Review on Menopause and Immunity
Yıl 2025,
Cilt: 34 Sayı: 2, 156 - 161, 30.06.2025
Ayşe Nur Çakır Güngör
,
Aslıhan Candevir
Öz
Menopausal transition is one of the important life events in a woman’s life. Menopausal symptoms are primarily caused by estrogen insufficiency. Estrogen deficiency also causes long-term problems like osteoporosis and an increment of cardiovascular events, and it might have some impact on immunity and vice versa.
In this review we will summarize the effect of menopause and the immune system on each other and elaborate on the relationship between early menopause and the immune system. Finally, we will discuss the impact of menopausal hormone replacement therapy (HRT) on the immune system.
Kaynakça
-
1. Dai Q, Zhang Y, Zhao X, Yang X, Sun H, Wu S, et al. Trajectories of peripheral white blood cells count around the menopause: a prospective cohort study. BMC Womens Health 2024; 24: 504. doi: 10.1186/s12905-024-03344-0.
-
2. Gameiro C, Romao F. Changes in the immune system during menopause and aging. Front Biosci (Elite Ed) 2010; 2: 1299-303. doi: 10.2741/e190.
-
3. Han A, Kim JY, Kwak-Kim J, Lee SK. Menopause is an inflection point of age-related immune changes in women. J Reprod Immunol 2021; 146: 103346. doi: 10.1016/j.jri.2021.103346.
-
4. Vrachnis N, Zygouris D, Iliodromiti Z, Daniilidis A, Valsamakis G, Kalantaridou S. Probing the impact of sex steroids and menopause-related sex steroid deprivation on modulation of immune senescence. Maturitas 2014; 78: 174-8. doi: 10.1016/j.maturitas.2014.04.014.
-
5. Shen Z, Vom Steeg LG, Patel MV, Rodriguez-Garcia M, Wira CR. Impact of aging on the frequency, phenotype, and function of CD4+ T cells in the human female reproductive tract. Front Immunol 2024; 15: 1465124. doi: 10.3389/fimmu.2024.1465124.
-
6. Kverka M, Stepan JJ. Associations Among Estrogens, the Gut Microbiome and Osteoporosis. Curr Osteoporos Rep 2024; 23: 2. doi: 10.1007/s11914-024-00896-w.
-
7. Shieh A, Epeldegui M, Karlamangla AS, Greendale GA. Gut permeability, inflammation, and bone density across the menopause transition. JCI Insight 2020; 5: e134092. doi: 10.1172/jci.insight.134092.
-
8. Zheng Y, Li J, Li Y, Wang J, Suo C, Jiang Y, et al. Plasma proteomic profiles reveal proteins and three characteristic patterns associated with osteoporosis: A prospective cohort study. J Adv Res 2024; S2090-1232(24)00474-0. doi: 10.1016/j.jare.2024.10.019.
-
9. Ullah A, Chen Y, Singla RK, Cao D, Shen B. Exploring cytokines dynamics: Uncovering therapeutic concepts for metabolic disorders in postmenopausal women- diabetes, metabolic bone diseases, and non-alcohol fatty liver disease. Ageing Res Rev 2024; 101: 102505. doi: 10.1016/j.arr.2024.102505.
-
10. Cassalia F, Belloni Fortina A. Psoriasis in women with psoriatic arthritis: hormonal effects, fertility, and considerations for management at different stages of life. Reumatismo 2024; 76. doi: 10.4081/reumatismo.2024.1775.
-
11. Shah L, Elshaikh AO, Lee R, Joy Mathew C, Jose MT, Cancarevic I. Do Menopause and Aging Affect the Onset and Progression of Rheumatoid Arthritis and Systemic Lupus Erythematosus? Cureus 2020; 12: e10944. doi: 10.7759/cureus.10944.
-
12. Min J, Jo H, Chung YJ, Song JY, Kim MJ, Kim MR. Vitamin D and the Immune System in Menopause: A Review. J Menopausal Med 2021; 27: 109-14. doi: 10.6118/jmm.21011.
-
13. Peters BA, Xue X, Sheira LA, Qi Q, Sharma A, Santoro N, et al. Menopause Is Associated With Immune Activation in Women With HIV. J Infect Dis 2022; 225: 295-305. doi: 10.1093/infdis/jiab341.
