The association of menopause with cardiometabolic disease risk factors in women living with and without HIV in sub-Saharan Africa: Results from the AWI-Gen 1 study.

BACKGROUND: Menopause and HIV are associated with cardiometabolic disease. In sub-Saharan Africa there is a growing population of midlife women living with HIV and a high prevalence of cardiometabolic disease. OBJECTIVES: The aim of this study was to determine whether menopause and HIV were associated with cardiometabolic disease risk factors in a population of midlife sub-Saharan African women. STUDY DESIGN: This was a cross-sectional comparison of cardiometabolic disease risk factors between 944 premenopausal women (733 living without HIV and 211 living with HIV) and 1135 postmenopausal women (932 living without HIV and 203 living with HIV) in sub-Saharan Africa. MAIN OUTCOME MEASURES: Anthropometric and cardiometabolic variables were compared between pre- and postmenopausal women living without HIV and between pre- and postmenopausal women living with HIV and between women living without HIV and women living with HIV. RESULTS: The prevalence of HIV was 19.9 %. Age at menopause was lower in women living with HIV than in women living without HIV (48.1 ± 5.1 vs 50.9 ± 4.7 years, p < 0.001). Women living with HIV and receiving efavirenz-based antiretroviral therapy had a lower body mass index (BMI), hip circumference, blood pressure and carotid intima media thickness but higher triglyceride levels and insulin resistance than women living without HIV. Antiretroviral therapy-naïve women living with HIV had lower HDL-cholesterol than women living without HIV. In this study, menopause was associated with higher LDL-C levels, regardless of HIV status. CONCLUSION: The high prevalence of obesity and related cardiometabolic disease risk factors in these midlife sub-Saharan African women is not related to the menopausal transition. The association of cardiometabolic disease risk factors with HIV and antiretroviral therapy is complex and requires further investigation in longitudinal studies, as does the negative association of age at final menstrual period with HIV.

Menopause and brain fog: how to counsel and treat midlife women.

Brain fog, referring to menopause-related subjective cognitive difficulties, is common in midlife women. Longitudinal studies find small but reliable declines in objective memory performance as women transition into perimenopause, and these are not explained by advancing age alone. When memory declines occur, performance levels remain within normal limits for all but a very small number of women. Women's experience of brain fog extends beyond memory complaints, reflecting the negative effect on a broad range of cognitive abilities. Clinicians can counsel women about how menopause symptoms, estrogen, hormone therapy, and modifiable risk factors (eg, hypertension, sedentary lifestyle) can influence cognitive health.

Recommended measurement instruments for menopausal vasomotor symptoms: the COMMA (Core Outcomes in Menopause) consortium.

OBJECTIVE: The aim of the study is to identify suitable definitions and patient-reported outcome measures (PROMs) to assess each of the six core outcomes previously identified through the COMMA (Core Outcomes in Menopause) global consensus process relating to vasomotor symptoms: frequency, severity, distress/bother/interference, impact on sleep, satisfaction with treatment, and side effects. METHODS: A systematic review was conducted to identify relevant definitions for the outcome of side-effects and PROMs with acceptable measurement properties for the remaining five core outcomes. The consensus process, involving 36 participants from 16 countries, was conducted to review definitions and PROMs and make final recommendations for the measurement of each core outcome. RESULTS: A total of 21,207 publications were screened from which 119 reporting on 40 PROMs were identified. Of these 40 PROMs, 36 either did not adequately map onto the core outcomes or lacked sufficient measurement properties. Therefore, only four PROMs corresponding to two of the six core outcomes were considered for recommendation. We recommend the Hot Flash Related Daily Interference Scale to measure the domain of distress, bother, or interference of vasomotor symptoms and to capture impact on sleep (one item in the Hot Flash Related Daily Interference Scale captures interference with sleep). Six definitions of "side effects" were identified and considered. We recommend that all trials report adverse events, which is a requirement of Good Clinical Practice. CONCLUSIONS: We identified suitable definitions and PROMs for only three of the six core outcomes. No suitable PROMs were found for the remaining three outcomes (frequency and severity of vasomotor symptoms and satisfaction with treatment). Future studies should develop and validate PROMs for these outcomes.

The association of menopause with cardiometabolic disease risk factors in low- and middle-income countries: a systematic review and meta-analyses.

