Resilience, depressed mood,_and_menopausal.10


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Resilience, depressed mood,_and_menopausal.10

  1. 1. Menopause: The Journal of The North American Menopause Society Vol. 21, No. 2, pp. 159/164 DOI: 10.1097/gme.0b013e31829479bb * 2013 by The North American Menopause Society Resilience, depressed mood, and menopausal symptoms in postmenopausal women Faustino R. Pe´rez-Lo´pez, MD, PhD,1,2 Gonzalo Pe´rez-Roncero, RN,1 Jose´ Ferna´ndez-In˜arrea, MD,3 Ana M. Ferna´ndez-Alonso, MD, PhD,1,4 Peter Chedraui, MD, MSc,1,5 Pla´cido Llaneza, MD, PhD,6 and for The MARIA (MenopAuse RIsk Assessment) Research Group Abstract Objective: This study aims to assess resilience, depressed mood, and menopausal symptoms in postmenopausal women. Methods: In this cross-sectional study, 169 postmenopausal women aged 48 to 68 years were asked to fill out the Wagnild and Young Resilience Scale (WYRS), the Center for Epidemiologic Studies Depression Scale (CESD-10), the Menopause Rating Scale (MRS), and a questionnaire containing personal and partner sociodemographic data. Results: The median [interquartile range] age of participating women was 54 [10.0] years. Among the women, 55.6% had increased body mass index, 76.9% had a partner, 17.8% were current smokers, 14.2% had hypertension, 25.4% used psychotropic drugs, and 13.0% used hormone therapy. Forty-five percent of the women had depressed mood (CESD-10 scores Q10), and 34.9% had severe menopausal symptoms (total MRS scores Q17). Less resilience (lower WYRS scores) correlated with depressed mood (higher CESD-10 scores) and severe menopausal symptoms (higher total, psychological, and urogenital MRS scores). Multiple linear regression analysis determined that WYRS scores positively correlated with exercising regularly and inversely correlated with CESD-10 scores (depressed mood). CESD-10 scores positively correlated with somatic and psychological MRS subscale scores and inversely correlated with WYRS scores (less resilience). Conclusions: In this postmenopausal sample, depressed mood and participation in regular exercise correlate with lower and higher resilience, respectively. Depressed mood is associated with the severity of menopausal symptoms (somatic and psychological). Key Words: Postmenopausal women Y Depressive mood Y Resilience Y Menopausal symptoms Y Center for Epidemiologic Studies Depression Scale Y Wagnild and Young Resilience Scale Y Menopause Rating Scale. M enopausal transition is a time when physical, psy- chological, and social value changes take place, in turn affecting women_s health. Despite this, the importance of comorbid conditions and individual personali- ties is still not clear.1<3 Psychological resilience is an indi- vidual_s capacity to prevent, minimize, or overcome stressful situations imposed by life adversity.4<7 It is a measure of how individuals cope with, overcome, or become positively strengthened by changes and challenges.8,9 Resilience is piv- otal to healthy aging, maintains well being, and has been correlated with mortality and longevity.10 Women who dis- play higher resilience may in fact have fewer menopausal complaints.11 Furthermore, complex relationships between de- pressive symptoms and resilience exist. Resilience, life satis- faction, perceived stress, and feelings of loneliness are not routinely included in tools designed to assess menopausal symptoms and related quality of life. These tools tend to spe- cifically address symptom frequency and severity, and physical and emotional aspects among perimenopausal or postmeno- pausal women, as compared with premenopausal women serving as controls.12<17 Although resilience is important for coping with meno- pause, updated studies assessing resilience, depressive symp- toms, and menopausal symptoms, specifically in postmenopausal women, are still limited.5,11,18 Therefore, the aim of the present study was to assess resilience, depressed mood, and meno- pausal symptoms among postmenopausal women. Received February 4, 2013; revised and accepted March 25, 2013. From the 1 Red de Investigacio´n en Ginecologı´a, Obstetricia y Reproduccio´n, Zaragoza, Spain; 2 Departamento de Obstetricia y Ginecologı´a, Universidad de Zaragoza, Zaragoza, Spain; 3 Departamento de Obstetricia y Ginecologı´a, Hospital de Cabuen˜es, Gijo´n, Asturias, Spain; 4 Departamento de Obstetricia y Ginecologı´a, Hospital Torreca´rdenas, Almerı´a, Spain; 5 Instituto de Biomedicina, A´ rea de Investigacio´n para la Salud de la Mujer, Facultad de Ciencias Me´dicas, Universidad Cato´lica de Santiago de Guayaquil, Gua- yaquil, Ecuador; and 6 Departamento de Obstetricia y Ginecologı´a, Hospital Central de Asturias, Universidad de Oviedo, Oviedo, Spain. Funding/support: None. Financial disclosure/conflicts of interest: None reported. Address correspondence to: Faustino R. Pe´rez-Lo´pez, MD, PhD, De- partment of Obstetrics and Gynecology, University of Zaragoza Hos- pital Clı´nico, Domingo Miral s/n, Zaragoza 50009, Spain. E-mail: Menopause, Vol. 21, No. 2, 2014 159 Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
