ORIGINAL ARTICLES: GYNECOLOGY AND MENOPAUSE

Vasomotor and sexual symptoms

in older Australian women:
a cross-sectional study
Berihun M. Zeleke, M.D., M.P.H.,a,c Robin J. Bell, M.B.B.S., M.P.H., Ph.D.,a
Baki Billah, B.Sc.(Hons.), M.Sc., M.A.S., Ph.D.,b and Susan R. Davis, M.B.B.S., Ph.D.a
a
Women's Health Research Program and b Department of Epidemiology and Preventive Medicine, School of Public Health
and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; and c Department of Epidemiology and
Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Objectives: To determine the prevalence and severity of vasomotor symptoms (VMS) and sexual symptoms in community-dwelling
older women, and to explore factors associated with VMS.
Design: Population-based cross-sectional study.
Setting: Not applicable.
Participant(s): A total of 1,548 women aged 65–79 years.
Intervention(s): None.
Main Outcomes Measure(s): The presence and self-rated severity of VMS (hot flashes, night sweats, or sweating), and sexual
symptoms (intimacy, desire, and vaginal dryness) were determined with the use of the Menopause Quality of Life (MenQOL)
questionnaire.
Result(s): All items of the vasomotor and the sexual MenQOL domains were completed by 1,532 and 1,361 of the study participants,
respectively. Menopausal hormone therapy (MHT) use was reported by 6.2% of the women, and 6.9% reported using vaginal estrogen.
Among the 1,426 women not using MHT, at least 1 VMS was reported by 32.8%. The prevalence of VMS rated as moderately to severely
bothersome was 3.4%. A total of 54.4% of currently partnered women had sexual symptoms, and 32.5% reported vaginal dryness during
intercourse in the past month. In the multivariate analysis, factors significantly associated with VMS were age, obesity, being a care-
giver for another person, and bilateral oophorectomy.
Conclusion(s): VMS and vaginal atrophy symptoms are common in community-dwelling
older women, but they are predominantly untreated. The degree of distress caused by sexual
symptoms among older women needs further exploration. (Fertil SterilÒ 2016;105:149–55. Use your smartphone
Ó2016 by American Society for Reproductive Medicine.) to scan this QR code
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W
ith the increase in life ex- night sweats, the cardinal symptoms mounting evidence suggests that VMS
pectancy in developed of postmenopausal estrogen deficiency, last longer than originally presumed,
countries (1), most women are experienced by most women during current estimates of the prevalence
can expect to live one-third of their perimenopause and early postmeno- and severity of VMS are primarily
lives after menopause. Vasomotor pause (2, 3) and can significantly based on studies of women at midlife
symptoms (VMS), or hot flashes and affect quality of life (4, 5). Although (6–8). Avis et al. reported the median
duration of menopausal symptoms
Received July 2, 2015; revised September 2, 2015; accepted September 10, 2015; published online
October 9, 2015. following the final menstrual period
B.M.Z. has nothing to disclose. R.J.B. has nothing to disclose. B.B. has nothing to disclose. S.R.D. has to be 4.5 years (6). In a recent study,
been a consultant to Trimel Pharmaceuticals, has received honoraria from Abbott Pharmaceuti-
cals, and has research support from Lawley Pharmaceuticals. 42% of women aged 60–65 years
Supported by International Menopause Society Research Bursary, Monash University Postgraduate reported hot flashes and/or night
Research Scholarship (to B.M.Z.) and Australian NHMRC Principal Research Fellow grant (no
1041853 to S.R.D.).
sweats, with 6.5% of those women
Reprint requests: Professor Susan R. Davis, M.B.B.S., Ph.D., Director, Women's Health Research being moderately-severely bothered
Program, Department of Epidemiology and Preventive Medicine, School of Public Health and by the symptoms (7).
Preventive Medicine, Monash University, Level 6, 99 Commercial Rd, Melbourne, Victoria,
Australia, 3004 (E-mail: susan.davis@monash.edu). Little attention has been given to
the persistence of VMS in older women,
Fertility and Sterility® Vol. 105, No. 1, January 2016 0015-0282/$36.00
Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc.
although the limited available data
http://dx.doi.org/10.1016/j.fertnstert.2015.09.017 suggest that the proportion of older