IMPORTANCE: Menopause is an integral part of women's health, and studies in high-income countries have shown an increase in cardiometabolic disease (CMD) risk factors in postmenopausal compared with premenopausal women. However, to date, no study has combined and assessed such studies across low- and middle-income countries. This would better inform early monitoring and intervention strategies for reducing CMD risk factor levels in midlife women in these regions. OBJECTIVE: This study aimed to evaluate evidence from the literature on differences in CMD risk factors between premenopausal and postmenopausal midlife women living in low- and middle-income countries. EVIDENCE REVIEW: A systematic review with meta-analysis of original articles of all study designs from the databases PubMed, PubMed Central, Scopus, and ISI Web of Science was conducted from conception until April 24, 2023. Studies that met the inclusion criteria were included in the analysis. Quality assessment of the articles was done using the Newcastle-Ottawa Scale, adapted for each study design. The study protocol was registered with the International Prospective Register of Systematic Reviews and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. For the meta-analysis, fixed-effects models were used to pool the odds ratios (OR), as measures of association. FINDINGS: Our search identified 4,849 relevant articles: 44 for the systematic review and 16 for the meta-analysis, in accordance with our inclusion criteria. Compared with premenopausal women, the postmenopausal stage was associated with metabolic syndrome (OR, 1.18 [95% CI, 1.11-1.27]), high waist-to-hip ratio (OR, 1.22 [95% CI, 1.12-1.32]), hypertension (OR, 1.10 [95% CI, 1.04-1.16]), elevated triglycerides (OR, 1.16 [95% CI, 1.11-1.21]), and elevated plasma glucose (OR, 1.21 [95% CI, 1.15-1.28]). CONCLUSIONS AND RELEVANCE: This study confirmed that CMD risk factors are present at higher levels in postmenopausal than premenopausal women. This demonstrates an urgent need for public health policies that focus on early monitoring and interventions targeted at reducing CMD risk and related adverse outcomes in midlife women in these nations.

Cardiometabolic disease risk factors in pre- and postmenopausal women from four sub-Saharan African countries: A cross-sectional study.

OBJECTIVE: To compare the risk factors for cardiometabolic disease between pre- and postmenopausal women from four sub-Saharan African countries. STUDY DESIGN: This cross-sectional study included 3609 women (1740 premenopausal and 1869 postmenopausal) from sites in Ghana (Navrongo), Burkina Faso (Nanoro), Kenya (Nairobi), and South Africa (Soweto and Dikgale). Demographic, anthropometric and cardiometabolic variables were compared between pre- and postmenopausal women, within and across sites using multivariable regression analyses. The sites represent populations at different stages of the health transition, with those in Ghana and Burkina Faso being rural, whilst those in Kenya and South Africa are more urbanised. MAIN OUTCOME MEASURES: Anthropometric and cardiometabolic variables. RESULTS: The prevalence rates of risk factors for cardiometabolic disease were higher in South (Soweto and Dikgale) and East (Nairobi) Africa than in West Africa (Nanoro and Navrongo), irrespective of menopausal status. Regression models in combined West African populations demonstrated that postmenopausal women had a larger waist circumference (ß = 1.28 (95 % CI: 0.58; 1.98) cm), log subcutaneous fat (ß =0.15 (0.10; 0.19)), diastolic (ß = 3.04 (1.47; 4.62) mm Hg) and log systolic (ß = 0.04 (0.02; 0.06)) blood pressure, log carotid intima media thickness (ß = 0.03 (0.01; 0.06)), low-density lipoprotein cholesterol (ß = 0.14 (0.04; 0.23) mmol/L) and log triglyceride (ß= 0.10 (0.04; 0.16)) levels than premenopausal women. No such differences were observed in the South and East African women. CONCLUSIONS: Menopause-related differences in risk factors for cardiometabolic disease were prominent in West but not East or South African study sites. These novel findings should inform cardiometabolic disease prevention strategies in midlife women specific to rural and urban and peri-urban locations in sub-Saharan Africa.

The Impact of Human Immunodeficiency Virus and Menopause on Bone Mineral Density: A Longitudinal Study of Urban-Dwelling South African Women.