  2. 2. METHODS Study design and participants This was a cross-sectional study carried out at the Asturias Central University Hospital (Oviedo, Spain) and the Cabuen˜es Hospital (Gijo´n, Spain), both affiliated with the University of Oviedo (Oviedo, Spain), where postmenopausal women (48-68 y) attending the outpatient clinics for their annual gyne- cological checkup were asked to fill out an itemized general questionnaire (personal and partner sociodemographic data), the Wagnild and Young Resilience Scale (WYRS), the Center for Epidemiologic Studies Depression Scale (CESD-10), and the Menopause Rating Scale (MRS).16,19<24 Participants were informed of the study and its objectives. Those who chose to participate provided a written informed consent form. Women who were unable to verbalize an adequate understanding of the study, did not provide consent for participation, or had psychological or physical incapacity imposing difficulties during the interview were excluded. This research protocol was reviewed and approved by the Asturias Ethical Commit- tee (Oviedo, Spain). General survey The general questionnaire collected the following data on women: age, parity, marital and partner status, educational level, place of residency, current height and weight (to calculate body mass index [BMI]), engagement in regular exercise (yes/no), time since menopause, surgical menopause status, smoking habit, hypertension, and use of hormone therapy (HT), psychotropic drugs, or sleep-aiding drugs. Postmeno- pause status was defined as amenorrhea in the past 12 months or bilateral oophorectomy (surgical menopause). BMI was calculated as body weight (kg) divided by height (m) squared and categorized as low (G18.5 kg/m2 ), normal (18.5-24.9 kg/m2 ), or high (Q25 kg/m2 ). Women with high BMI were further cate- gorized as overweight (25-29.99 kg/m2 ) or obese (Q30 kg/m2 ).25 Data related to the partner were provided by the participating women and included age, educational level, engagement in regular exercise (yes/no), alcohol abuse, and presence of sexual dysfunction (erectile dysfunction, premature ejacula- tion, or both). Wagnild and Young Resilience Scale The WYRS is a 14-item Likert-type scale used to assess resilience status in various age groups and under different conditions. Each item can be graded from B1[ (strongly dis- agree) to B7[ (strongly agree).20,21 Graded items are summed up to provide a total score. Although no cutoff value is available to define abnormality, lower scores are indicative of less resilience. Center for Epidemiologic Studies Depression Scale CESD-10 is a 10-item questionnaire used to assess how in- dividuals felt during the past week. This is a short version of the 20-item CESD tool.22<24 Each item can be graded according to a Likert scale: 0, rarely or none of the time (G1 d); 1, some or a little of the time (1-2 d); 2, occasionally or a moderate amount of time (3-4 d); 3, all the time (5-7 d). Items 5 and 8 are scored inversely. All graded items are summed up to provide a total score. Scores of 10 or greater were used to de- fine depressed mood.23,24 Menopause Rating Scale The MRS assesses the presence and severity of menopausal symptoms through 11 items grouped into three subscales: so- matic, psychological, and urogenital. Each item can be graded as 0 (not present), 1 (mild), 2 (moderate), 3 (severe), or 4 (very severe). Graded items within each subscale are summed up to provide a total subscale score. The total MRS score is the sum of subscale scores.16,19 A total MRS score of 17 or more is defined as severe. Sample size calculation A minimal sample size of 160 participants was calculated, assuming that 40% of participating women would present lower resilience,11,19,20 with a 10% desired precision and a 99% confidence level. Statistical methods Predictive Analytics Software version 17 (SPSS Inc, Chicago, IL) was used to perform the analyses. Data are presented as mean (SD), median [interquartile range], percen- tiles (25th-75th), percentages, coefficients, and 95% CI. The internal consistency of the instruments used (WYRS, CESD-10, and MRS) was assessed by computing Cronbach_s > co- efficients. Kolmogorov-Smirnov test was used to determine the normality of data distribution. According to this, nonparametric continuous data were compared with Mann-Whitney U test (two independent samples) or Kruskal-Wallis test (various in- dependent samples). Student_s t test or analysis of variance was used for parametric comparisons. Spearman_s Q coefficients were calculated to determine correlations between WYRS, CESD-10, and MRS scores and various numeric variables (bivariate analysis). Multiple linear regression analysis was performed to obtain two independent models: the first model analyzes variables correlating with WYRS scores (resilience, dependent variable), and the second model analyzes variables correlating with CESD-10 scores (depressed mood, dependent variable). These models were constructed from independent variables (woman and partner) achieving P e 0.10 during bivariate analysis. Entry of variables into the models was performed using a forward/backward stepwise procedure. For all calculations, P G 0.05 was con- sidered statistically significant. RESULTS During the study period, a total of 205 postmenopausal women were invited to participate. Eleven (5.4%) declined participation, and 25 (12.2%) provided incomplete data. Hence, 169 women provided complete data for statistical analysis. The general characteristics of the participants and their part- ners are depicted in Table 1. The median [interquartile range] age of participating women was 54 years [10], with 82.8% residing in urban areas, 33.1% completing primary education, 75.1% being married, and 76.9% currently having a partner. 160 Menopause, Vol. 21, No. 2, 2014 * 2013 The North American Menopause Society PE´REZ-LO´PEZ ET AL Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
  3. 3. Regarding general health, 14.2% had hypertension, 55.6% had increased BMI (overweight or obese), and 33.1% engaged in regular exercise. Comorbidity, including gastric reflux, hypo- thyroidism, and dyslipidemia (the three most frequent), was present in 29.0% of women (data not shown in Table 1). Among the women, 10.7% had surgical menopause, and 13.0% and 25.4% were taking HT and psychotropic drugs, respectively. In addition, severe menopausal symptoms and depressed mood were present in 34.9% and 45.0% of women, respectively. Data on men were available for 76.9% of women who stated that they currently have a partner (n = 100/130). The median [interquartile range] age was 59 years [7.0]. Twenty- five percent of the women exercised regularly, 3.0% abused alcohol, and 39.0% had primary education only. Erectile dysfunction was present in 17.0%, and premature ejaculation was present in 3.0%. A descriptive analysis of MRS, WYRS, and CESD-10 scores is depicted in Table 2. The computed Cronbach_s > coeffi- cients for CESD-10, WYRS, and MRS were 0.813, 0.893, and 0.849, respectively. Spearman_s Q coefficients between tools (CESD-10, WYRS, and MRS) and other numeric variables are depicted in Table 3. There was a significant inverse correlation between WYRS scores and depressed mood (higher CESD-10 scores) and severe menopausal symptoms (higher total, psy- chological subscale, and urogenital subscale MRS scores). There was also a positive correlation between CESD-10 scores (more depressed mood) and MRS scores (total score and all subscale scores). Multiple linear regression analysis was used to obtain two final reduced best-fit models displaying variables correlating with WYRS and CESD-10 scores (Table 4). In the first model (explaining 22.7% of the total variance), WYRS scores in- versely correlated with depressed mood and positively corre- lated with women_s regular exercise. In the second model (explaining 53.2% of the total variance), CESD-10 scores positively correlated with somatic and psychological MRS scores and inversely correlated with WYRS scores. DISCUSSION The present study aimed to assess resilience in a sample of postmenopausal women and to establish correlations with de- pressed mood and menopausal symptoms after controlling for several sociodemographic factors. The tools used in our study have been widely validated under different conditions in other studies, displaying high internal consistencies,5,6,11,16,20<24,26,27 in correlation with our results. Severe menopausal symptoms (as