation to health. Health was not influenced by the use of HRT.
4. Discussion In many women the years around the menopause are characterised by a deterioration of health [1]. In the present study it was found that both the perceived health and the perceived health development during the last 5 years deteriorated with increasing age (Fig. 1). The most striking finding, however, was the worsening of health in women with nocturia. Poor health was eight times more common in women with three or more nocturnal voiding episodes than in women with no such episodes. There are several possible explanations for this result. It is well known that the number of nocturnal voiding episodes increases with age [8], and that there is an age-related decrease in general health and an age-related increase in many symptoms [1,9–11]. During the years of the menopause health is affected by an increase in sexual problems and vasomotor symptoms such as hot flushes and sweating [12]. There have also been reports on an age-related increase in urogenital diseases
R. Asplund, H.E. A, berg / Maturitas 35 (2000) 143–148
and symptoms in women. Urgency of micturition increases with increasing age as a consequence of detrusor hyper-reactivity [13]. Such symptoms are the most common ones among women of ages around the menopause [1]. Of the urogenital symptoms, most attention has been paid to incontinence, on account of its common occurrence and its consequences for comfort, well-being and social functioning [14]. Frequent urinary urgency, especially at night, is also, however, a source of impaired health [9]. During the menopause, disturbances of micturition increase as a result of altered function of the distal urinary tract due to oestrogen deficiency [4]. We also observed in the present study that women in poor health and women who had experienced an unfavourable health development during the last 5 years were more often receiving HRT. HRT is more common in women with an increased number of nocturnal micturitions [2] Among persons with nocturia, a deterioration of health and of the quality of life has been reported in adult women and in elderly persons of both sexes [2,8,9,15]. Many persons suffer from somatic diseases and symptoms that may lead to nocturia, among other consequences, and hence may serve as confounders in the studies of nocturia and health. For example, nocturia is a common symptom in persons suffering from cardiac diseases, diabetes, disorders of breathing during sleep, and leg oedema with or without diuretic treatment [5–7,16,17]. The occurrence of nocturnal micturition was associated with an increase in the frequency of poor health, even after all other explanatory factors had been taken into account (Table 1). There was also a stepwise increase in negatively perceived health with increasing number of nocturnal voiding episodes, with a fivefold increase in reports on poor health among women with three or more such episodes. The presence of spasmodic chest pain, irregular heart beats, diabetes, leg oedema, diuretic therapy and snoring also represented sources of health deterioration, a finding in accordance with reports from other studies [5 – 7]. The multivariate analysis also revealed that health underwent a deterioration during the menopausal transition and that this deterioration
147
increased with the number of years after the menopause, in contrast to the findings of Hunter [3]. The occurrence of snoring was also associated with an increased frequency of poor health. This result is in conformity with earlier reports on an increased occurrence of serious diseases among snorers [18,19]. The frequency of snoring was higher in most age groups in our study than in a study of 40- to 59-year-old women in Iceland (11.2% habitual snoring and 21.7% intermittent snoring) [20]. The different frequency figures may be explained by differences in the formulation of the questions and in age differences between the two studies. Breathing disorders during sleep in women seldom occur before the menopause, whereas in postmenopausal women the prevalence and severity of such disorders approach those found in men [16]. One surprising finding was that the number of nocturnal voiding episodes was unaffected by parity. It is known that incontinence in women increases with the number of childbirths [8]. The absence of an increase in nocturia in women of the present study after several childbirths may support the view that nocturia can also be caused by other factors than disturbances in the distal urinary tract [9,10,21,22]. A shift in the urinary output throughout the 24-h period may be such an explanation for the increase in nocturnal voidings [21]. This may also explain the previous finding of a very slight increase in the total number of diurnal voiding episodes in adult women, but a substantial increase in nocturnal voiding episodes [8]. To summarise., an increased frequency of nocturnal micturition is a common problem in women of ages 40–64 years. The perceived state of health is profoundly affected by nocturia, independently of heart diseases, diabetes, age and menopausal status (Table 1). To the best of our knowledge, this has not been reported before. References [1] losif CS, Becassy Z. Prevalence of genito-urinary symptoms in the late menopause. Acta Obstet Gynecol Scand 1984;63:257 – 60.