VOL. 105 NO. 1 / JANUARY 2016 149

ORIGINAL ARTICLE: GYNECOLOGY AND MENOPAUSE
women with ongoing estrogen deficiency symptoms is not
small (8–10). Earlier studies are limited by their small size
(9, 11), inclusion of a narrow birth cohort (12), or being
restricted to women presenting for medical care (9, 10). We
therefore investigated the prevalence and severity of VMS
and sexual symptoms in a representative sample of older
community-dwelling Australian women and explored factors
associated with VMS.
METHODS
Study Design
This was a questionnaire-based cross-sectional population-
based study designed to identify the extent to which older
women are bothered by estrogen deficiency symptoms usu-
ally associated with menopause.
Study Population
Recruitment was from an Australian database based on the
electoral roll (Roy Morgan Research Single Source). In
Australia, where voting is compulsory, every Australian is
registered on this roll. The dynamic database covers all metro-
politan and nonmetropolitan electoral areas across Australia.
It is continually refreshed, with 50,000 new contacts each
year, which remain on the database for
2 years. To be
eligible for the database, women need to be community dwell-
ing, that is, living at a private residential address and not be in
any form of institutionalized care. For recruitment from this
database to our study, women aged 65–79 years were invited
by telephone to participate in a study. If verbal consent was
obtained, a copy of the questionnaire and the study explana-
tory statement were posted with a reply-paid envelope.
Return of a completed study questionnaire was taken as writ-
ten consent. Participants were asked to provide permission to
be recontacted by telephone for essential data clarification.
The study was approved by the Monash University Human
Research Ethics Committee.
Study Questionnaire
Data collected included self-reported height and weight, level
of education, employment status, partnership status, smoking
and alcohol use, and general medical history. Systemic
menopausal hormone therapy (MHT) included prescription
estrogen and/or estrogen plus progestogen (including com-
pounded hormones) and tibolone.
Menopausal symptoms were assessed with the use of the
Menopause-Specific Quality of Life (MenQOL) questionnaire,
a validated self-administered instrument consisting of 29
questions grouped into four domains: vasomotor (three items:
hot flashes, night sweats, and sweating), sexual (three items:
change in sexual desire, vaginal dryness, and avoiding inti-
macy), psychosocial (seven items), and physical (16 items)
(13). All items begin with a yes or no question regarding the
presence of the symptom over the past 4 weeks. If the symptom
is present (yes), the respondent then rates the degree of bother
caused by the symptom using a 7-point scale. The results from
both questions (presence of symptoms and degree of bother)
provide the final score, ranging from 1 (symptom not present)
150
to 8 (symptom is present and extremely bothersome). VMS and
sexual symptoms were considered to be moderately to severely
bothersome if the score was above the halfway score of the
7-point scale (>5 to 8 in the total score). Similarly, the overall
VMS or sexual domain scores (the mean of the scores of the
three questions in each domain) were categorized as none
(score ¼ 1) or ‘‘any VMS’’ or ‘‘any sexual symptom’’ (score
>1 to %8). ‘‘Any VMS’’ or ‘‘any sexual symptom’’ were subse-
quently categorized as mildly (score >1 to %5), or moderately
to severely bothersome (score >5 to 8).
Women who answered ‘‘yes’’ to a symptom and did not
provide a degree of bother were treated as missing data.
Statistical Analysis
The sample size was determined on the basis of the precision
of the estimate of the prevalence of moderate to severe VMS.
The total sample size of 1,511 was based on a 95% confidence
interval of 1.8% around a percentage prevalence estimate of
15% for moderate to severe VMS (14, 15). We purposefully
sampled women so that the age distribution of our sample
population mimicked the age distribution of the Australian
female population in the age range of 65–79 years as of
November 2011 (16).
After data entry, a random sample (n ¼ 30) of the SPSS
(Statistical Packages for Social Sciences) database was
audited for accuracy. Descriptive statistics were used to
present data by means of tables and graphs.
MenQOL domain scores, by age group, were presented for
each of the items under the vasomotor and the sexual
domains. The main outcome variable, VMS, was defined in
two ways: ‘‘any VMS’’ versus ‘‘no VMS,’’ or ‘‘moderately to
severely bothersome VMS’’ versus ‘‘mild or no VMS.’’ Women
using systemic MHT were excluded from the analysis of the
MenQOL domain scores and tests of association with VMS.
Women using vaginal estrogen were excluded from the anal-
ysis of the MenQOL sexual domain score. Associations
between the outcome variable and other factors were tested
with the use of multivariable logistic regression. The variables
included in the multivariable analysis were chosen because
they have been identified in previous studies as either associ-
ated with VMS or potentially confounding an association
with VMS. All selected variables (age, body mass index
[BMI], residence, current marital status, education, employ-
ment, being a caregiver for another person, history of any
cancer, surgery including hysterectomy with and without
bilateral oophorectomy, housing financial security, and
smoking and alcohol consumption) were fitted into the multi-
variable logistic regression model simultaneously (with the
use of the enter method). We also checked for effect modifica-
tion between the variables of being a caregiver for another
person, housing financial security, education, and employ-
ment. We excluded underweight (BMI <18.5 kg/m2) women
(n ¼ 37) from the logistic regression analysis, because we
considered that they may be unwell. Adjusted and unadjusted
odds ratios with 95% confidence intervals (CIs) were calcu-
lated. A P value of < .05 was considered to be statistically sig-
nificant. All analyses were performed with the use of Stata
version 13.1 (Statacorp).
VOL. 105 NO. 1 / JANUARY 2016
 Fertility and Sterility®

