Perceived control, lifestyle, health, socio-demographic factors and menopause: Impact on hot flashes and night sweats

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ContentslistsavailableatScienceDirect

Maturitas

j ou rna l h o me pa g e:w w w . e l s e v i e r . c o m / l o c a t e / m a t u r i t a s

Perceived

control,

lifestyle,

health,

socio-demographic

factors

and

menopause:

Impact

on

hot

ﬂashes

and

night

sweats

Filipa

Pimenta

∗

,

Isabel

Leal,

João

Maroco,

Catarina

Ramos

PsychologyandHealthResearchUnit,ISPA–InstitutoUniversitário,RuaJardimdoTabaco,34,1149-041Lisboa,Portugal

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received18February2011

Receivedinrevisedform21March2011 Accepted4May2011 Keywords: Hotﬂashes Nightsweats Predictors Perceivedcontrol Lifestyle Socio-demographic

a

b

s

t

r

a

c

t

Objective:Todevelopamodeltopredicttheperceivedseverityofhotﬂashes(HF)andnightsweats(NS) insymptomaticmiddle-agedwomen.

Methods:Thiswasacross-sectionalstudyofacommunity-basedsampleof243womenwithvasomotor symptoms.Menopausalstatuswasascertainedusingthe‘StagesofReproductiveAgingWorkshop’ crite-ria.Women’s‘perceivedcontrol’overtheirsymptomswasmeasuredbyavalidatedPortugueseversionof thePerceivedControloverHotFlushesIndex.Structuralequationmodellingwasemployedtoconstruct acausalmodelofself-reportedseverityofbothHFandNS,usingasetof20variables:age,maritalstatus, parity,professionalstatus,educationallevel,familyannualincome,recentdiseasesandpsychological problems,medicalhelp-seekingbehaviourtomanagemenopausalsymptoms,useofhormonetherapy andherbal/soyproducts,menopausestatus,intakeofalcohol,coffeeandhotbeverages,smoking,physical exercise,bodymassindexandperceivedcontrol.

Results:Signiﬁcantpredictorsof perceivedseverity weretheuseofhormone therapyforbothHF (ˇ=−.245;p=.022)andNS(ˇ=−.298;p=.008),coffeeintakeforbothHF(ˇ=−.234;p=.039)andNS (ˇ=−.258;p=.029)andperceivedcontrolforbothHF(ˇ=−1.0;p<.001)andNS(ˇ=−1.0;p<.001).The variablesexplainedrespectively67%and72%ofthevariabilityintheperceivedseverityofHFandNS. Womenwithhighperceivedcontrolhadasigniﬁcantlylowerfrequency(t(235)=2.022;p=.044)and intensityofHF(t(217)=3.582;p<.001);similarly,participantswithhighperceivedcontrolpresenteda lowerfrequency(t(235)=3.267;p<.001)andintensity(t(210)=3.376;p<.001)ofNS.

Conclusion:Perceivedcontrolwasthestrongestpredictoroftheself-reportedseverityofbothHFandNS. Othercausalpredictorswerehormonetherapyandcaffeineintake.Allthreewereassociatedwithless severevasomotorsymptoms.

1. Introduction

Mostwomenexperiencevasomotorsymptomsduringmidlife; inparticular,thereisanincreaseinthereportingofthesesymptoms aswomengofromonemenopausalstagetothenext[1].Although around70%ofwomenreportvasomotorsymptoms[2],onlyafew considerthembothersome:inonestudyjust9%consideredhot ﬂashes(HF)tobebothersome,while 6%described nightsweats (NS)astroublesome [3].Thesesametwo setsof symptomsare consideredproblematicby12–20%ofwomen[2,4].Regardingthe menopausalstages,ithasbeenshownthatlateperi-menopause (duringwhichamenorrhealasting2monthsormoremayoccur) andpost-menopause(whichstartsaftertheﬁnalmenstrualperiod) [5]arestronglyassociatedwithbothersomeHF[1].