assessed with the MRS) were present in one third of the participating women, despite the relatively low rate of HT use (13%). HT use is particularly infrequent among Spanish women and those from other re- gions. This occurred basically because of the negative infor- mation on HT disseminated in the last decade after the publication of the Women_s Health Initiative trial results.19,27,28 Three validated instruments were used in the present research to render a more profound understanding of menopause-related resilience. Overall, upon bivariate analysis, WYRS scores displayed significant correlations with depressive scores and all MRS scores (except for the somatic subscale). Depressive scores correlated with resilience scores and all MRS subscale scores (Table 3). Resilience is the ability to be reinforced after overcoming life difficulties or stressing events. This ability has genetic, TABLE 1. General characteristics of the participants and their partners Parameters Women (n = 169) Age, y 54.0 [10.0] e50 55 (32.5) 51-55 45 (26.6) 56-60 40 (23.7) 960 29 (17.2) Parity 2.0 [1.0] Nulliparous 33 (19.5) 1-2 114 (67.5) Q3 22 (13.0) Marital status Married 127 (75.1) Single 17 (10.1) Widowed 9 (5.3) Divorced 13 (7.7) Cohabiting 3 (1.8) Currently has a partner 130 (76.9) Highest educational level achieved Primary school 56 (33.1) High school 77 (45.6) University 36 (21.3) Urban residency 140 (82.8) Body mass index, kg/m2 25.1 [5.9] Low 2 (1.2) Normal 73 (43.2) Overweight 63 (37.3) Obese 31 (18.3) Engages in regular exercise 56 (33.1) Current smoker 30 (17.8) Hypertension 24 (14.2) Time since menopause onset, y 3.0 [8.0] G5 92 (54.4) 5-7 77 (45.6) Q8 45 (26.6) Surgical menopause 18 (10.7) Depressed mood (CESD-10 score Q10) 76 (45) Severe menopausal symptoms (total MRS score Q17) 59 (34.9) Current use of HT 22 (13.0) Current use of psychotropic drugs 43 (25.4) Current use of sleep-aiding drugs 64 (37.9) Partner data (n = 100) Age, y 59.0 [7.0] e50 5 (5.0) 51-55 21 (21.0) 56-60 35 (35.0) 61-65 29 (29.0) 965 10 (10.0) Highest educational level achieved Primary school 39 (39.0) High school 44 (44.0) University 17 (17.0) Engages in regular exercise 25 (25.0) Alcohol abuse 3 (3.0) Erectile dysfunction 17 (17.0) Premature ejaculation 3 (3.0) Data are presented as n (%) or median [interquartile range]. CESD-10, Center for Epidemiologic Studies Depression Scale; MRS, Meno- pause Rating Scale; HT, hormone therapy. Menopause, Vol. 21, No. 2, 2014 161 RESILIENCE IN POSTMENOPAUSAL WOMEN Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
  4. 4. neural, health, learning, economic, stress, and social compo- nents.3<6,11,18,29,30 Menopausal transition is a long process that is lived, in many cases, with negative feelings and lack of support. Therefore, a resilient woman can better cope with adversity. However, assessing all the components of resilience is not easy. Many tools assess indirect measures of resil- ience such as self-esteem, sense of coherence, loneliness, or happiness.26,30<32 The WYRS, on the other hand, displays high measures of consistency and correlation with life satis- faction scales.4,20,21 Few studies have analyzed resilience in middle-aged women, specifically postmenopausal women. In a large female German sample (18-92 y), life satisfaction was associated with younger age, resilience, employment status, higher household income, having a partner, lack of anxiety and depression, good self- esteem, and religious affiliation.5 In this population, there was a significant reduction of resilience between the ages of 61 and 70 years (most pronounced after 70 y). Resilience positively correlated with life satisfaction and self-esteem and inversely correlated with anxiety and depression. In a previous study of middle-aged Ecuadorian women, lower WYRS scores (less resilience) correlated with more se- vere hot flushes.11 Duffy et al18 studied factors associated with resilience and vulnerability to hot flushes and night sweats during the menopausal transition in a female Scottish sample. Women resilient to hot flushes had previously not been both- ered by their menstrual periods, did not experience somatic symptoms or night sweats, and perceived their symptoms as having low consequences on their lives. Those vulnerable to hot flushes had children, had high BMI, reported night sweats, and perceived their symptoms as having high life consequences. Women resilient to night sweats were non- smokers, did not have sleep difficulties, were not treated for psychological symptoms, and