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[2] Asplund R, Aberg H. Nocturnal micturition, sleep and well being in women of ages 40–64 years. Maturitas 1996;24:73 – 81. [3] Hunter M. The south-east England longitudinal study of the climacteric and postmenopause. Maturitas 1992;14:117 – 26. [4] Balfour JA, Heel RC. Transdermal estradiol. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic efficacy in the treatment of menopausal complaints. Drugs 1990;40:561–82. [5] Baggio E, Gandini R1 Plancher AC, Passed M, Carmosino G. Italian multicenter study on the safety and efficacy of coenzyme Q10 as adjunctive therapy in heart failure. CoQ10 Drug Surveillance Investigators. Mol Aspects Med 1994;15 (Suppl):S287–94. [6] Bulpitt Q, Palmer AJ, Battersby C, Fletcher AE. Association of symptoms of type 2 diabetic patients with severity of disease, obesity, and blood pressure. Diabetes Care 1998;21:111 – 5. [7] Baruzzi A, Riva R, Cirgnotta F, Zucconi M, Capelli M, Lugaresi E. Atrial natriuretic peptide and catecholamines in obstructive sleep apnea syndrome. Sleep 1991;14:83. [8] Sommer P, Bauer T, Nielsen KK, Kristensen ES, Hermann CC, Steven K, Nordling J. Voiding patterns and prevalence of incontinence in women. A questionnaire survey. Br J Urol 1990;66:12–5. [9] Asplund R, A, berg H. Health of the elderly with regard to sleep and nocturnal micturition. Scand J Prim Health Care 1992;10:98 – 104. [10] Asplund R, A, berg H. Diurnal variation in the levels of antidiuretic hormone in the elderly. J Int Med 1991;229:131 – 4. [11] Stanbury SW, Thomas AE. Diurnal variations in electrolyte excretion. Clin Sci Mol Med 1951;10:267–93.
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[12] Hunter M, Battersby R, Whitehead M. Relationships between psychological symptoms, somatic complaints and menopausal status. Maturitas 1986;8:217 – 28. [13] Thuroff JW, Chartier Kastler EJ, Hurnke J, Jonas U, Palmtag H, Tanagho EA. Medical treatment and medical side effects in urinary incontinence in the elderly. World J Urol 1998;16:S48 – 61. [14] Parulkar BG, Barrett DM. Urinary incontinence in adults. Surg Clin North Am 1988;68:945 – 63. [15] Epstein SR, Deverka PA, Chute CC, Lieber NIM, Oesterling IE, Panser L, et al. Urinary symptoms and quality of life questions indicative of obstructive benign prostatic hyperplasia. Result of a pilot study. Urology 1991;38:S20 – 6. [16] Bloch AJ, Wynne JAY, Boysen PC. Sleep disordered breathing and nocturnal oxygen desaturation in postmenopausal women. Am J Med 1980;69:75 – 9. [17] Reynard J. Fluid balance therapy of nocturia in women. Int Urogynecol J Pelvic Floor Dysfunct 1999;10(1):43 – 8. [18] Partinen M, Palomaki H. Snoring and cerebral infarction. Lancet 1985;ii:1325 – 1326. [19] D’Alessandro R, Magnelli C, Gamberini Q, Baccelli S, Cristina E, Magnani B, et al. Snoring every night as a risk factor for myocardial infarction: a case-control study. Br Med J 1990;300:1557– 8. [20] Gislason T, Benediktsdottir B, Bjornsson JK, Kjartansson Q, Kjeld M, Kristbiamarson H. Snoring, hypertension, and the sleep apnea syndrome. An epidemiologic survey of middle-aged women. Chest 1993;103:1147– 51. [21] Asplund R, A, berg H. Micturition habits of older people. Voiding frequency and urine volumes. Scand J Urol Nephrol 1992;26:345 – 9. [22] Asplund R, Aberg H. Diurnal rhythm of antidiuretic hormone in elderly subjects with nocturia. Med Sci Res 1991;19:765 – 6.