∗ Correspondingauthor.Tel.:+351218811700;fax:+351218860954. E-mailaddress:ﬁlipa pimenta@ispa.pt(F.Pimenta).

Unsurprisingly,health-andmenopause-relatedvariableshave beenreportedtohaveaneffectonvasomotorsymptoms:theuse hormonaltherapydecreasestheirbothersomeness[6,7];havinga goodhealthstatusdiminishesboththeirfrequencyandthe asso-ciated distress [3]; and less medical help-seeking is associated withlessfrequentandlessseveresymptoms[8–10].Furthermore, despitethephysiologicalnatureofthesesymptoms,ithasbeen shownthatsocio-demographicandlifestylefactorshaveanimpact: lowcaffeineintakepredictsalowersymptomseverity[11,12];high perceivedcontrolisrelatedtolowerfrequencyanddistress[13]; ahighereducationallevelpredictslowerprevalenceandseverity [4,8,14,15];andnotbeingdivorcedisassociatedwithalowerrating ofhowbothersomethesesymptomsarereportedtobe[8].

Someothercharacteristicshavebeenreportedinsomebutnot allstudiestobeassociatedwithvasomotorsymptoms.Forinstance, alcohol [3,11,12,14,16], smoking [1,3,8,12,17], physical exercise [1,10,11,14,15],bodymassindex(BMI)[4,12,14,18–20]and educa-tionallevel[3]haveallbeenreportedtopredicteitheranincrease orasigniﬁcantdecreaseinthereportingofvasomotorsymptoms. 0378-5122/$–seefrontmatter © 2011 Elsevier Ireland Ltd. All rights reserved.

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Somefactorsmayhaveanimpactonboth(HFandNS)orononly onesymptom.

Researchintoavarietyofhealth-relatedconditionshasfound thatperceivedcontroloversymptomsisastrongpredictorofless emotionaldistress[21],lowerprevalenceandseverityofsymptoms [22,23],andofengagementinhealth-protectivebehaviours[24].

Thepresentresearchhad theobjective ofexploringwhether socio-demographic,health-related and menopause-related vari-ables,aswellaslifestylefactorsandperceivedcontrol,predictthe severityofvasomotorsymptoms(measuredasthefrequencyand intensityofHFandNSseparately)inasymptomaticcommunity sampleofpre-,peri-andpost-menopausalwomen.

2. Materialsandmethods 2.1. Participants

Acommunitysampleofwomenwhohadreportedhavinghot ﬂashes(HF)and/ornightsweats(NS)inthepreviousmonthﬁlled inaseriesofself-reportmeasures(seebelow)thatassessedthe frequencyandintensityofvasomotorsymptoms,perceivedcontrol, socio-demographic,health-andmenopause-relatedvariables,and lifestylecharacteristics.

Table1summarizesthecharacteristicsofthesample.The inclu-sioncriteriainthisresearchwerefemalegender,age42–60years andtheexperienceofvasomotorsymptomsinthelastmonth(HF and/orNS).Thestudyinstruments(seebelow)wereﬁlledinby302 women.Fromthistotal,59womenwereexcludedfornot provid-inginformationregardingthefrequencyandintensityofHFandNS, orbecausetheyhadnotexperiencedtheminthepreviousmonth. Thisleft243womenforwhomdatacouldbeanalysed.

2.2. Procedure

Thecommunitysamplewasrecruitedmainlythroughschools anduniversitiesinthecityof Lisbon.Questionnairesand forms forwritteninformedconsentweregiventostudents,insidesealed envelopes,totaketotheirmothers.

TheAmericanPsychologicalAssociation’sstandardsonethical treatmentof participantswerefollowed. The informedconsent formexplained theaims of thestudy; it emphasized that par-ticipation in the research was voluntary and that participants couldinterrupttheircollaborationatanytime,withoutany con-sequences.Eachparticipantkeptacopyoftheinformedconsent form,onwhichcontactdetailsfortheresponsibleresearcherwere included(sothatwomencouldcontactheriftheyhadanyquestions duringthecourseofthestudy).