Owing to some missing values, the sample sizes vary be-

TABLE 1
tween variables. The maximum number of missing responses
was 26 (1.8%) for the vasomotor domain. Missing data for the Sociodemographic characteristics, medical history, and distribution
sexual domain was higher (6.5%), owing to some questions of participants (n [ 1,548).
not being applicable to women who were not sexually active.
Characteristica Data
Age (y), mean  SD 71.5  4.1 y
Role of the Funding Source 65–69 667 (43.1)
The study was supported by an International Menopause So- 70–74 506 (32.7)
75–79 375 (24.2)
ciety Research Bursary. The funding source had no role in the Body mass index (kg/m2), mean  SD (n ¼ 1,540) 27.9  6.0
design of the study, analysis or interpretation of the data, <18.5 37 (2.4)
drafting of the manuscript, or the decision to submit the 18.5 to <25 501 (32.5)
25 to <30 500 (32.5)
manuscript for publication. R30 502 (32.6)
Residential location
RESULTS Metropolitan 1,024 (66.15)
Nonmetropolitan 524 (33.85)
Study Population Country of birth (n ¼ 1,547)
Australia 1,186 (76.7)
Phone contact was attempted with 10,144 potentially eligible United Kingdom/Europe 275 (17.9)
women, and 4,714 (46.5%) were successfully contacted. Of Otherb 86 (5.4)
these 2,156 (45.7%) declined to participate and 581 (12.3%) Race/ethnicity (n ¼ 1,509)
were excluded because their age-group quota was filled (n White 1,471 (97.5)
Asian 11 (0.7)
¼ 548) or their age was outside the study range (n ¼ 33). A Aboriginal/Torres Strait Islander 6 (0.6)
study questionnaire was therefore sent to 1,977 (42.0%) of Other 21 (1.2)
the women able to be contacted, and 1,592 (80.5%) of these Educational status (n ¼ 1,544)
women returned the questionnaire (Supplemental Fig. 1, High school or less 940 (60.9)
Beyond high school 604 (39.1)
available online at www.fertstert.org). After excluding re- Employment (h/wk), median (range) 15 (1–60)
turned blank questionnaires, late replies, and women found Yes 160 (10.3)
to be outside the target age group, the final study sample Current relationship status
Married/de facto or single with partner 815 (52.6)
comprised 1,548 women. Their mean (SD) age was 71.5 (4.1) Not currently partnered (including widows) 733 (47.4)
years. Most (76.5%) were Australian born, lived in metropol- Caregiver (h/wk), median (range) (n ¼ 1,538) 35 (2–148)
itan areas (66.1%), and were white (97.5%). Nearly one-half Yes 249 (16.2)
(49.8%) were married, and 39.1% were educated beyond Hysterectomy without oophorectomy (n ¼ 1,544) 336 (21.8)
Bilateral oophorectomy  hysterectomy (n ¼ 1,544) 266 (17.2)
high school. Ten percent of the participants were in paid Ever been diagnosed with any cancer (n ¼ 1,545) 387 (25.1)
employment and 16.2% were caregivers for another person Current smoking (n ¼ 1,547) 129 (8.3)
(Table 1). Caregivers were more likely to be married (c2 ¼ Current alcohol consumption (n ¼ 1,547) 979 (63.3)
Postmenopausal systemic hormone use 96 (6.2)
67; P< .001) and to live in financially insecure housing (c2 Nonhormonal prescription therapy for VMS 10 (0.7)
¼ 4.3; P¼ .038), and most were caring for their partner Vaginal estrogen use 106 (6.8)
(57.4%). The mean (SD) BMI was 27.9 (6.0) kg/m2, with Note: VMS ¼ vasomotor symptoms.
28.6% obese (BMI 30 to <40 kg/m2) and 4.0% morbidly obese
a
Values are expressed as n (%) from 1,548 women unless otherwise indicated.
b
Two Central/South American, one Melanesian/Maori, and one North Africa/Middle East
(BMI R40 kg/m2). Ninety-six women (6.2%) were taking one born.
or more forms of systemic MHT, and 106 (6.9%) were using Zeleke. Hot flashes are common in older women. Fertil Steril 2016.

