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)

Hall, Mary N.

Leach, Laura

University of Missouri: MOspace

VOL 54, NO 10 / OCTOBER 2005 895w w w. j f p o n l i n e . c o mCLINICAL INQUIRIESE V I D E N C E - B A S E D A N S W E RC L I N I C A L C O M M E N T A R YIn menopausal women, does fatigue indicate disease?■ Evidence summaryStudies evaluating whether menopausalwomen experience fatigue at higher ratesthan pre- or perimenopausal women are ofvariable quality and yield conflicting results.1Though several studies suggest an associa-tion between fatigue among menopausalwomen and disease states, poor methodolo-gy limits the strength of their findings. In an Internet-based survey, 448 mid-dle-aged women who reported being eitherperimenopausal or menopausal respondedto questions about their symptoms.2Feeling tired and lacking energy were the 2most frequently reported symptoms, in380 (89%) and 355 (83%) of respondents,respectively. These self-selected respon-dents probably do not represent themenopausal population of women at large. A prospective cohort study, using a 1-page questionnaire that included 2 fatiguescales, identified 276 (24%) of 1159 pri-mary care patients who indicated fatigue asa major problem.3 The mean age of patientswas 57 years and 66% were women.Extensive laboratory testing was not help-ful in determining the cause of fatigue. TheBeck Depression Inventory, the ModifiedSomatic Perception Questionnaire, and theSocial Readjustment Rating Scale identifieddepression or anxiety in 80% of patientswith fatigue and 12% of controls. Thereare no similar studies for strictlymenopausal women. The prevalence of obstructive sleepapnea and sleep-disordered breathingincreases at the time of menopause andpeaks at age 65.4,5 In a retrospective chartreview of patients referred for evaluation ofsnoring, 22 (91%) of the women withHistory and exam usually uncover conditions causing fatigue other than menopauseRemember that menopause is a natural transitionin the life of many women, not a medical conditioncharacterized by debilitating fatigue. Symptomscausally associated with the decline in estrogen,which triggers menopause, include hot flashes,night sweats, vaginal dryness, and urethral irrita-tion. For patients complaining of fatigue, a carefulhistory and physical examination usually uncover1 or more acute or chronic physiological, psycho-logical, and therapeutic conditions that have beenshown to be associated with fatigue. Some of themore common ones I have encountered includedepression, chronic pain, cardiovascular disease,diabetes, thyroid disease, chronic infections, ane-mia, insomnia, sleep apnea, restless leg syndrome,medication side effects, and recent surgery.Robert Kynerd, MDUniversity of AlabamaThough fatigue is a commonly reported symptom,high-quality studies evaluating it as a marker fordiseases among menopausal women are lacking.Middle-aged women who report fatigue are more apt to screen positive for clinical depressionor anxiety (strength of recommendation [SOR]: B, case series). Fatigue may signal obstructivesleep 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). Mary N. Hall, MDDepartment of Family Medicine, Chair, Carolinas HealthCare System, Charlotte, NCLaura Leach, MLISCarolinas Healthcare System, Charlotte, NC.JFP_1005_CI.final  9/20/05  9:48 AM  Page 895obstructive sleep apnea (based on sleepstudies) were more likely to report daytimefatigue as a presenting symptom than werethe 44 (55%) of men with obstructive sleepapnea (P<.01).6 Most striking was a sub-group (40%) of women with documentedobstructive sleep apnea who reported onlyfatigue and morning headache but did notnote apnea or restless sleep.Coronary heart disease is the primarycause of death for women in the UnitedStates. A retrospective study of 515 women4 to 6 months after a myocardial infarctionexplored self-reported symptoms.7 The meanage was 66 ± 12 years and 93% were white.Unusual fatigue was the most frequent pro-dromal symptom experienced by 70.7% ofwomen 1 month before a myocardial infarc-tion, with 42.9% reporting fatigue in theacute setting. Though this retrospectivestudy is limited both by its methodologicalquality and by the narrow population stud-ied, the results suggest a gender differencebetween men and women in their report ofsymptoms of coronary artery disease.A