Differences in Scores on the Midlife Women's Symtom Index Between Women with and without Cardiovascular Disease

Sunday, 27 July 2014: 8:30 AM

Youjeong Kang, MPH, CCRN1
Ok Kyung Ham, PhD, RN2
Timothy J. Sowicz, MSN, CRNP3
Wonshik Chee, PhD4
Eun-Ok Im, RN, MPH, PhD, CNS, FAAN3
(1)Nursing, Univeresity of Pennsylvania, Philadelphia, PA
(2)Department of Nursing, Inha University, Incheon, South Korea
(3)School of Nursing, University of Pennsylvania, Philadelphia, PA
(4)Department of Family and Community Health, Univ. of Pennsylvania, Philadelphia, PA


Menopause in midlife women is a risk factor for cardiovascular disease (CVD) due to changes in estrogen levels which may cause hypertension (Ashraf & Vongpatanasin, 2006; Colditz et al., 1987; Markovitz, Matthews, Wing, Kuller, & Meilahn, 1991; Rosano, Vitale, Marazzi, & Volterrani, 2007). Although menopause is not a disease, low levels of estrogen are associated with hardening of the arteries ('American Heart Association', Oct 1, 2013). Declines in estrogen are also associated with elevations in LDL cholesterol and triglycerides ('American Heart Association', Oct 1,2013).

Biological measures such as serum estrogen levels and lipids are one method for assessing CVD risk in humans; however, these require a prescription from a health care provider. While these measures may yield important data on risk factors and markers of CVD and should be assessed based on current screening recommendations, women’s self assessment and interpretation of their menopausal symptoms may be a self-care strategy that provides early signs and symptoms of CVD. The Midlife Women’s Symptom Index (MSI) is a self-administered instrument to assess menopausal symptom frequency and severity (Im, Lee, Chee, Brown, & Dormire, 2010; Lee, Im, & Chee, 2010). Comparisons of the MSI scores between midlife women with and without CVD have not been reported in the literature. This study provides evidence that the MSI may not only be used to assess menopausal symptoms, but as a screening tool for CVD in midlife women. Thus, the purpose of this study is to compare the MSI scores between midlife women with and without CVD.


This is a secondary analysis of the data from a cross-sectional web-based survey on menopausal symptom experiences of 542 midlife women aged 40 to 60 years in the United States. Participants from the parent study were recruited through the Internet using convenience sampling. Data were collected using the MSI, which contains two subscales measuring prevalence and severity of menopausal symptoms (Lee et al., 2010). Both subscales are further divided into physical, psychological and psychosomatic menopausal symptom items (Lee et al., 2010). Prevalence is dichotomized (yes or no) and severity is reported using a Likert scale (Lee et al., 2010). Measures of central tendency and dispersion were performed for all included variables. To assess for differences between groups (midlife women with and without CVD), continuous variables were compared using one-way ANOVA. Categorical variables were compared using chi-square tests. For all analyses, p < 0.05 was considered statistically significant. A linear regression using the Genmod procedure in SAS 8was employed, and a multiple linear regression model was built to examine differences between groups in reporting menopausal symptoms with adjustment for significant demographic variables.  


In the participants with CVD, mean age was 50 years (p=0.0112), with 96% of using health advice from doctor’s office, clinic or health center (p=0.0016), 60% married (p=0.0027), 70% reporting being healthy (p=0034), and 49% being absence of period for one or more years (p=0.0198). The racial/ethnic composition of women differs between groups (p=0.0040). Blacks (30.37%) had the highest prevalence of CVD compared to Hispanics (18.90%), Asians (13.82%) and Whites (16.56%).

Differences in the prevalence and severity of the MSI scores by group were analyzed without controlling for demographic variables. The participants with CVD reported higher prevalence and severity scores in menopausal symptoms than those without CVD. There were significant differences in the prevalence and severity scores between groups except for the severity of psychological symptoms (p=0.0889).

The scores for the prevalence and severity subscales controlling for statistically significant demographic variables (age, health advice, marital status, racial/ethnic group, self-rated health and menopausal status) were analyzed. Those with CVD reported higher MSI prevalence and severity scores than participants without CVD while controlling for statistically significant demographic variables. There were significant differences in the prevalence and severity scores between groups except for the prevalence (p=0.1344) and severity of psychological symptoms (p=0.3491).

This study found significant differences in age, using health advice, self-rated health status, menopausal status, and racial/ethnic background between groups. Women with CVD were approximately two years older than women without CVD which is similar to data reported by Gold et al. (2001) which demonstrated age is related to all-cause mortality. 

It is well documented that the experience (Freeman et al., 2001; Im et al., 2010) , perception and tolerance of physical symptoms of menopause (Gold et al., 2001; Im et al., 2010) differ by ethnicity in U.S. women. In addition, Gold et al. (2006) demonstrated that Black women reported the highest rates of vasomotor symptoms; consistent with the findings from the present study.

The overall findings of this study show that there are differences in physical and psychosomatic menopausal symptom severity scores between groups. Overall, women with CVD reported higher MSI prevalence and severity scores compared to women without CVD. Thus, future research is needed to test MSI scores focused on specific types of CVD such as hypertension or heart failure using a larger sample.


Measurement of physical and psychosomatic severity symptom scores using MSI as a self-care tool may be reliable to predict CVD in midlife women. Recognizing symptoms of menopause as predictors of CVD risk may prompt women and health care providers to undertake measures to prevent CVD or slow its progression if diagnosed. Using the MSI as a self-screening tool allows women to use information gleaned from common signs and symptoms experienced during menopause to seek care from health care providers to protect themselves from CVD.

Acknowledgement: This analysis was conducted as a part of a larger study funded by NIH/NINR (1R01NR010568-01) entitled "Ethnic-Specific Midlife Women's Attitudes Toward Physical Activity.”