-
14. Nouri N, Aghebati-Maleki L, Soltani-Zangbar MS, Kamrani A, Mehdizadeh A, Danaii S, et al. Analysis of Th17 cell population and expression of microRNA and factors related to Th17 in patients with premature ovarian failure. J Reprod Immunol 2024; 165: 104290. doi: 10.1016/j.jri.2024.104290.
-
15. Verma P, K Sharma A, Shankar H, Sharma A, Rao DN. Role of Trace Elements, Oxidative Stress and Immune System: a Triad in Premature Ovarian Failure. Biol Trace Elem Res 2018; 184: 325-33. doi: 10.1007/s12011-017-1197-6.
-
16. Lu Y, Yao Y, Zhai S, Ni F, Wang J, Chen F, et al. The role of immune cell signatures in the pathogenesis of ovarian-related diseases: a causal inference based on mendelian randomization. Int J Surg 2024; 110: 6541-50. doi: 10.1097/JS9.0000000000001814.
-
17. Kunicki M, Rzewuska N, Gross-Kępińska K. Immunophenotypic profiles and inflammatory markers in Premature Ovarian Insufficiency. J Reprod Immunol 2024; 164: 104253. doi: 10.1016/j.jri.2024.104253.
-
18. Jiang LQ, Zhang RD, Musonye HA, Zhao HY, He YS, Zhao CN, et al. Hormonal and reproductive factors in relation to the risk of rheumatoid arthritis in women: a prospective cohort study with 223 526 participants. RMD Open 2024; 10: e003338. doi: 10.1136/rmdopen-2023-003338.
-
19. Namavari N, Jokar M, Ghodsian A, Jahromi HK, Rahmanian V. Menopausal state and rheumatoid arthritis: a systematic review and meta-analysis. BMC Rheumatol 2024; 8: 48. doi: 10.1186/s41927-024-00418-2.
-
20. Wong CA, Sanchez-Rodriguez G, Ethier CR, Wood LB, Feola AJ. Ovariectomy drives increase of an ECM transcription signature in the posterior eye and retina. Vision Res 2024; 225: 108507. doi: 10.1016/j.visres.2024.108507.
-
21. Siyu Y, Shixiao Z, Congying S, Xinqin Z, Zhen H, Xiaoying W. Advances in cytokine-based herbal medicine against premature ovarian insufficiency: A review. J Ethnopharmacol 2024; 333: 118477. doi: 10.1016/j.jep.2024.118477.
-
22. Dai F, Wang R, Deng Z, Yang D, Wang L, Wu M, et al. Comparison of the different animal modeling and therapy methods of premature ovarian failure in animal model. Stem Cell Res Ther 2023; 14: 135. doi: 10.1186/s13287-023-03333-4.
-
23. Huang C, AlSubki L, Yamaya A, Sung N, Kwak-Kim J. Poor ovarian response in assisted reproductive technology cycles is associated with anti-ovarian antibody and pro-inflammatory immune responses. J Reprod Immunol 2023; 160: 104152. doi: 10.1016/j.jri.2023.104152.
-
24. Sun S, Chen H, Zheng X, Ma C, Yue R. Analysis on the level of IL-6, IL-21, AMH in patients with auto-immunity premature ovarian failure and study of correlation. Exp Ther Med 2018; 16: 3395-8. doi: 10.3892/etm.2018.6592.
-
25. Liu F, Tian Y, Qu Z, Liu Q, Xia Y, Hu X. Adenohypophysis-Inducible Sex Hormones Correlate with Interleukin-6, -8, and Tumor Necrosis Factor-α in Patients with Systemic Lupus Erythematosus. J Interferon Cytokine Res 2024. doi: 10.1089/jir.2024.0160. Online ahead of print.
-
26. Moktan VP, Daoud ND, Tremaine WJ, Loftus EV Jr, Kane SV, Hochwald AP, et al. A Cohort Study of the Age at Menopause in Female Patients With and Without Inflammatory Bowel Disease. Crohns Colitis 360. 2022; 4: otac027. doi: 10.1093/crocol/otac027.
-
27. Chen M, Li L, Chai Y, Yang Y, Ma S, Pu X, et al. Vitamin D can ameliorate premature ovarian failure by inhibiting neutrophil extracellular traps: A review. Medicine (Baltimore) 2023; 102: e33417. doi: 10.1097/MD.0000000000033417.