2.3. Measures

Twoitems of theMenopause Symptoms’ SeverityInventory (MSSI-38)[25]wereusedtoassessHFandNSduringthe previ-ousmonth,intermsofbothfrequencyandintensity,onaﬁve-point Likertscale(from0to4)thatrangedfrom‘never’to‘dailyoralmost everyday’,andfrom‘notintense’to‘extremeintensity’.The per-ceivedseverityofHFandNSwasgivenbythemeanofthefrequency andintensityvaluesforeachsymptom.

Toevaluateperceivedcontrol,the Portuguesevalidated ver-sionofthePerceivedControloverHotFlushesIndexwasapplied [13]. This version excluded item 15 (‘I want to learn as much as Ican about hot flashes and themenopause’), as it was not significantlycorrelatedwiththeconstruct,presentinganegative standardizedestimate(=−.105;p=.134),andonly1.1%ofits vari-ancewasexplainedbytheconstruct.Moreover,themodification index(MI=33.785)showedthatthisitemhadthestrongest nega-tiveinfluenceonthequalityoffitofthemeasurementmodel.The

Table1

Characterization of participants in relation to socio-demographic, health, menopause-relatedandlifestylevariables.

Characteristics Participants

n %

Age(M;SD) 51.8±4.501

Maritalstatus

Marriedorinarelationship 171 70.7

Notmarriednorinarelationship 71 29.3

Parity 0 25 10.6 1 84 35.6 2 99 41.9 3 21 8.9 >3 7 2.9 Education Primaryschool 34 14.3 Middleschool 65 27.4 Highschool 60 25.3 Universitydegree 78 32.9 Professionalstatus Active 197 82.8 Inactive 41 17.2

Familyannualincome

≤10.000D 56 26.7 10.001–20.000D 52 24.8 20.001–37.500D 54 25.7 37.501–70.000D 34 16.2 ≥70.001D 14 6.7 Recentdisease Yes 62 26.3 No 174 73.7

Recentpsychologicalproblem

Yes 55 23.1

No 183 76.9

Searchformedicalhelptodealwithmenopause

Yes 155 70.8

No 64 29.2

Hormonetherapy(HT),herbal/soytherapyornothing

HT 23 10.5 Herbal/soytherapy 31 14.1 Nothing 166 75.5 Menopausalstatus Pre- 15 6.3 Peri- 75 31.5 Post- 148 62.2

Bodymassindex(kg/m2₎_(M,_SD) _26.3_±_4.826

≤24.9 112 46.9 >24.9 127 53.1 Physicalactivity Yes 105 43.8 No 135 56.3 Smokingbehaviour Currentsmoker 58 24.2 Currentnon-smoker 182 75.8 Alcoholconsumption Yes 129 53.5 No 112 46.5 Coffeeconsumption Yes 208 86.3 No 33 13.7

Hotbeveragesintake

Daily 198 87.6

Occasionallyornever 28 12.4

resulting14-iteminstrumentpresentedgoodpsychometric

prop-erties.Conﬁrmatory factoranalysisof theinstrument showeda

goodﬁt(2_/df₌_2.239;_CFI₌_.888;_GFI₌_.909;_RMSEA₌_.072;_CI_90%

.057to.086;p=.009).Itsreliability(estimatedbyCronbach’salpha)

wasalsogood(.78).

MenopausalstatuswasdeﬁnedaccordingtotheStagesof

Repro-ductiveAgingWorkshopcriteria[5].Pre-menopausalwomenwere

thosewho hadnotexperienced anychanges intheirmenstrual cycle.Peri-menopausal participantswerethose who reporteda variablecyclelength(adifferencefrom‘usual’ofmorethan7days)

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orwhohadmissedtwoormorecyclesandhadhadanepisodeof amenorrhealastingover60days.Post-menopausalwomenwere thosewhohadhadatleast12monthsofamenorrhea.