An estimated 25% of South African women live with human immunodeficiency virus (HIV). Antiretroviral therapy roll-out has improved life expectancy, so many more women now reach menopause. We aimed to quantify changes in bone mineral density (BMD) during the menopausal transition in urban-dwelling South African women with and without HIV and determine whether HIV infection modified the effect of menopause on BMD changes. A 5-year population-based longitudinal study recruited women aged 40-60 years residing in Soweto and collected demographic and clinical data, including HIV status, anthropometry, and BMD, at baseline and at 5-year follow-up. All women were staged as pre-, peri-, or postmenopausal at both time points. Multivariable linear regression assessed relationships and interactions between HIV infection, menopause, and change in BMD. At baseline, 450 women had mean age 49.5 (SD 5.7) years, 65 (14.4%) had HIV, and 140 (31.1%), 119 (26.4%), and 191 (42.4%) were pre-, peri-, and postmenopausal, respectively; 34/205 (13.6%) women ≥50 years had a total hip (TH) or lumbar spine (LS) T-score ≤ -2.5. At follow-up 38 (8.4%), 84 (18.7%), and 328 (72.9%) were pre-, peri-, and postmenopausal. Those with HIV at baseline lost more total body (TB) BMD (mean difference -0.013 [95% confidence interval -0.026, -0.001] g/cm2 , p = 0.040) and gained more weight 1.96 [0.32, 3.60] kg; p = 0.019 than HIV-uninfected women. After adjusting for age, baseline weight, weight change, and follow-up time, the transition from pre- to postmenopause was associated with greater TB BMD losses in women with HIV (-0.092 [-0.042, -0.142] g/cm2 ; p = 0.001) than without HIV (-0.038 [-0.016, -0.060] g/cm2 , p = 0.001; interaction p = 0.034). Similarly, in women who were postmenopausal at both time points, those with HIV lost more TB BMD (-0.070 [-0.031, -0.108], p = 0.001) than women without HIV (-0.036 [-0.015, -0.057], p = 0.001, interaction p = 0.049). Findings were consistent but weaker at the LS and TH. Menopause-related bone loss is greater in women with HIV, suggesting women with HIV may be at greater risk of osteoporotic fractures. HIV services should consider routine bone health assessment in midlife women as part of long-term HIV care delivery. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Menopause is associated with bone loss, particularly at the distal radius, in black South African women: Findings from the Study of Women Entering and in Endocrine Transition (SWEET).

Menopause transition is associated with accelerated bone loss, though data are limited from sub-Saharan African (SSA). Our objective was to describe bone density, geometry and estimated strength in women by menopause status and to explore whether patterns differed within those living with HIV. METHODS: Radius and tibia peripheral QCT data were collected for Black South African women (n = 430) aged 40-61 years with verified menopause and HIV status. pQCT outcomes were distal 4 % radius and tibia total cross-sectional area (CSA), total volumetric bone mineral density (vBMD), and compressive bone strength (BSIc); proximal 66 % radius and 38 % tibia cortical vBMD, total CSA, cortical thickness, and Stress-strain Index (SSI). Linear regression assessed associations between pre, peri-, and postmenopausal groups and pQCT outcomes adjusting for age, height, and weight, and then stratified by HIV status. Mean [95%CI] and tests for trend (p-trend) across menopausal groups are presented. RESULTS: Women were mean (SD) age 49.2 (5.3) years, with a body mass index (BMI) of 32.4 (6.3) m/kg2, and 18 % were living with HIV. After adjustment, later menopause stage was associated with lower 4 % radius total mean [95%CIs] vBMD (premenopause: 345.7 [335.8,355.5] vs. postmenopause: 330.1 [322.7,337.6] mg/cm3, p-trend = 0.017) and BSIc (premenopause: 0.39 [0.37,0.41] vs. postmenopause: 0.36 [0.35,0.37] g2/cm4; p-trend = 0.012). Similar trends were observed at the 66 % radius for cortical vBMD (premenopause: 1146.8 [1138.9,1154.6] vs. postmenopause: 1136.1 [1130.1,1142.0] mg/cm3; p-trend = 0.028) and cortical thickness (premenopause: 2.01 [1.95,2.06] vs. postmenopause: 1.93 [1.89,1.98] mm; p-trend = 0.036). After stratification by HIV status a similar patten was observed in women with HIV (cortical vBMD premenopause: 1152.9 [1128.5,1177.2] mg/cm3 vs. postmenopause: 1123.6 [1106.0,1141.2] mg/cm3, p-trend = 0.048). Total CSA varied little by menopause or HIV status at either radius sites; few differences were found at the tibia. CONCLUSION: In black South African women, menopause is associated with lower bone density and strength at the distal radius, a common site of osteoporotic fracture, in addition to lower cortical density and thickness at the proximal radius. Although the sample size was small, following stratification by HIV, women living with HIV had evidence of lower cortical density across menopause stages, unlike those without HIV. These findings raise concern for the incidence of Colles' fractures in postmenopausal women in South Africa; longitudinal studies of fracture incidence and implications of living with HIV are required.