Nocturia and health in women aged 40–64 years Ragnar Asplund a,b,*, Hans Edvard A, berg b b
a Family Medicine Stockholm, Karolinska Institutet, SE-141 57 Huddinge, Stockholm, Sweden Center for studies in Health and Quality of Life (CSL), Mid Sweden Uni6ersity, SE-831 25, O8 stersund, Sweden
Received 17 June 1999; accepted 17 February 2000
Abstract To analyse the relationship between nocturnal micturition and health in 40- to 64-year-old women. A questionnaire study was carried out in 3669 randomly selected women (out of 6000 invited) in the County of Ja¨mtland, Sweden. Questions were asked about the general health status of health, health development during the last 5 years, nocturnal micturition, parity, menstrual status, menopausal symptoms, hormone replacement therapy, cardiac diseases, diabetes and snoring. Poor health was reported by 10.4%. In 24.1% of the women health development had been unfavourable in the last 5 years. Poor health was reported by 4.7% of women without nocturnal micturition, and by 11.2, 20.1 and 39.0% (PB0.0001) of women with one, two, and three or more nocturnal voiding episodes, respectively. In a multiple logistic regression analysis significant independent correlates of health were: one versus no nocturnal micturitions (odds ratio [OR] 2.2; confidence interval [CI] 1.5–3.3), two versus none (OR 3.2; 1.9 – 5.3), and three or more versus none (OR 6.5; 3.5–11.9), spasmodic chest pain (OR 6.6; CI 3.0 – 14.5), irregular heart beats (OR 3.0; CI 2.1 – 4.3), diabetes (OR 5.1; CI 2.8–9.4), leg oedema ]6 days/month versus B 6 days/month (OR 23; CI 1.6 – 3.3), snoring:53 times/week versus never (OR 1.4; CI 1.0–2.0), snoring 4 – 7 times/week versus never (OR 1.6; CI 1.1 – 2.2), beingB5 years after versus being before the menopause (OR 1.6; 95% CI 1.0 – 2.5), 5 – 9 years after versus before the menopause (OR 1.7; CI 1.0–2.9), ]10 years after versus before the menopause (OR 2.2; CI 1.3 – 3.7), diuretic treatment (OR 2.8; CI 1.7–4.6). The perceived state of health in 40- to 64- year-old women is profoundly affected by nocturia, independently of heart diseases, diabetes, snoring, age and menopausal status. © 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Health; Hormone replacement therapy; Menopause; Nocturia; Parity; Snoring; Woman
1. Introduction
* Corresponding author. Present address: Tallva¨gen 3, S-833 34 Stro¨msund, Sweden. Tel.: + 46-670-10007; fax: + 46-63165626. E-mail address: [email protected] (R. Asplund)
Urogenital diseases and symptoms are common in adult women. The frequency of urogenital symptoms is increasing at ages around the menopause [1]. In an earlier study of women aged 40–64 years we found that frequent nocturnal micturition was
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associated with poor sleep, daytime sleepiness and impaired well-being [2]. With increasing numbers of nocturnal voiding episodes the women were also more prone to experience poor appetite, unhappiness and lack of confidence in the future [2]. In addition they paid more visits to doctors and received more medical treatment. The number of days on the sick list was five times higher in women with three or more voiding episodes than in those without nocturnal voiding [2]. Besides nocturia, there is an increase in the frequency of several symptoms, such as vasomotor symptoms, sleep disturbances and, to some extent, depression during the peri- and postmenopausal period [3]. The increased occurrence of nocturia in women at perimenopausal ages may be partly due to atrophy of the genital mucosal membranes due to oestrogen deficiency [4]. Nocturia may also occur in association with cardiac diseases, diabetes or snoring [5–7]. The relationship between nocturia and health may therefore reflect the impact of certain somatic diseases, rather than a connection between nocturnal micturition per se and health. The mechanism of the negative influence of nocturia on health is obscure. We considered it important to elucidate the question of whether this relationship could be attributed to some disease, or whether the increase in reports on health deterioration in women with nocturia could be reflect an age-related or menopause-related phenomenon, or whether both nocturia and poor health could be attributable to certain somatic diseases or symptoms, such as cardiovascular diseases, diabetes or snoring. The present study was therefore undertaken to investigate the nature of the previously observed relationship between nocturia and health among 40- to 64-year-old women [2].