perceived their menopausal symp- toms as having low life consequences. Those vulnerable to night sweats had lower education, had previously been bothered by their menstrual periods, had below-average physical health, reported musculoskeletal symptoms and hot flushes, and per- ceived their menopausal symptoms as having high life con- sequences. In our study, although WYRS scores displayed significant bivariate correlations with all MRS scores (except for the somatic subscale), no correlation was found between WYRS scores and any of the MRS scores, interestingly, after multivariate linear regression analysis. CESD-10 is a validated instrument for detecting depressed mood, which accounted for 45.0% of our postmenopausal population. Our multivariate analysis found that resilience was inversely related to depressive mood (higher CESD-10 scores) and positively related to exercising regularly. Reports indicate that the prevalence of depression is higher in women than in men and tends to increase as women age. The causal role of this increaseVwhether related to age, progressive hormonal decrease, or bothVis still a matter of controversy.33 Using the long version of CESD in an 8-year longitudinal study, Freeman et al34 demonstrated that total CESD scores of 16 or higher (depressed mood) and depressive disorders were, respectively, 4 and 2.5 times more likely to occur during the menopausal transition as compared with the premenopausal years. In a middle-aged and multiethnic female sample, Woods and Mitchell35 used CESD and other tools to develop a multi- dimensional model for explaining depressed mood. Three as- pects were identified as correlating with depressed mood: TABLE 2. Descriptive analysis of MRS, WYRS, and CESD-10 scores (n = 169) MRS (> = 0.849)a WYRS (> = 0.893)a CESD-10 (> = 0.813)a Total Somatic Psychological Urogenital Mean 13.9 5.3 5.1 3.4 77.7 9.3 Median 13.0 5.0 5.0 3.0 79.0 8.0 25th-75th percentiles 8.0-19.0 3.0-7.0 2.0-7.0 1.0-5.0 70.0-87.0 5.0-12.5 Interquartile range 11.0 4.0 5.0 4.0 17.0 7.5 MRS, Menopause Rating Scale; WYRS, Wagnild and Young Resilience Scale; CESD-10, Center for Epidemiologic Studies Depression Scale. a Values in parentheses represent the computed Cronbach’s > coefficient for the scale. TABLE 3. Spearman_s Q coefficients obtained between tool scores and various numeric variables WYRS CESD-10 MRS Total Somatic Psychological Urogenital Age j0.069 0.065 0.177 0.252 0.086 0.146 P 0.370 0.404 0.021 0.001 0.267 0.058 Parity 0.059 0.031 0.107 0.135 0.007 0.142 P 0.449 0.689 0.165 0.079 0.927 0.065 Body mass index j0.069 0.133 0.107 0.166 0.101 j0.007 P 0.371 0.085 0.166 0.031 0.190 0.932 WYRS Y j0.432 j0.248 j0.143 j0.295 j0.157 P G0.001 0.001 0.063 G0.001 0.042 CESD-10 Y Y 0.610 0.487 0.642 0.346 P G0.001 G0.001 G0.001 G0.001 WYRS, Wagnild and Young Resilience Scale; CESD-10, Center for Epidemiologic Studies Depression Scale; MRS, Menopause Rating Scale. 162 Menopause, Vol. 21, No. 2, 2014 * 2013 The North American Menopause Society PE´REZ-LO´PEZ ET AL Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
  5. 5. menopausal transition, health status, and stressful life context. The latter was considered the most important factor, whereas health status had a direct effect and an indirect effect through stress, and menopausal changes had low explanatory power. A large number of neurobiological and psychosocial factors are associated with depression and resilience. Positive psychoso- cial factors, such as optimism, humor, cognitive flexibility, so- cial support, role models, coping style, and capacity to recover, are reduced in depressed individuals, which may explain the inverse correlation between resilience and depression found in our study. It is probable that neurobiological changes associated with depressive mood may secondarily affect resilience capac- ity36 orVseen the other way aroundVthat less resilient persons may be more vulnerable to developing depression. Further research may indeed give insights into determining which is cause and which is consequence. Cognitive vulnerable indivi- duals have a severe risk of losing resilience because of de- pression, whereas social support and positive life events may enhance their resilience.35 Therefore, cognitive education aimed at highlighting positive experiences during menopause may boost resilience. It is interesting to recall that our population displayed comorbid conditions (hypertension and sleep disor- ders) that may also contribute to the alteration of the neuro- biology of resilience