review of 15 studies from 1989 to2002 reported that some studies foundwomen were more likely to seek medicalcare for extreme fatigue and dyspnea thanthey were for chest pain. In acute coronarysyndromes, 18% of women (comparedwith 9% of men) reported fatigue as a pre-senting symptom (P<.05). This review waslimited by small sample sizes, retrospectivechart review designs, and lack of explicitlystated critical appraisal criteria.8Recommendations from othersNo recommendations were identified. R E F E R E N C E S1. Nelson HD, Haney E, Humphrey L, et al. Managementof menopause-related symptoms. Evidence Report/Technology Assessment No. 120. (Prepared by theOregon Evidence-Based Practice Center, underContract No. 290-02-0024.) AHRQ Publication No. 05-E016-2. Rockville, Md: Agency for Healthcare Researchand Quality; 2005.2. Conboy L, Domar A, O'Connell E. Women at mid-life:symptoms, attitudes and choices, an internet basedsurvey. Maturitas 2001; 38:129–136. 3. Kroenke K, Wood DR, Mangelsdorff AD, Meier NJ,Powell JB. Chronic fatigue in primary care. Prevalence,patient characteristics and outcomes. JAMA 1988;260:929–934. 4. Bixler EO, Vgontzas AN, Lin HM, et al. Prevalence ofsleep-disordered breathing in women: effects of gen-der. Am J Respir Crit Care Med 2001; 163:608–613. 5. Young T, Finn L, Austin D, Peterson A. Menopausal sta-tus and sleep-disordered breathing in the WisconsinSleep Cohort Study. Am J Respir Crit Care Med 2003;167:1181–1185. 6. Ambrogetti A, Olson LG, Saunders NA. Differences inthe symptoms of men and women with obstructivesleep apnoea. Aust NZ J Med 1991; 21:863–866. 7. McSweeney JC, Cody M, O'Sullivan P, Elberson K,Moser DK, Garvin BJ. Women's early warning symp-toms of acute myocardial infarction. Circulation 2003;108:2619–2623.8. Patel H, Rosengren A, Ekman I. Symptoms in acutecoronary syndromes: does sex make a difference? AmHeart J 2004; 148:27–33. Middle-agedwomen whoreport fatigue are more likely to screen positivefor depression oranxiety896 VOL 54, NO 10 / OCTOBER 2005  THE JOURNAL OF FAMILY PRACTICECLINICAL INQUIRIESFAST TRACKWhat are Clinical Inquiries?Clinical Inquiries answer recent questions from thepractices of family physicians.  Practicing familyphysicians choose the most relevant questionssubmitted through a web-based voting systemoperated by the Family Physicians InquiriesNetwork (FPIN; online at www.fpin.org). FPIN is national, not-for-profit consortium of family medicine departments, community residencyprograms, academic health sciences libraries, pri-mary care practice-based research networks, andother specialists. Once questions are selected, FPINeditors then organize teams of clinicians and librar-ians to answer them based on systematic review of the world literature. Answers are developedthrough an explicit, systematic method:❚ FPIN librarians and editors identify questionsrecently answered in best evidence sources (e.g. Cochrane Reviews, Clinical Evidence, the USPreventive Services Task Force, Evidence BasedGuidelines, a published systematic review).❚ FPIN librarians then conduct systematic and standardized literature searches of best evidencesources, Medline, and other databases in collabo-ration with an FPIN clinician or clinicians. If a bestevidence source has been identified, the searchbegins from the date of the search conducted forthat source. Otherwise, the searches are compre-hensive. ❚ FPIN clinician authors then choose the highestquality original research sources, and criticallyappraise the research and integrate the findingsin the Evidence Based Answer and EvidenceSummary section of Clinical Inquiries.Authoritative sources are also quoted in the“Recommendations from Others” section of theClinical Inquiry.❚ Each Clinical Inquiry is reviewed by 4 or morepeers or editors before publication in JFP.❚ FPIN medical librarians are accountable for thethoroughness of the literature search, for record-ing the databases searched, search hedges usedand the search terms. The details of each searchis available to any interested reader (contactmanagingeditor@fpin.org).❚ Finally, a practicing family physician or other clinician writes an accompanying commentaryto provide a clinical perspective.JFP_1005_CI.final  9/20/05  9:48 AM  Page 896

In menopausal women, does fatigue indicate disease?

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