-
28. Sheikhansari G, Aghebati-Maleki L, Nouri M, Jadidi-Niaragh F, Yousefi M. Current approaches for the treatment of premature ovarian failure with stem cell therapy. Biomed Pharmacother 2018; 102: 254-62. doi: 10.1016/j.biopha.2018.03.056.
-
29. Zhang L, Sun Y, Zhang XX, Liu YB, Sun HY, Wu CT, et al. Comparison of CD146 +/- mesenchymal stem cells in improving premature ovarian failure. Stem Cell Res Ther 2022; 13: 267. doi: 10.1186/s13287-022-02916-x.
-
30. Wang Z, Wei Q, Wang H, Han L, Dai H, Qian X, et al. Mesenchymal Stem Cell Therapy Using Human Umbilical Cord in a Rat Model of Autoimmune-Induced Premature Ovarian Failure. Stem Cells Int 2020; 2020: 3249495. doi: 10.1155/2020/3249495.
-
31. Yin N, Zhao W, Luo Q, Yuan W, Luan X, Zhang H. Restoring Ovarian Function With Human Placenta-Derived Mesenchymal Stem Cells in Autoimmune-Induced Premature Ovarian Failure Mice Mediated by Treg Cells and Associated Cytokines. Reprod Sci 2018; 25: 1073-82. doi: 10.1177/1933719117732156.
-
32. Yamchi NN, Rahbarghazi R, Bedate AM, Mahdipour M, Nouri M, Khanbabaee R. Menstrual blood CD146+ mesenchymal stem cells reduced fibrosis rate in the rat model of premature ovarian failure. Cell Biochem Funct 2021; 39: 998-1008. doi: 10.1002/cbf.3669.
-
33. Vrachnis N, Zygouris D, Vrachnis D, Antonakopoulos N, Fotiou A, Panagopoulos P, et al. Effects of Hormone Therapy and Flavonoids Capable on Reversal of Menopausal Immune Senescence. Nutrients. 2021; 13: 2363. doi: 10.3390/nu13072363.
-
34. Kumru S, Godekmerdan A, Yilmaz B. Immune effects of surgical menopause and estrogen replacement therapy in peri-menopausal women. J Reprod Immunol 2004; 63: 31-8. doi: 10.1016/j.jri.2004.02.001.
-
35. Schneider AH, Kanashiro A, Dutra SGV, Souza RDN, Veras FP, Cunha FQ, et al. Estradiol replacement therapy regulates innate immune response in ovariectomized arthritic mice. Int Immunopharmacol 2019; 72: 504-10. doi: 10.1016/j.intimp.2019.04.048.
-
36. Averyanova M, Yureneva S, Kiseleva V, Yakushevskaya O, Iskusnykh M, Pavlova A, et al. Effect of Menopausal Hormone Therapy on Cellular Immunity Parameters and Cytokine Profile. Biomedicines 2024; 12(8): 1892. doi: 10.3390/biomedicines12081892.
-
37. Kiss O, Bahri R, Watson REB, Chike C, Langton AK, Newton VL, et al. The impact of irritant challenge on the skin barrier and myeloid-resident immune cells in women who are postmenopausal is modulated by hormone replacement therapy. Br J Dermatol 2024; 191: 746-59. doi: 10.1093/bjd/ljae226.
-
38. Salliot C, Nguyen Y, Gusto G, Gelot A, Gambaretti J, Mariette X, et al. Female hormonal exposures and risk of rheumatoid arthritis in the French E3N-EPIC cohort study. Rheumatology (Oxford) 2021; 60: 4790-4800. doi: 10.1093/rheumatology/keab101.
-
39. Kim JW, Kim HA, Suh CH, Jung JY. Sex hormones affect the pathogenesis and clinical characteristics of systemic lupus erythematosus. Front Med (Lausanne) 2022; 9: 906475. doi: 10.3389/fmed.2022.906475.
-
40. Itaborahy RM, de Medeiros SF. Influence of estrogen therapy on immune markers in postmenopausal women. Climacteric 2016; 19: 496-500. doi: 10.1080/13697137.2016.1212828.