vaginal estrogen.

VMS was 4.3% (95% CI 3.0%–6.3%) for women aged

Vasomotor Symptoms
Among the 1,452 women not using MHT, 1,426 (98.2%) re-
sponded to all three of the questions in the vasomotor domain
of the MenQOL questionnaire. The overall mean (SD) score for
the vasomotor domain was 1.67 (1.27). Hot flashes in the past
4 weeks were reported by 19.1% (95% CI 17.1%–21.2%) of the
women, night sweats by 15.7% (95% CI 13.9%–17.7%), and
sweating by 20.9% (95% CI 18.8%–23.0%). At least one of
these VMS was reported by 32.8% of the participants. The
pattern of the severity of VMS by age of women is shown
in Figure 1.
The highest prevalence of any VMS, 39.2% (95% CI
35.4%–43.2%), was seen for women aged 65–69 years. The
overall prevalence of moderately to severely bothersome
VMS was 3.4% (95% CI 2.5%–4.4%). When examined by
age, the prevalence of moderately to severely bothersome
65–69, 3.2% (95% CI 1.9%–5.2%) for those aged 70–74, and
2.0% (95% CI 0.9%–4.1%) for those aged 75–79 years
(Table 2).
Sexual Symptoms
Any sexual symptoms were reported by 39.0% (95% CI
36.3%–41.7%), with 20.3% (95% CI 18.2%–22.7%) reporting
‘‘vaginal dryness during intercourse in the past month’’
(Table 2). The overall mean (SD) sexual domain score was
1.81 (1.51). Sexual symptoms were significantly more
common among partnered than nonpartnered women, with
54.4% versus 21.5% having any sexual symptoms (c2 ¼
142; P< .001), and 32.5% of all partnered women reporting
vaginal dryness during intercourse in the preceding month.
For partnered women the overall mean (SD) sexual domain