and depression in labile women. A stressful life context and associated issues may be important determi- nants of depressed mood. It has been reported that bad health status has a direct effect on mood and an indirect effect on per- ceived stress, whereas menopausal changes have low power at explaining depressive mood.33,35 Our regression model found that women who exercised regularly displayed higher resilience. In one study, low spiri- tuality among individuals with depression and anxiety was revealed as a leading predictor of lower resilience, and less frequent exercise was associated with moderate resilience.37 Our results seem to suggest that exercising may contribute to increased resilience and may improve treatment response among those who display depressed mood. This may in fact be true for those women who display higher BMI (who may engage in less exercises). Unfortunately, our regression model did not find a correlation between resilience and depressive scores and BMI. Nevertheless, we have previously reported11 that women with higher abdominal circumference (obesity) display lower resilience. Hence, in this high-risk group, ex- ercise may have a positive impact on mood and resilience. In any case, further studies are needed to delineate the separate influences of exercise intensity and exercise-related body changes associated with both depressed mood and resilience. The regression model for CESD-10 scores in our study found a significant and positive correlation between depressive scores and menopausal somatic and psychological symptoms. This is in agreement with our previous research in which middle-aged women (premenopausal, perimenopausal, and postmenopausal) displayed a high prevalence of depressed mood in correlation with more severe menopausal symptoms (somatic and psycho- logical) assessed with the same MRS.38 It is very well known that estradiol deprivation in postmenopausal women may in- crease depressive39 and menopausal1,2,28 symptoms. Finally, the cross-sectional design, which does not allow for the determination of causality for neither resilience nor de- pressed mood, is a limitation of this study. Although surveying only postmenopausal women does not allow for an analysis of the effects of age or menopause status on resilience or depres- sion status, selecting them (who may in fact be consulting for morbidity) from a gynecological outpatient service or a single Spanish site does not allow for a generalization of results to the rest of the Spanish population. Other potential drawbacks in- clude not assessing exercise intensity and finding moderate Q values upon bivariate analysis. Despite all the aforementioned limitations, there have been few reports addressing resilience during the menopausal transition and even fewer studies reporting specifically on postmenopausal women. Hence, to the best of our knowledge, the present study seems to be among the few studies reported to date. More studies that analyze psychosocial and sociodemographic factors, using resilience scales, among middle-aged women (including premenopausal, perimenopausal, and postmeno- pausal women) are needed. CONCLUSIONS In this postmenopausal female sample, depressed mood and participation in regular exercise correlate with lower and higher resilience, respectively. Depressed mood is associated with the severity of menopausal symptoms, specifically somatic and psychological symptoms. Although these correlations do not explain causality, they do, however, highlight the need to in- clude resilience, mood, and other life satisfaction aspects in the design of future tools assessing menopausal symptoms. TABLE 4. Factors correlating with WYRS and CESD-10 scores: multiple linear regression analysis Factors A SE 95% CI t P Model for WYRS scores (n = 169) Total CESD-10 score j0.911 0.148 j1.204 to j0.617 j6.133 G0.001 Regular exercise 2.439 0.984 0.496 to 4.382 2.478 0.014 r2 = 0.237; adjusted r2 = 0.227; P = 0.014 Model for CESD-10 scores (n = 169) Total WYRS score j0.130 0.026 j0.181 to j0.079 j5.007 G0.001 MRS somatic score 0.463 0.141 0.184 to 0.741 3.280 0.001 MRS psychological score 0.752 0.117 0.521 to 0.982 6.422 G0.001 r2 = 0.541; adjusted r2 = 0.532; P G 0.001 WYRS, Wagnild and Young Resilience Scale; CESD-10, Center for Epidemiologic Studies Depression Scale; MRS, Menopause Rating Scale. Menopause, Vol. 21, No. 2, 2014 163 RESILIENCE IN POSTMENOPAUSAL WOMEN Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.
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