Also assessed were socio-demographic characteristics (age, maritalstatus,parity,professionalstatus,educationallevel, fam-ily’sannualincome),andhealth-andmenopause-relatedvariables (recentdiseasesandpsychologicalproblems,medicalhelp-seeking tomanagemenopause,anduseofhormonetherapyandherbal/soy products),aswellaslifestyle(intakeofalcohol,coffeeandother hotbeverages,smoking,physicalexerciseandbodymassindex). Thelifestylevariableswereassessedintermsofpresence/absence, amountand/orfrequency.Forexample,physicalexercisewas mea-suredintermsoftimesperweek,andforhowmanyminutesthe participantexercised;ameanvalueforweeklyfrequencyand dura-tionwasusedinthemultivariatemodel.Intakeofcoffeeandother hotbeverages,whenpresent,wasassessedonafour-pointscale, rangingfrom‘occasionally’ to‘morethan ﬁveper day’. Alcohol intake,whenobserved,wasmeasuredintermsofbothfrequency (daily,everyweekendorrarely)andquantity(untilIfeeldrunk, moderately,orless thanone glassper occasion);a meanvalue ofbothwasusedasasinglealcoholconsumptionvariableinthe causalmodel.Finally,forcurrentsmokers,smokingwasquantiﬁed onasix-pointLikert-typescalethatrangedfrom‘fewerthan10 cigarettespermonth’to‘morethan40cigarettesperday’. 2.4. Statisticalanalysis

Valueswereimputedforvariableswherethefrequencyof miss-ingdatawaslowerthan10%ofthesample.Thiswasdoneusingthe meaninterpolationmethod.

Multi-collinearity between the independent variables was exploredwiththevarianceinﬂationfactorgivenbySPSSStatistics (v.19,IBMSPSSInc,Chicago,IL).Allvariablespresentedavalue below5,indicatingtheabsenceofcollinearity[26,27].

Totestthecausalmodelforvasomotorsymptoms,astructural equationmodelwasbuiltrelating thetwo dependentvariables (perceivedseverityofHFandofNS)with20independentvariables:

perceivedcontrol;age;maritalstatus;parity;professionalstatus; family’s annual income;educational level;transition from pre-toperi-andfromperi-topost-menopause;medicalhelp-seeking behaviour; use of hormone therapy or herbal/soy products for menopausalsymptoms;presenceofarecentpsychological prob-lemora disease;alcohol intake;intakeofcoffee andotherhot beverages;smoking;physicalexercise;andbodymassindex.

ThemodelwasevaluatedwithSPSSAMOSsoftware(v.18,IBM SPSSInc,Chicago,IL).Thequalityoftheﬁtofthestructuralmodel wasevaluatedusingchi-squarestatistics(2_/df),_comparative_ﬁt

index(CFI),goodnessofﬁtindex(GFI)androotmeansquareerror ofapproximation(RMSEA),againstthereferencevaluescurrently recommendedforstructuralequationmodelling[27,28].

Atwo-stepapproachwasemployedtoevaluatethecausal struc-turalmodel.First,eachfactor’smeasurementmodelwasevaluated todemonstrateanacceptableﬁt.Thereafter,thestructuralcausal model,encompassingthetwodependentandthe20independent variables,wasadjustedandthesigniﬁcanceofthecausal trajecto-rieswasevaluated.

Groupdifferenceswereevaluatedwithone-wayanalysisof vari-ance(ANOVA)(followedbypost-hocTukey’stest)andStudent-t testsimplementedinSPSSStatistics(v.19,IBMSPSSInc,Chicago, IL).Thehomogeneityofthevarianceswasconﬁrmedbeforethe Studentt-testswereconducted.