Menopoz ve İmmunite Üzerine Bir Derleme
Yıl 2025,
Cilt: 34 Sayı: 2, 156 - 161, 30.06.2025
Ayşe Nur Çakır Güngör
,
Aslıhan Candevir
Öz
Menopozal geçiş kadın hayatında önemli bir yaşam olayıdır. Menopozal semptomlar temelde östrojen eksikliğinden kaynaklanır. Östrojen eksikliği uzun dönemde osteoporoz ve kardiyak olaylarda artış gibi problemlere de neden olmaktadır. Östrojen ekiskliğinin aynı zamanda bağışıklık üzerinde de etkileri olabilir. Bağışıklık sisteminin de menopoz üzerinde etkileri olabilir.
Bu derlemede menopozun bağışıklık sistemi, bağışıklık sisteminin de menopoz üzerindeki etkilerini özetleyeceğiz. Erken menopozun immün system üzerindeki etkilerini gözden geçireceğiz. Son olarak da hormon replasman tedavisinin (HRT) bağışıklık sistemi üzerindeki etkilerinden bahsedeceğiz.
Kaynakça
-
1. Dai Q, Zhang Y, Zhao X, Yang X, Sun H, Wu S, et al. Trajectories of peripheral white blood cells count around the menopause: a prospective cohort study. BMC Womens Health 2024; 24: 504. doi: 10.1186/s12905-024-03344-0.
-
2. Gameiro C, Romao F. Changes in the immune system during menopause and aging. Front Biosci (Elite Ed) 2010; 2: 1299-303. doi: 10.2741/e190.
-
3. Han A, Kim JY, Kwak-Kim J, Lee SK. Menopause is an inflection point of age-related immune changes in women. J Reprod Immunol 2021; 146: 103346. doi: 10.1016/j.jri.2021.103346.
-
4. Vrachnis N, Zygouris D, Iliodromiti Z, Daniilidis A, Valsamakis G, Kalantaridou S. Probing the impact of sex steroids and menopause-related sex steroid deprivation on modulation of immune senescence. Maturitas 2014; 78: 174-8. doi: 10.1016/j.maturitas.2014.04.014.
-
5. Shen Z, Vom Steeg LG, Patel MV, Rodriguez-Garcia M, Wira CR. Impact of aging on the frequency, phenotype, and function of CD4+ T cells in the human female reproductive tract. Front Immunol 2024; 15: 1465124. doi: 10.3389/fimmu.2024.1465124.
-
6. Kverka M, Stepan JJ. Associations Among Estrogens, the Gut Microbiome and Osteoporosis. Curr Osteoporos Rep 2024; 23: 2. doi: 10.1007/s11914-024-00896-w.
-
7. Shieh A, Epeldegui M, Karlamangla AS, Greendale GA. Gut permeability, inflammation, and bone density across the menopause transition. JCI Insight 2020; 5: e134092. doi: 10.1172/jci.insight.134092.
-
8. Zheng Y, Li J, Li Y, Wang J, Suo C, Jiang Y, et al. Plasma proteomic profiles reveal proteins and three characteristic patterns associated with osteoporosis: A prospective cohort study. J Adv Res 2024; S2090-1232(24)00474-0. doi: 10.1016/j.jare.2024.10.019.
-
9. Ullah A, Chen Y, Singla RK, Cao D, Shen B. Exploring cytokines dynamics: Uncovering therapeutic concepts for metabolic disorders in postmenopausal women- diabetes, metabolic bone diseases, and non-alcohol fatty liver disease. Ageing Res Rev 2024; 101: 102505. doi: 10.1016/j.arr.2024.102505.
-
10. Cassalia F, Belloni Fortina A. Psoriasis in women with psoriatic arthritis: hormonal effects, fertility, and considerations for management at different stages of life. Reumatismo 2024; 76. doi: 10.4081/reumatismo.2024.1775.
-
11. Shah L, Elshaikh AO, Lee R, Joy Mathew C, Jose MT, Cancarevic I. Do Menopause and Aging Affect the Onset and Progression of Rheumatoid Arthritis and Systemic Lupus Erythematosus? Cureus 2020; 12: e10944. doi: 10.7759/cureus.10944.
-
12. Min J, Jo H, Chung YJ, Song JY, Kim MJ, Kim MR. Vitamin D and the Immune System in Menopause: A Review. J Menopausal Med 2021; 27: 109-14. doi: 10.6118/jmm.21011.
-
13. Peters BA, Xue X, Sheira LA, Qi Q, Sharma A, Santoro N, et al. Menopause Is Associated With Immune Activation in Women With HIV. J Infect Dis 2022; 225: 295-305. doi: 10.1093/infdis/jiab341.