1200 women in every 5-year age interval received a questionnaire during the first 3 months of 1993. One more questionnaire was sent to those who did not respond within 1 month. In relation to information obtained in this way on health, two statements were analysed: ‘I am essentially healthy’, with the alternative answers ‘yes’ or ‘no’ (y/n), referred to in the following as ‘health’, and ‘My health is poorer than 5 years ago’ (y/n), referred to in the following as ‘health development’. The questionnaire included a question on the number of nocturnal voiding episodes. If the number was reported as an interval, e.g. 0–1, 1–2 etc., the woman was allocated to the group with the lower number. There were also two statements on heart diseases, namely ‘I suffer from spasmodic chest pain’ (y/n), and ‘I suffer from irregular heart beats’ (y/n) and a statement ‘I suffer from diabetes’ (y/n). Snoring was reported as ‘never’, ‘no more than three times a week’ or ‘four or more times a week’. Leg oedema (six or more days per month) and treatment with diuretics (y/n) were reported. There were also questions on the menopausal status, menopausal symptoms, and hormone replacement therapy (HRT). The questionnaire was approved by the committee on ethics of the Faculty of Medicine, University of Umea˚, Sweden.
2. Material and methods
3. Results
The study was carried out in the County of Ja¨mtland in northern Sweden, a county which at the beginning of 1993 had a total population of 135 910. There were 19 639 women of ages 40 – 64 years. Of these, a stratified, random selection of
3.1. General results
2.1. Statistical methods Standard methods were used for calculating mean values and standard deviations (SD). Group comparisons of non-numerical data were made with the x 2-test. For simultaneous evaluation of the influence of more than one independent variable on health, logistic regression analysis (StatView 5.0 for Macintosh) was performed.
The questionnaire was initially answered by 3019 of the 6000 women. After a reminder, 650 further responses were received. The response rate
R. Asplund, H.E. A, berg / Maturitas 35 (2000) 143–148
was thus 61.2% and decreased to some extent with increasing age. In the whole group, poor health was reported by 10.4%. The proportion of women who had experienced an unfavourable health development during the last 5 years was 24.1%.
3.2. Age and menopausal status, parity and hormone replacement therapy Both the percentage of women reporting poor health and the percentage reporting an unfavourable health development increased with every 5-year age group (Fig. 1). Of the whole group, 6.6% reported poor health, and of the premenopausal women 19.6% reported an unfavourable health development. The frequencies of both poor health and an unfavourable health development increased during the first 5 years after the menopause in comparison with the premenopausal frequencies, and there was a further increase in the following 5-year periods. The women had given birth to 2.3 91.1 (mean 9SD) children. HRT was being used by 18.1% of the healthy women and 25.4%, of the women in poor health (P B0.001). The corresponding frequencies in women without and with an unfavourable health development were 17.2 and 24.6%, respectively (P B 0.0001). Of the women with no nocturnal micturition, 13.1% were
145
receiving HRT, and the corresponding frequencies in women with one, two, and three or more nocturnal voiding episodes were 21.3, 23.5 and 27.6%, respectively (PB 0.0001).
3.3. Nocturnal micturition The number of nocturnal micturitions increased with age. No nocturnal micturition was reported by 32.9% of the women and one, two and three or more episodes by 52.4, 10.8 and 3.9%, respectively. Among premenopausal women no nocturnal micturition was reported by 43.9%, and one, two and three or more episodes by 46.9, 7.3 and 2.0%, respectively. The corresponding frequencies among women during the first 5 years after the menopause were 25.9, 58.7, 10.8 and 4.6%, respectively. In the groups of women 5–9 years and ] 10 years after the menopause there was no further change in this frequency distribution. Poor health was reported by 4.7% of the women without nocturnal micturition, and by 11.2, 20.1 and 39.0% (PB0.0001) of the women with one, two, and three or more nocturnal voiding episodes, respectively. The number of such episodes showed no relation to parity.