VOL. 105 NO. 1 / JANUARY 2016 151

ORIGINAL ARTICLE: GYNECOLOGY AND MENOPAUSE
FIGURE 1
Severity of vasomotor symptoms (VMS) by age of women.
Zeleke. Hot flashes are common in older women. Fertil Steril 2016.
score was 2.25 (1.77). Vaginal dryness during intercourse was
most prevalent among women aged 65–69 years who were
partnered (40.8%, 95% CI 35.6%–46.4%), with 16.8% of those
women being moderately to severely bothered by this
symptom.
Factors Associated with VMS
Factors associated with VMS (any or moderately to severely
bothersome) are presented in Table 3. After adjustment for
all covariates, age (odds ratio [OR] 0.68, 95% CI 0.52–0.89;
P< .01) and being in paid employment (OR 0.62, 95% CI
0.41–0.94; P< .05) were inversely associated with any VMS.
Compared with women aged 65–69 years, women aged
70–74 had a lower likelihood of VMS (OR 0.68, 95% CI
0.52–0.89; P< .01) and those aged 75–79 had a 54% lower
likelihood of any VMS (OR 0.46, 95% CI 0.34–0.63;
P< .001). Obesity (BMI R30 kg/m2, OR 1.45, 95% CI
1.08–1.93; P< .05), being a caregiver for another person (OR
1.39, 95% CI 1.02–1.90; P< .05), being in financially insecure
housing (OR 1.58, 95% CI 1.03–2.43; P< .01), and having
history of cancer (OR 1.43, 95% CI 1.10–1.86; P< .01) were
positively associated with having any VMS. Independent
factors associated with moderately to severely bothersome
VMS included being a caregiver for another person (OR
2.25, 95% CI 1.17–4.36; P< .05) and a history of bilateral
oophorectomy (OR 2.66, 95% CI 1.33–5.30; P< .01).
DISCUSSION
VMS are signature symptoms of menopause, but data pertain-
ing to their persistence in older women have been lacking.
Although studies have suggested that symptoms attributable
to postmenopausal estrogen deficiency are common in elderly
women (9, 10, 12, 14), our search of the published literature
(English language, MEDLINE search, unrestricted dates)
indicates that ours is the first study to examine the
prevalence of VMS in a representative sample of
community-dwelling older women. Nearly one-third of our
152
study sample reported VMS, and 39% reported sexual
symptoms. Whereas other studies have reported on VMS fre-
quency (6, 9) we were interested in the degree to which women
were bothered by their VMS. The prevalence of VMS is lower
than reported for younger postmenopausal women in
Australia and the United States (7, 17), but higher for older
women (70–79 years) than reported from the Women's
Health Initiative (WHI) baseline data (18, 19).
Obesity, younger age, being a caregiver for another per-
son, being in financially insecure housing, and having history
of cancer were positively associated with VMS. In younger
postmenopausal women, VMS have been negatively associ-
ated with age (10, 20, 21) and positively associated with
obesity (7, 21–25). Several other studies have also found the
risk of VMS to be higher in women with higher BMI than in
those with lower BMI (7, 23–26). Although the mechanisms
responsible for link between obesity and VMS are not well
understood, findings of positive associations between BMI
and VMS are consistent with a thermoregulatory model of
VMS, in which adipose tissue acts as an insulator,
preventing the heat dissipation (3).
Having had a bilateral oophorectomy or being a caregiver
for another person were significantly associated with a
greater likelihood of moderate-to-severely bothersome
VMS. Surgical menopause has been associated with a greater
likelihood of VMS in younger postmenopausal women (7, 27).
Although the timing of oophorectomy in relation to
menopause in our study sample was not known, our data
shows that the association between surgical menopause and
VMS persists beyond the seventh decade of life.
The impact of being a caregiver on reporting of VMS has
not previously been reported. Being a caregiver has been
associated with physical and mental stress (20, 28), and
older women who are caregivers are more likely to feel
‘‘worried or depressed’’ than noncaregiver older women (29).
The positive association between VMS and a history of
cancer in the present study may partly be due to the conse-
quences of the cancer itself or to its treatment. We have pre-
viously observed a higher prevalence of hot flashes and night
sweats among breast cancer survivors no longer taking endo-
crine therapy than among healthy women of the same age
(30). Our finding that VMS were more common among
women living in financially insecure housing is consistent
with housing insecurity being associated with adverse health
outcomes (31). The exclusion of women taking MHT from our
study might result in the underestimation of the prevalence of
VMS. Our estimate of the use of MHT was lower than recently
reported for Australian postmenopausal women aged
60–65 years (6.2% vs. 9.2%) (7).
An important finding was that more than one-third of the
women in our study who reported not using systemic MHT or
vaginal estrogen reported having sexual symptoms in the past
30 days. Notably, we specifically asked about ‘‘vaginal
dryness during intercourse’’ as opposed to vaginal and genital
dryness as reported in other studies of older women (32, 33).
In the study by Pastore et al., the prevalence of vaginal or
genital dryness among 70–79-year-old women was 23.7%
(32). Vaginal dryness is a cardinal symptom of vulvovaginal
atrophy (VVA). Having only asked about one aspect of
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TABLE 2