Amediansplitwasusedtodividetheparticipantsintoahigh perceivedcontrol(HPC)groupandalowperceivedcontrol(LPC) group,forthepurposesofcomparison.

3. Results

Both the measurement model (2_/df₌_2.786; _CFI₌_.891;

GFI=.910; RMSEA=.077; CI 90% .065 to.090; p<.001)and the causalmodel(2_/df₌_1.593;_CFI₌_.888;_GFI₌_.890;_RMSEA₌_.049;_CI

90%.042to.057;p=.534)showedagoodﬁt.Signiﬁcantpredictors arehighlightedinFig.1.

As shown, the causal model accounted for 72% and 67% of thevariabilityintheperceivedseverityofnightsweats(NS)and

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Table2

Differencesinfrequencyandintensityofhotﬂashes(HF)andnightsweats(NS) betweenwomenwithhigh(HPC)andlowperceivedcontrol(LPC).

M(SD) t-Student HPCvs.LPCt(df)pa LPC HPC FrequencyofHF 3.4(1.209) 3.1(1.172) 2.022(235)* IntensityofHF 3.4(1.188) 2.8(1.110) 3.582(217)*** FrequencyofNS 3.3(1.400) 2.7(1.279) 3.267(235)*** IntensityofNS 3.2(1.388) 2.6(1.172) 3.376(210)*** a_p_(2-tailed) * _p_<_.05. ***_p_<_.001.

hot ﬂashes (HF), respectively. Signiﬁcant predictors were: hor-monetherapyforbothHF(ˇ=−.245;p=.022)andNS(ˇ=−.298; p=.008); coffee intakefor both HF(ˇ=−.234; p=.039) and NS (_ˇ=_−.258;p=.029);andperceivedcontrolforbothHF(_ˇ=_−1.0; p<.001)andNS(ˇ=−1.0;p<.001).

Themedianperceivedcontrolscorewas34.1(SD=5.977).This issimilartovaluesfoundinpreviousstudies[13,29].Lowperceived control(LPC),thatis,below34.1, wasrecordedfor104women inthepresentsample;139recordedhighperceivedcontrol(HPC) (scoresabove34.1).Inthissymptomaticsampletherewere signif-icantdifferencesbetweentheHPCandLPCgroupsregardingboth thefrequencyandtheintensityofvasomotorsymptoms(Table2). Perceived control was not signiﬁcantly associated with age (Pearsoncorrelationr=−.040;p=.536).

Regarding perceived control in women who used hormone therapy (HT), herbal/soy products or nothing to manage the menopausalsymptoms,thereweresigniﬁcantdifferencesbetween groups. Participants who did not take anything for the symp-tomsscored higher for perceivedcontrol than those who took HT(MD=.275;p=.009). Womenwhoused herbal/soyproducts alsohadhigherscoresforperceivedcontrolthanthosewhotook HT(MD=.297; p=.026). No signiﬁcantdifferencewasobserved betweenwomenwhousedherbal/soytherapyandthosewhodid notuseanythingtomanagesymptoms(MD=.022;p=.960).

Toexplorewhetherthesedifferencescouldbeexplainedby dif-ferentperceivedseverityscores,thethreegroups (womenwho usedHT,whousedherbal/soyproductsandwhousednothingto managetheirsymptoms)werecomparedconcerningthereported severityof vasomotorsymptoms.Therewerenosigniﬁcant dif-ferencesbetweenthethreegroupsinrelationtoHF(F(2)=1.848; p=.160)ortoNS(F(2)=1.491;p=.227).

4. Discussion

Socio-demographicvariables(age,maritalstatus,professional status,parity,educationallevel,andannualincome)and health-relatedvariableswerenotsigniﬁcantpredictorsoftheperceived severityofhotﬂashes(HF)andnightsweats(NS).Theseresultsgo againstwhathasbeenreportedfromotherstudies[3,4,8–10,14,15]. Nevertheless,thisabsenceofarelationhasbeenreported previ-ously[30].

