Clinical Inquiries

In menopausal women, does fatigue indicate disease?

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EVIDENCE-BASED ANSWER

Though fatigue is a commonly reported symptom, high-quality studies evaluating it as a marker for diseases among menopausal women are lacking. Middle-aged women who report fatigue are more apt to screen positive for clinical depression or anxiety (strength of recommendation [SOR]: B, case series). Fatigue may signal obstructive sleep apnea (SOR: B, retrospective cohort). For menopausal women with cardiac risk factors, extreme fatigue may be a sign of coronary artery disease (SOR: C, review without critical appraisal).

CLINICAL COMMENTARY

History and exam usually uncover conditions causing fatigue other than menopause
Robert Kynerd, MD
University of Alabama

Remember that menopause is a natural transition in the life of many women, not a medical condition characterized by debilitating fatigue. Symptoms causally associated with the decline in estrogen, which triggers menopause, include hot flashes, night sweats, vaginal dryness, and urethral irritation. For patients complaining of fatigue, a careful history and physical examination usually uncover 1 or more acute or chronic physiological, psychological, and therapeutic conditions that have been shown to be associated with fatigue. Some of the more common ones I have encountered include depression, chronic pain, cardiovascular disease, diabetes, thyroid disease, chronic infections, anemia, insomnia, sleep apnea, restless leg syndrome, medication side effects, and recent surgery.

Evidence summary

Studies evaluating whether menopausal women experience fatigue at higher rates than pre-or perimenopausal women are of variable quality and yield conflicting results.1 Though several studies suggest an association between fatigue among menopausal women and disease states, poor methodology limits the strength of their findings.

In an Internet-based survey, 448 middle-aged women who reported being either perimenopausal or menopausal responded to questions about their symptoms.2 Feeling tired and lacking energy were the 2 most frequently reported symptoms, in 380 (89%) and 355 (83%) of respondents, respectively. These self-selected respondents probably do not represent the menopausal population of women at large.

A prospective cohort study, using a 1-page questionnaire that included 2 fatigue scales, identified 276 (24%) of 1159 primary care patients who indicated fatigue as a major problem.3 The mean age of patients was 57 years and 66% were women. Extensive laboratory testing was not helpful in determining the cause of fatigue. The Beck Depression Inventory, the Modified Somatic Perception Questionnaire, and the Social Readjustment Rating Scale identified depression or anxiety in 80% of patients with fatigue and 12% of controls. There are no similar studies for strictly menopausal women.

The prevalence of obstructive sleep apnea and sleep-disordered breathing increases at the time of menopause and peaks at age 65.4,5 In a retrospective chart review of patients referred for evaluation of snoring, 22 (91%) of the women with studies) were more likely to report daytime fatigue as a presenting symptom than were the 44 (55%) of men with obstructive sleep apnea (P<.01).6 Most striking was a sub-group (40%) of women with documented obstructive sleep apnea who reported only fatigue and morning headache but did not note apnea or restless sleep.

Coronary heart disease is the primary cause of death for women in the United States. A retrospective study of 515 women 4 to 6 months after a myocardial infarction explored self-reported symptoms.7 The mean age was 66±12 years and 93% were white. Unusual fatigue was the most frequent prodromal symptom experienced by 70.7% of women 1 month before a myocardial infarction, with 42.9% reporting fatigue in the acute setting. Though this retrospective study is limited both by its methodological quality and by the narrow population studied, the results suggest a gender difference between men and women in their report of symptoms of coronary artery disease.

A review of 15 studies from 1989 to 2002 reported that some studies found women were more likely to seek medical care for extreme fatigue and dyspnea than they were for chest pain. In acute coronary syndromes, 18% of women (compared with 9% of men) reported fatigue as a presenting symptom (P<.05). This review was limited by small sample sizes, retrospective chart review designs, and lack of explicitly stated critical appraisal criteria.8

Recommendations from others

No recommendations were identified.

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