The negative association of lower body fat mass with cardiometabolic disease risk factors is partially mediated by adiponectin.

Gluteofemoral fat correlates negatively with a number of cardiometabolic disease risk factors, but the mechanisms involved in these relationships are unknown. The aim of this study was to test the hypothesis that gluteofemoral fat attenuates the risk of cardiometabolic disease by increasing blood adiponectin levels. This was a cross-sectional study in which arm, leg, gluteofemoral, abdominal s.c. and visceral fat levels were measured by dual-energy X-ray absorptiometry in 648 African females. Fasting serum adiponectin, lipid, insulin and plasma glucose levels and blood pressure were measured. Relationships between variables were analysed using multivariable linear regression and structural equation modelling. Adiponectin correlated positively (ß = 0.45, P < 0.0001) with gluteofemoral fat in a multivariable regression model that included age, height, and arm, s.c. and visceral fat levels. In further regression models, there was a negative correlation of gluteofemoral fat with fasting glucose (ß = -0.28; P < 0.0001) and triglyceride levels (ß = -0.29; P < 0.0001) and insulin resistance (HOMA; ß = -0.26; P < 0.0001). Structural equation modelling demonstrated that adiponectin mediated 20.7% (P < 0.01) of the association of gluteofemoral fat with insulin resistance and 16.1% (P < 0.01) of the association with triglyceride levels but only 6.67% (P = 0.31) of the association with glucose levels. These results demonstrate that gluteofemoral and leg fat are positively associated with adiponectin levels and that the negative association of lower body fat with insulin resistance and triglyceride levels may partially be mediated by this adipokine. Further studies are required to determine other factors that mediate the effect of lower body fat on cardiometabolic disease risk factors.

The Association of Reproductive Aging with Cognitive Function in Sub-Saharan African Women.

Life expectancy in sub-Saharan African women is increasing, and by the late 2020s an estimated 76% of postmenopausal women globally will be living in developing countries. Menopause transition has been associated with cognitive decline in a wide range of studies, but data on cognition and reproductive aging are lacking in sub-Saharan African women. Approximately 72 million people in the region are expected to suffer from dementias and neurocognitive decline by 2050. Studies show that compromised cognitive health in low-income countries has significant implications for adult quality of life and socioeconomic development. There is now an urgent need to further examine risk factors for cognitive decline in these aging women and to understand the ability of public health programs to diagnose and treat cognitive dysfunction. This review examines studies assessing cognition and aging in sub-Saharan African adults, while addressing the significant research gaps. It examines data on the association of the menopause transition with cognitive function and describes how validated tools should be available to assess both menopausal stage and symptoms. Culturally appropriate and validated neurocognitive measures are required to better understand the relationship of reproductive aging with cognition. Longitudinal population-based studies are needed to assess the effect of lifestyle interventions, such as diet and exercise, on cognitive health in sub-Saharan African populations, with an emphasis on women as they transition into menopause.

Demographic, socio-economic and behavioural correlates of BMI in middle-aged black men and women from urban Johannesburg, South Africa.