Althoughintakeofalcohol [3,11,12,14,16]andhot beverages [12], physical exercise [1,10,11,14,15], body mass index (BMI) [4,12,14,18–20]andsmoking[1,3,8,12,17]havebeenconsidered predictorsofvasomotorsymptoms,thevastmajorityoflifestyle factorsinthepresentstudyhadnocausalassociationswiththe perceivedseverityofthesesymptoms.

In one of the previous studies which indicated that a high BMIisassociated withHF,participantshad ahigher meanBMI (29.8kg/m2₎_[30]_than_participants_in_the_present_study_(M₌_26.3;

SD=4.826),andthiscouldpartiallyexplaintheabsenceofacausal relationfoundhere.

Hormonetherapy(HT)significantlypredictedalowerperceived severityofbothHFandNS,whichiscongruentwithprevious stud-ies[6,7]. Moreover,and asReynolds [13] alsofound, perceived controlvariessignificantlybetweenwomenwhouseHT,herbal/soy productsornothingformenopausalsymptoms:participantswho usednomedicationorwhousedherbal/soyproductstoease vaso-motorsymptomshadahigherperceivedcontrolthanthosewho weretakingHT.Thisresultwasnotduetodifferencesinthe symp-toms’severity,asthisdidnotsignificantlydifferbetweenthethree groups.Additionally,inthissymptomaticsample,women catego-rizedashavinghighperceivedcontrol(i.e.,scoresgreaterthan34, onamediansplit)hadalowerfrequencyandintensityofbothtypes ofvasomotorsymptomsthanwomencategorizedaslowperceived control.Althoughtheconstructofperceivedcontrolisorientedto HT,significantdifferenceswerealsofoundinrelationtoNS.

CongruentwithReynolds’[13,29]results,therewasno associa-tionbetweenageandperceivedcontrol.Apreviousstudysimilarly foundthatperceivedcontrolandhealthchangesarestrongly asso-ciatedin women over 65 years of age,but not in middle-aged participants[31].

Caffeineintakehaspreviouslybeenfoundtobeapositive pre-dictorofHF[11,12].However,inthepresentstudytheamount ofcoffee consumedwasastrongnegativepredictorofthe per-ceivedseverityofvasomotorsymptoms:womenwhodrankmore coffeehad lessseverevasomotorsymptomsthantheoneswho dranklesscoffee.Caffeineisacentralnervoussystemstimulant [32];itincreasesclarityofthought,limitsfatigueanddrowsiness, increasesconcentrationandmotoractivityanddiminishesreaction time[33].It ispossiblethatthesebehaviouraloutcomesof caf-feineintakearepartiallyassociatedwitheffectivecopingstrategies, whichwouldeventuallydecreasevasomotorsymptoms.

Also, certain selective serotonin reuptake inhibitors (SSRIs), whichcanbeusedinthetreatmentofHF[34],aremetabolizedby thesameisoenzymethatisinvolvedinthemetabolismofcaffeine [32].Despitethishighpotentialforpharmacokineticinteraction, with an expected inhibition of SSRI metabolism, coffee intake predicteda decreasein theself-reportedseverityof vasomotor symptomsinthissample.Itcanbehypothesizedthatthisstrong predictiveeffectresultsfromaninteractionofcaffeinewithother substances(i.e.otherthanSSRIs),whichwerenotexaminedinthis researchandcouldreducetheseverityofvasomotorsymptoms. Moreover,decreasedestronelevelshavebeenobservedinwomen withvasomotorsymptoms[35],andcaffeineintakeispositively associatedwithestronelevels[36]. Thismight partiallyexplain howcoffeecouldbeastrongnegativepredictorofthereported severityofHFandNS.Thisneedsfurtherexplorationand conﬁr-mationinothersamples,controllingforothersourcesofcaffeine intake(suchasteaandsoftdrinks).