3.4. Heart diseases and diabetes Of the total group of women, 1.6% suffered from spasmodic chest pain, 8.2% from irregular heart beats and 2.3% from diabetes. The frequency of both cardiac diseases and diabetes increased with age (Table 1). Poor health was 13.5 (7.5–23.8) times more commonly reported by women with spasmodic chest pain. The corresponding figure for irregular heart beats was 3.3 (2.4–4.4) times and for diabetes 8.3 (5.3–13.2) times.
3.5. Snoring
Fig. 1. The occurrence of poor health and an unfavourable health development in relation to age.
Of the total group of women, 57.7% were never troubled by snoring, 24.1% reported that they snored 5 3 nights per week and 18.2% snored 4–7 nights per week. Snoring increased with age, and also increased during the menopausal transition and with each following five-year period.
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146
Table 1 Odds ratios (OR) and 95% confidence intervals (CI 95%) for variables included in the logistic model with poor health as the dependent variable OR
CI 95%
Nocturnal 6oiding episodes. No micturition =1.0 One 2.1 Two 2.8 Three or more 4.8
1.4–3.2 1.6–4.7 2.4–9.3
Spasmodic chest pain. No =1.0 Yes 5.1
2.2–11.6
Irregular heart beats. No =1.0 Yes
2.9
2.0–4.3
Diabetes. No =1.0 Yes
4.5
23–8.7
Leg oedema. No 1.0 Yes
2.3
1.6–3.3
Snoring. Ne6er 1.0 53 Times/week 4–7 Times/week
1.4 1.5
1.0–2.0 1.0–2.1
Years after the menopause. Before the menopause =1.0 B5 Years after 1.5 0.9–2.4 5–9 Years after 1.6 1.0–2.8 ]10 Years after 2.1 1.2–3.8 Diuretic therapy. No =1.0 Yes
2.8
1.7–4.6
Snoring 4–7 nights per week was reported by 12.7% of the women without nocturnal micturition, and by 20.4, 31.4 and 34.0% (P B0.0001) of those reporting one, two, or three or more nocturnal voiding episodes, respectively.
3.6. Leg oedema and diuretic treatment Oedema in the legs 6 days per month was reported by 11.4% of the women. Such oedema was reported by 7.2% of the women without nocturnal micturition, and by 11.8, 26.8 and 33.0% (P B 0.0001) of the women with one, two, and three or more nocturnal voiding episodes, respectively. Treatment with diuretics was reported by 4.3% of the women. Of the women with no nocturnal micturition, 1.2% were receiving such treatment, and the corresponding frequencies among women with one, two, and three or more nocturnal voiding episodes were 4.5, 11.9 and 18.1% (P B 0.0001), respectively.
3.7. Logistic regression analysis The logistic regression analysis included health as the dependent variable and the number of nocturnal micturitions, age, menopausal status, spasmodic chest pain, irregular heart beats, diabetes, leg oedema, snoring, diuretics, and HRT as explanatory variables. The analyses revealed that the occurrence of nocturnal micturition was associated with poorer health, and increasing numbers of nocturnal micturitions were associated with increasingly negative reports on health (Table 1). Age and HRT were deleted by the logistic model. The reported health was poorer after the menopause than before, but was not age-related. Spasmodic chest pain, irregular heart beats and diabetes all affected the perceived health. Health was also worse among women who suffered from leg oedema and in those on diuretics. Snoring was associated with an increase in poor health, while the frequency of snoring showed no relation to health. Health was not influenced by the use of HRT.