BACKGROUND: There is a high and increasing prevalence of overweight and obesity in South Africans of all ages. Risk factors associated with overweight and obesity must be identified to provide targets for intervention. OBJECTIVE: To identify the demographic, socio-economic and behavioural factors associated with body mass index (BMI) in middle-aged black South African men and women. METHODS: Data on demographic and socio-economic factors were collected via questionnaire on 1027 men and 1008 women from Soweto Johannesburg, South Africa. Weight and height were measured and BMI was determined. Behavioural factors included tobacco use and consumption of alcohol, and physical activity data were collected using the Global Physical Activity Questionnaire. Menopausal status was determined for the women, and HIV status was available for 93.6% of the men and 39.9% of the women. RESULTS: Significantly more women were overweight or obese than men (87.9 vs. 44.9%). Smoking prevalence (current or former) and minutes spent in moderate to vigorous intensity physical activity was significantly different between the sexes (both p < 0.0001). In the final hierarchical model, marital status (+ married/cohabiting), household asset score (+), current smoking (-), moderate to vigorous physical activity (-) and HIV status (- HIV infected) significantly contributed to 26% of the variance in BMI in the men. In the women, home language (Tswana-speaking compared to Zulu-speaking), marital status (+ unmarried/cohabiting), education (-), current smoking (-) and HIV status (- HIV infected) significantly contributed to 14% of the variance in BMI. CONCLUSIONS: The sex difference in BMI and the prevalence of overweight and obesity between black South African men and women from Soweto, as well as the sex-specific associations with various demographic, socio-economic and behavioural factors, highlight the need for more tailored interventions to slow down the obesity epidemic.

Stress and midlife women's health.

Stress is ubiquitous in everyday life, and chronic stress can have negative consequences for health and social welfare. Although a growing body of research addresses the relationships between stress, health, and quality of life, there is a gap in the literature with regard to the effects of stress among women at midlife. The purpose of this commentary is to provide a brief history of stress research, including various methods for measuring stress; discuss the physiological effects of stress; and review relevant studies about women at midlife in order to identify unanswered questions about stress. This commentary also serves as an introduction to a thematic series on stress and women's midlife health where stress is examined in relation to a wide range of symptom experiences, in the context of family and negative life events, as associated with women's work, and correlated with the challenges of violence and discrimination. The goal of this commentary and thematic series is to extend the conversation about stress to include women at midlife, and to examine where we are, and where we are going, in order to direct future research and provide relevant care for this growing population.

Metabolic and Body Composition Risk Factors Associated with Metabolic Syndrome in a Cohort of Women with a High Prevalence of Cardiometabolic Disease.

BACKGROUND: The aetiology of the metabolic syndrome and the inter-relationship between risk factors for this syndrome are poorly understood. The purpose of this investigation was to determine the risk factors for metabolic syndrome and their interactions in a cohort of women with a high prevalence of metabolic syndrome. MATERIALS AND METHODS: Abdominal and whole body composition (ultrasound and dual-energy X-ray absorptiometry), blood pressure, and cardiometabolic and demographic factors were measured in a cross-sectional study of 702 black African women from Soweto, Johannesburg. Data was analysed using multivariate logistic regression. RESULTS: Metabolic syndrome was present in 49.6% of the study cohort. Logistic regression analysis demonstrated that adiponectin (odds ratio [95% CIs]: 0.84 [0.77, 0.92], p<0.0005) and abdominal subcutaneous fat (0.56 [0.39, 0.79], p = 0.001) reduced metabolic syndrome risk whilst insulin resistance (1.31 [1.16, 1.48], p<0.0005) and trunk fat-free soft-tissue mass (1.34 [1.10, 1.61], p = 0.002) increased risk. Within this group of risk factors, the relationship of adiponectin with metabolic syndrome risk, when analysed across adiponectin hexiles, was the least affected by adjustment for the other risk factors. CONCLUSIONS: Adiponectin has a significant protective role against metabolic syndrome and is independent of other risk factors. The protective and possible augmentive effects of abdominal subcutaneous fat and lean trunk mass, respectively on metabolic syndrome risk demonstrate the existence of novel interactions between body composition and cardiometabolic disease.

The Role of Body Fat and Fat Distribution in Hypertension Risk in Urban Black South African Women.

Developing countries are disproportionately affected by hypertension, with Black women being at greater risk, possibly due to differences in body fat distribution. The objectives of this study were: (1) To examine how different measures of body composition are associated with blood pressure (BP) and incident hypertension; (2) to determine the association between baseline or change in body composition, and hypertension; and (3) to determine which body composition measure best predicts hypertension in Black South African women. The sample comprised 478 non-hypertensive women, aged 29-53 years. Body fat and BP were assessed at baseline and 8.3 years later. Body composition was assessed using dual-energy X-ray absorptiometry (DXA) (n = 273) and anthropometry. Hypertension was diagnosed based on a systolic/diastolic BP ≥140/90 mmHg, or medication use at follow-up. All body composition measures increased (p<0.0001) between baseline and follow-up. SBP and DBP increased by ≥20%, resulting in a 57.1% cumulative incidence of hypertension. Both DXA- and anthropometric-derived measures of body composition were significantly associated with BP, explaining 3-5% of the variance. Baseline BP was the most important predictor of hypertension (adjusted OR: 98-123%). Measures of central adiposity were associated with greater odds (50-65%) of hypertension than total adiposity (44-45%). Only change in anthropometric-derived central fat mass predicted hypertension (adjusted OR: 32-40%). This study highlights that body composition is not a major determinant of hypertension in the sample of black African women. DXA measures of body composition do not add to hypertension prediction beyond anthropometry, which is especially relevant for African populations globally, taking into account the severely resource limited setting found in these communities.