Highperceivedcontrolhasbeenreportedtobeassociatedwith thereportingoffewerandlessseveresymptomsindiverseareas [21–23],andalsospeciﬁcallyinrelationtoHF[13,37].Inthis sam-ple,this associationwasvery strongand signiﬁcant,evenafter controllingforallthesocio-demographic,health-and menopause-relatedfactors,aswellasavarietyoflifestyle variables.Infact, perceivedcontrolhadthestrongestimpactontheperceived sever-ityofvasomotorsymptoms.Itcouldbehypothesizedthat,since perceivedcontrolhasbeenassociatedwithbehaviouralchangesin otherareas[24],somebehaviouraladjustments(perhapsdressing withseverallayersofclothingtoallowmorescopeforadjustingto ambienttemperature,avoidingspicyfoods,effectivestress man-agement),stronglyassociatedwithasenseofcontrol,mayhave ledtothereductioninsymptoms’severity.

The fact that perceived control had the strongest negative impactonself-reportedsymptoms’severityemphasizesthe impor-tanceof cognitiveappraisal. Reynolds[13] alsohighlightedthis whenconcludingthat,althoughthedistressassociatedwithHFwas

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higherinwomenwhoexperiencedthesymptommorefrequently, lowlevelsofperceivedcontrolwereevenmorepredictiveof dis-tressthanfrequencyitself.Furthermore,cognitiveappraisalshave beenidentiﬁedasaccountingforsomeoftheindividualvariation regardingHF[38].Theseconclusionsaresupportedbythefactthat thefrequencyofHFcandecreasebyaround20–40%withplacebo effectsalone[39].

However,fromthepresentstudyitcouldalsobehypothesized thathigherperceivedcontrolisaconsequenceoflowerseverityof HFandNS.Therefore,itisrecommendedthatfurtherinvestigation clariﬁesthis,evidentlystrong,association.

Thesamplesize(243participants)wasadequateforthistypeof statisticalanalysis,as10subjectspermanifestvariableis recom-mendedforstructuralequationmodelling[27,40].Nevertheless, thefactthatthisresearchhadacross-sectionaldesign,anduseda samplewhereathirdofthewomenhadacollegedegree,limitsthe generalizabilityoftheresults.

5. Conclusions

Perceivedcontrolwasthestrongestnegativepredictorofthe self-reportedseverityofvasomotorsymptoms:womenwithhigh levels of perceived control reported lower symptoms’ severity than women withlow perceived control; this result was inde-pendentofsocio-demographic,health-related,menopause-related andlifestylefactors.Theuseofhormonetherapyandcoffeeintake werealsosigniﬁcantnegativepredictorsofsymptoms’severity.The causalmodelexploredinthestudyaccountedfor72%and67%of thevariabilityintheperceivedseverityofnightsweatsandhot ﬂashes,respectively.

Thisresearchemphasizestheimportanceofperceivedcontrol inthemanagementofvasomotorsymptomsandcontributeswith newdataontheeffectsofcaffeineonthesesymptoms.

Contributors

IsabelLealparticipatedinthesupervisionoftheresearchand inthecriticalreviewofthearticle.JoãoMarocoparticipatedinthe supervisionoftheresearch,inthestatisticalanalysisandEnglish review.CatarinaRamosparticipatedindatacollectionand statis-ticalanalysis.FilipaPimentamadetheliteraturereview,research designandarticleconstruction.Shealsoparticipatedindata col-lectionandstatisticalanalysis.

Conﬂictofinterests

Theauthorsofthearticlehavenoconﬂictofinterest. Funding

The article was funded by a PhD grant of the Portuguese Fundac¸ãoparaaCiênciaeTecnologia(grantSFRH/BD/32359/2006). Acknowledgement

WethankRaquelOliveiraforproofreadingthemanuscript References

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