4. Discussion In many women the years around the menopause are characterised by a deterioration of health [1]. In the present study it was found that both the perceived health and the perceived health development during the last 5 years deteriorated with increasing age (Fig. 1). The most striking finding, however, was the worsening of health in women with nocturia. Poor health was eight times more common in women with three or more nocturnal voiding episodes than in women with no such episodes. There are several possible explanations for this result. It is well known that the number of nocturnal voiding episodes increases with age [8], and that there is an age-related decrease in general health and an age-related increase in many symptoms [1,9–11]. During the years of the menopause health is affected by an increase in sexual problems and vasomotor symptoms such as hot flushes and sweating [12]. There have also been reports on an age-related increase in urogenital diseases
R. Asplund, H.E. A, berg / Maturitas 35 (2000) 143–148
and symptoms in women. Urgency of micturition increases with increasing age as a consequence of detrusor hyper-reactivity [13]. Such symptoms are the most common ones among women of ages around the menopause [1]. Of the urogenital symptoms, most attention has been paid to incontinence, on account of its common occurrence and its consequences for comfort, well-being and social functioning [14]. Frequent urinary urgency, especially at night, is also, however, a source of impaired health [9]. During the menopause, disturbances of micturition increase as a result of altered function of the distal urinary tract due to oestrogen deficiency [4]. We also observed in the present study that women in poor health and women who had experienced an unfavourable health development during the last 5 years were more often receiving HRT. HRT is more common in women with an increased number of nocturnal micturitions [2] Among persons with nocturia, a deterioration of health and of the quality of life has been reported in adult women and in elderly persons of both sexes [2,8,9,15]. Many persons suffer from somatic diseases and symptoms that may lead to nocturia, among other consequences, and hence may serve as confounders in the studies of nocturia and health. For example, nocturia is a common symptom in persons suffering from cardiac diseases, diabetes, disorders of breathing during sleep, and leg oedema with or without diuretic treatment [5–7,16,17]. The occurrence of nocturnal micturition was associated with an increase in the frequency of poor health, even after all other explanatory factors had been taken into account (Table 1). There was also a stepwise increase in negatively perceived health with increasing number of nocturnal voiding episodes, with a fivefold increase in reports on poor health among women with three or more such episodes. The presence of spasmodic chest pain, irregular heart beats, diabetes, leg oedema, diuretic therapy and snoring also represented sources of health deterioration, a finding in accordance with reports from other studies [5 – 7]. The multivariate analysis also revealed that health underwent a deterioration during the menopausal transition and that this deterioration
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increased with the number of years after the menopause, in contrast to the findings of Hunter [3]. The occurrence of snoring was also associated with an increased frequency of poor health. This result is in conformity with earlier reports on an increased occurrence of serious diseases among snorers [18,19]. The frequency of snoring was higher in most age groups in our study than in a study of 40- to 59-year-old women in Iceland (11.2% habitual snoring and 21.7% intermittent snoring) [20]. The different frequency figures may be explained by differences in the formulation of the questions and in age differences between the two studies. Breathing disorders during sleep in women seldom occur before the menopause, whereas in postmenopausal women the prevalence and severity of such disorders approach those found in men [16]. One surprising finding was that the number of nocturnal voiding episodes was unaffected by parity. It is known that incontinence in women increases with the number of childbirths [8]. The absence of an increase in nocturia in women of the present study after several childbirths may support the view that nocturia can also be caused by other factors than disturbances in the distal urinary tract [9,10,21,22]. A shift in the urinary output throughout the 24-h period may be such an explanation for the increase in nocturnal voidings [21]. This may also explain the previous finding of a very slight increase in the total number of diurnal voiding episodes in adult women, but a substantial increase in nocturnal voiding episodes [8]. To summarise., an increased frequency of nocturnal micturition is a common problem in women of ages 40–64 years. The perceived state of health is profoundly affected by nocturia, independently of heart diseases, diabetes, age and menopausal status (Table 1). To the best of our knowledge, this has not been reported before. References [1] losif CS, Becassy Z. Prevalence of genito-urinary symptoms in the late menopause. Acta Obstet Gynecol Scand 1984;63:257 – 60.
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