Body composition in the Study of Women Entering and in Endocrine Transition (SWEET): A perspective of African women who have a high prevalence of obesity and HIV infection.

OBJECTIVES: Little data are available for sub-Saharan African women on changes in body composition in menopause transition (MT). The study aimed to determine whether there are differences in body adiposity, lean muscle mass, and bone mineral density (BMD) across MT groups in urban African women, who have a high prevalence of obesity and HIV infection, and if this is related to an altered hormonal milieu. DESIGN: Participants were 702 black urban women. Menopause stage was defined using STRAW+10 criteria. Levels of follicle stimulating hormone (FSH), estradiol (E2), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), testosterone (T) and sex hormone blinding globulin (SHBG) were measured. Body composition was measured with dual-energy X-ray absorptiometry (DXA) and ultrasound scans. RESULTS: Whole body lean mass (p=0.002) and BMD (p<0.0005) were significantly lower in postmenopausal compared to premenopausal groups. Estradiol (p<0.0005), SHBG (p<0.0005) and DHEAS (p=0007) were significantly lower in post- than premenopausal groups, while FSH was higher (p<0.0005). FSH correlated negatively (ß=-2.06, p<0.0005) with total lean mass while E2 correlated positively (ß=20.0, p=0.002) with BMD. Use of antiretroviral therapy (ART) correlated negatively with total fat mass (ß=-2.92, p=0.008) and total bone mineral content (BMC; ß=-78.8, p=0.003). CONCLUSIONS: The MT in this population is characterized by lower whole body lean mass and BMD in post- compared to premenopausal subjects but there are minimal differences in fat mass. Lower lean mass and BMD were associated with higher FSH and lower E2 serum levels, respectively. Use of ART was associated with lower fat mass and BMC.

Staging reproductive aging using Stages of Reproductive Aging Workshop + 10 in black urban African women in the Study of Women Entering and in Endocrine Transition.

OBJECTIVE: There has been limited research on accurate staging of the menopausal transition in sub-Saharan African women. Our aim was to assess the usefulness of the Stages of Reproductive Aging Workshop + 10 (STRAW + 10) criteria in staging ovarian aging in black South African women, examining whether obesity has any effect on the menopausal transition. METHODS: The study enrolled 702 women aged 40 to 60 years. STRAW + 10 criteria were used to categorize the stages of reproductive aging. The Menopause Rating Scale was used to measure the prevalence of vasomotor symptoms. Follicle-stimulating hormone (FSH) and estradiol levels were used as supportive criteria for staging. Human immunodeficiency virus status was assessed using a point-of-care method. RESULTS: Reported age at final menstrual period (FMP) was higher in women interviewed within 4 years of FMP (mean [SD], 49.0 [3.80] y) than in women interviewed 10 years or more after FMP (mean [SD], 42.0 [4.06] y; P < 0.0005). In women within 4 years of FMP, lower body mass index was associated with earlier age at FMP. FSH levels increased and estradiol levels decreased (P < 0.0005 for both trends) across seven staging groups. Human immunodeficiency virus status had no effect on menopause symptoms. Obesity (body mass index ≥35.0 kg/m) was associated with severe vasomotor symptoms. CONCLUSIONS: Reporting of age at FMP is unreliable in women interviewed 4 years or more after the event. STRAW + 10 seems accurate in staging reproductive aging, as confirmed by the strong association of FSH and estradiol levels with the menopausal transition stage. STRAW + 10 may be appropriate for use in resource-limited settings in the absence of biomarkers. Biocultural methods may be useful in assessing the menopausal transition in culturally diverse women.