Prevalence and scores of vasomotor symptoms (VMS) of the Menopause Quality of Life questionnaire (MenQOL) for the past 1 month by age of
women.a
Age category Total Score % With any symptoms % With moderate-to-severe
MenQOL domain (y) (provided data) (mean ± SD) (95% CI) symptoms (95% CI)
All women
VMS domain 65–79 1,452 (1,426) 1.67  1.27 32.8 (30.4–35.3) 3.4 (2.5–4.4)
65–69 613 (602) 1.82  1.36 39.2 (35.4–43.2) 4.3 (3.0–6.3)
70–74 481 (470) 1.64  1.24 31.3 (27.2–35.6) 3.2 (1.9–5.2)
75–79 358 (354) 1.44  1.08 24.0 (19.8–28.7) 2.0 (0.9–4.1)
Hot flushes 65–79 1,452 (1,442) 1.66  1.53 19.1 (17.1–21.2) 4.6 (3.7–5.9)
65–69 613 (608) 1.81  1.65 23.5 (20.3–27.1) 6.3 (4.6–8.5)
70–74 481 (478) 1.62  1.47 18.0 (14.8–21.7) 4.0 (2.5–6.2)
75–79 358 (356) 1.46  1.35 12.9 (9.8–16.8) 2.8 (1.5–5.1)
Night sweats 65–79 1,452 (1,443) 1.54  1.38 15.7 (13.9–17.7) 3.5 (2.6–4.5)
65–69 613 (609) 1.61  1.43 18.2 (15.4–21.5) 3.6 (2.4–5.4)
70–74 481 (478) 1.61  1.45 17.6 (14.4–21.3) 4.0 (2.5–6.2)
75–79 358 (354) 1.33  1.17 9.0 (6.4–12.4) 2.5 (1.3–4.8)
Sweating 65–79 1,452 (1,434) 1.81  1.78 20.9 (18.8–23.0) 7.5 (6.3–9.0)
65–69 613 (607) 2.09  2.03 26.4 (23.0–30.0) 11.5 (9.2–14.3)
70–74 481 (473) 1.68  1.62 18.4 (15.1–22.2) 5.3 (3.4–7.7)
75–79 358 (354) 1.54  1.42 14.7 (11.4–18.8) 3.7 (2.1–6.2)
Sexual domainb 65–79 1,362 (1,273) 1.81  1.51 39.0 (36.3–41.7) 6.0 (4.8–7.4)
65–69 572 (543) 2.02  1.67 45.1 (41.0–49.3) 7.9 (5.9–10.5)
70–74 443 (414) 1.81  1.52 38.9 (34.3–43.7) 5.8 (3.9–8.5)
75–79 347 (316) 1.46  1.09 28.5 (23.8–33.7) 2.8 (1.5–5.4)
Change in sexual desire 65–79 1,362 (1,309) 1.77  1.70 22.4 (20.2–24.7) 7.0 (5.7–8.5)
65–69 572 (556) 1.89  1.82 25.2 (21.7–29.0) 8.1 (6.1–10.7)
70–74 443 (429) 1.80  1.75 23.3 (19.5–27.6) 7.2 (5.1–10.1)
75–79 347 (324) 1.49  1.38 16.4 (12.7–20.8) 4.6 (2.8–7.5)
Vaginal dryness during 65–79 1,362 (1,244) 1.77  1.74 20.3 (18.2–22.7) 7.5 (6.1–9.1)
intercourse 65–69 572 (532) 2.03  1.97 26.9 (23.3–30.8) 10.7 (8.4–13.6)
70–74 443 (405) 1.69  168 18.0 (12.6–22.1) 6.4 (4.4–9.3)
75–79 347 (307) 1.40  1.26 12.1 (8.9–16.2) 3.3 (1.8–6.0)
Avoiding intimacy 65–79 1,362 (1,235) 1.89  1.87 26.3 (23.9–28.8) 8.4 (7.0–10.1)
65–69 572 (527) 2.13  2.07 31.5 (27.7–35.6) 11.4 (8.9–14.4)
70–74 443 (405) 1.87  1.88 25.4 (21.4–29.9) 7.9 (5.6–11.0)
75–79 347 (303) 1.50  1.36 18.5 (14.5–23.3) 4.0 (2.3–6.9)
Currently partnered women only
Sexual domainb 65–79 698 (673) 2.25  1.77 54.4 (50.6–58.1) 9.5 (7.5–12.0)
65–69 318 (313) 2.47  1.86 60.4 (54.8–65.7) 11.2 (8.1–15.2)
70–74 240 (228) 2.19  1.74 51.8 (45.2–58.2) 8.8 (5.7–13.2)
75–79 140 (132) 1.86  1.50 44.7 (36.4–53.3) 6.8 (3.6–12.6)
Change in sexual desire 65–79 698 (676) 2.17  2.01 31.5 (28.1–35.1) 10.9 (8.8–13.5)
65–69 318 (314) 2.27  2.06 33.4 (28.4–38.9) 12.1 (8.9–16.2)
70–74 240 (231) 2.13  2.00 30.3 (24.7–36.6) 9.5 (6.3–14.1)
75–79 140 (131) 2.02  1.92 29.0 (21.8–37.4) 10.7 (6.4–17.3)
Vaginal dryness during 65–79 698 (653) 2.27  2.10 32.5 (29.0–36.2) 12.6 (10.2–15.3)
intercourse 65–69 318 (304) 2.62  2.27 40.8 (35.6–46.4) 16.8 (13.0–21.4)
70–74 240 (222) 2.05  1.97 27.0 (21.6–33.3) 9.9 (6.6–14.6)
75–79 140 (127) 1.82  1.77 22.1 (15.6–30.1) 7.1 (3.7–13.1)
Avoiding intimacy 65–79 698 (656) 2.32  2.16 36.4 (32.8–40.2) 12.8 (10.5–15.6)
65–69 318 (305) 2.55  2.27 41.0 (35.6–46.6) 16.1 (12.3–20.6)
70–74 240 (223) 2.30  2.20 35.9 (29.8–42.4) 12.1 (8.4–17.1)
75–79 140 (128) 1.84  1.74 26.6 (16.6–34.9) 6.3 (3.1–12.0)
Note: CI ¼ confidence interval.
a
Excluding 96 women on menopausal hormone therapy and 106 women using vaginal estrogens.
b
Sexual domain: three items of the MenQOL questionnaire (change in sexual desire, vaginal dryness, and avoiding intimacy).
Zeleke. Hot flashes are common in older women. Fertil Steril 2016.

VVA, with other symptoms including irritation, itching, and
infection (34), the prevalence of VVA in our study sample is
likely to be greater than indicated by this symptom alone.
Our findings, however, highlight that VVA is a neglected
area of older women's health, despite this being a condition
that can be simply, effectively, and safely treated with low-
dose vaginal estrogen (35).
Strengths of this study include the recruitment of a large
community-based representative sample of older Australian
women with an age distribution that mimics that of the adult
Australian female population aged 65–79 years. Recruitment
to the original database was by a random process, based on
the electoral roll. Comparison of our study sample with
Australian 2011 census data indicates that our sample is na-
tionally representative of women of this age in terms of race,
location of residence (metropolitan vs. nonmetropolitan), BMI
(64.5% overweight and obese), employment, partnership sta-
tus, and being a caregiver for another person (16).

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ORIGINAL ARTICLE: GYNECOLOGY AND MENOPAUSE

TABLE 3

Logistic regression for predictors of vasomotor symptoms.

Any VMS Moderate-severe VMS
Unadjusted P Adjusted Unadjusted P Adjusted
Variable n (%) OR (95% CI) value OR (95% CI) OR (95% CI) value OR (95% CI)
Age group (y)
65–69 613 (42.2) Reference Reference Reference Reference
70–74 481 (33.1) 0.71 (0.55–0.91)b .006 0.68 (0.52–0.89)b 0.73 (0.38–1.40) .34 0.77 (0.40–1.51)
75–79 358 (24.7) 0.50 (0.37–0.67)b .000 0.46 (0.34–0.63)b 0.45 (0.19–1.04) .062 0.46 (0.19–1.09)
Body mass index (kg/m2)
18.5–24.9 507 (35.1) Reference Reference Reference Reference
25–29.9 458 (31.7) 1.29 (0.98–1.72) .072 1.28 (0.95–1.71) 2.46 (1.06–5.67)a .035 2.28 (0.97–5.32)
%30 479 (33.2) 1.58 (1.20–2.08)b .001 1.45 (1.08–1.93)a 2.68 (1.17–6.11)a .019 2.12 (0.91–4.96)
Residential location
Metropolitan 955 (65.8) Reference Reference Reference Reference
Nonmetropolitan 497 (34.2) 0.92 (0.73–1.16) .49 0.88 (0.69–1.1.3) 0.71 (0.37–1.35) .29 0.70 (0.36–1.36)
Education
High school or less 888 (61.3) Reference Reference Reference Reference
Beyond high school 561 (38.7) 0.91 (0.72–1.14) .41 0.89 (0.70–1.14) 0.94 (0.52–1.70) .84 0.89 (0.48–1.66)
Current relationship status
Married or partnered 760 (52.3) 1.17 (.94–1.46) .170 1.04 (.81–1.32) 1.55 (.86–2.81) .145 1.19 (.63–2.4)
Not currently partnered 692 (47.7) Reference Reference Reference Reference
Employment
Yes 144 (9.9) 0.79 (0.54–1.16) .24 0.62 (0.41–0.94)a 0.82 (0.29–2.33) .71 0.81 (0.28–2.38)
No 1,308 (90.1) Reference Reference Reference Reference
Caregiver for another person
Yes 233 (16.2) 1.40 (1.05–1.88)a .023 1.39 (1.02–1.90)a 2.43 (1.30–4.55)a .006 2.25 (1.17–4.36)a
No 1,209 (83.8) Reference Reference Reference Reference
Current smoker
No 1,328 (91.5) Reference Reference Reference
Yes 123 (8.5) 1.07 (0.72–1.58) .75 1.12 (0.73–1.72) 0.70 (0.21–2.28) .55 0.75 (0.22–2.59)
Any alcohol consumption
No 535 (36.9) Reference Reference Reference Reference
Yes 916 (63.1) 1.15 (0.91–1.45) .24 1.18 (0.92–1.51) 0.88 (0.49–1.58) .66 0.92 (0.50–1.70)
Hysterectomy without oophorectomy
No 1,132 (78.2) Reference Reference Reference Reference
Yes 316 (21.8) 1.17 (0.90–1.52) .25 1.27 (0.95–1.69) 0.94 (0.46–1.91) .87 1.29 (0.60–2.79)
Bilateral oophorectomy
No 1,211 (83.6) Reference Reference Reference
Yes 237 (16.4) 1.31 (0.98–1.76) .068 1.27 (0.92–1.76) 2.68 (1.45–4.97) .002 2.66 (1.33–5.30)b
History of any cancer
Yes 365 (25.2) 1.48 (1.15–1.90)a .002 1.43 (1.10–1.86)b 1.23 (0.65–2.33) .52 1.12 (0.58–2.14)
No 1,084 (74.8) Reference Reference Reference Reference
Financial security of house
Yes 1,340 (7.1) Reference Reference Reference
No 102 (92.9) 1.68 (1.11,2.53)a .014 1.58 (1.03,2.43)a 1.20 (0.42–3.42) .73 0.87 (0.30–2.54)
Note: All covariates were mutually adjusted for each other. CI, confidence interval; OR odds ratio.
a
P%.05.
b
P%.01.
Zeleke. Hot flashes are common in older women. Fertil Steril 2016.

A limitation was that weight and height were self-
reported. However, self-reported height and weight have
been shown to be valid for identifying associations in epide-
miologic studies (36, 37). The requirement for women to be
able to complete the study questionnaire in English is a
potential limitation. Because 94% of older Australian
women identify as speaking English (16), this is unlikely to
have introduced significant bias. Another limitation is that
45.7% of the contacted women declined to participate in
this study. Owing to privacy constraints, we were unable to
compare the demographic characteristics of respondents
versus nonrespondents to the initial invitation to participate
in our study. Our findings can not be generalized beyond
women living in the community, because women living in
residential care or nursing homes were not included. Our
sample is nationally representative in terms of ethnicity,
with the proportion of white women matching that of the
Australian population of this age (16). As a result, we were
unable to explore associations between race/ethnicity and
VMS.
CONCLUSION
Vasomotor and vaginal atrophy symptoms are common in
community-dwelling older Australian women. VMS are asso-
ciated with younger age, obesity, being a caregiver, and
history of any cancer. The degree of distress caused by sexual
symptoms in older women needs further exploration.
Acknowledgments: The authors thank the women who
participated in our study.

154 VOL. 105 NO. 1 / JANUARY 2016


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SUPPLEMENTAL FIGURE 1

Participant flow diagram.

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155.e1 VOL. 105 NO. 1 / JANUARY 2016