-
14. Nouri N, Aghebati-Maleki L, Soltani-Zangbar MS, Kamrani A, Mehdizadeh A, Danaii S, et al. Analysis of Th17 cell population and expression of microRNA and factors related to Th17 in patients with premature ovarian failure. J Reprod Immunol 2024; 165: 104290. doi: 10.1016/j.jri.2024.104290.
-
15. Verma P, K Sharma A, Shankar H, Sharma A, Rao DN. Role of Trace Elements, Oxidative Stress and Immune System: a Triad in Premature Ovarian Failure. Biol Trace Elem Res 2018; 184: 325-33. doi: 10.1007/s12011-017-1197-6.
-
16. Lu Y, Yao Y, Zhai S, Ni F, Wang J, Chen F, et al. The role of immune cell signatures in the pathogenesis of ovarian-related diseases: a causal inference based on mendelian randomization. Int J Surg 2024; 110: 6541-50. doi: 10.1097/JS9.0000000000001814.
-
17. Kunicki M, Rzewuska N, Gross-Kępińska K. Immunophenotypic profiles and inflammatory markers in Premature Ovarian Insufficiency. J Reprod Immunol 2024; 164: 104253. doi: 10.1016/j.jri.2024.104253.
-
18. Jiang LQ, Zhang RD, Musonye HA, Zhao HY, He YS, Zhao CN, et al. Hormonal and reproductive factors in relation to the risk of rheumatoid arthritis in women: a prospective cohort study with 223 526 participants. RMD Open 2024; 10: e003338. doi: 10.1136/rmdopen-2023-003338.
-
19. Namavari N, Jokar M, Ghodsian A, Jahromi HK, Rahmanian V. Menopausal state and rheumatoid arthritis: a systematic review and meta-analysis. BMC Rheumatol 2024; 8: 48. doi: 10.1186/s41927-024-00418-2.
-
20. Wong CA, Sanchez-Rodriguez G, Ethier CR, Wood LB, Feola AJ. Ovariectomy drives increase of an ECM transcription signature in the posterior eye and retina. Vision Res 2024; 225: 108507. doi: 10.1016/j.visres.2024.108507.
-
21. Siyu Y, Shixiao Z, Congying S, Xinqin Z, Zhen H, Xiaoying W. Advances in cytokine-based herbal medicine against premature ovarian insufficiency: A review. J Ethnopharmacol 2024; 333: 118477. doi: 10.1016/j.jep.2024.118477.
-
22. Dai F, Wang R, Deng Z, Yang D, Wang L, Wu M, et al. Comparison of the different animal modeling and therapy methods of premature ovarian failure in animal model. Stem Cell Res Ther 2023; 14: 135. doi: 10.1186/s13287-023-03333-4.
-
23. Huang C, AlSubki L, Yamaya A, Sung N, Kwak-Kim J. Poor ovarian response in assisted reproductive technology cycles is associated with anti-ovarian antibody and pro-inflammatory immune responses. J Reprod Immunol 2023; 160: 104152. doi: 10.1016/j.jri.2023.104152.
-
24. Sun S, Chen H, Zheng X, Ma C, Yue R. Analysis on the level of IL-6, IL-21, AMH in patients with auto-immunity premature ovarian failure and study of correlation. Exp Ther Med 2018; 16: 3395-8. doi: 10.3892/etm.2018.6592.
-
25. Liu F, Tian Y, Qu Z, Liu Q, Xia Y, Hu X. Adenohypophysis-Inducible Sex Hormones Correlate with Interleukin-6, -8, and Tumor Necrosis Factor-α in Patients with Systemic Lupus Erythematosus. J Interferon Cytokine Res 2024. doi: 10.1089/jir.2024.0160. Online ahead of print.
-
26. Moktan VP, Daoud ND, Tremaine WJ, Loftus EV Jr, Kane SV, Hochwald AP, et al. A Cohort Study of the Age at Menopause in Female Patients With and Without Inflammatory Bowel Disease. Crohns Colitis 360. 2022; 4: otac027. doi: 10.1093/crocol/otac027.
-
27. Chen M, Li L, Chai Y, Yang Y, Ma S, Pu X, et al. Vitamin D can ameliorate premature ovarian failure by inhibiting neutrophil extracellular traps: A review. Medicine (Baltimore) 2023; 102: e33417. doi: 10.1097/MD.0000000000033417.
-
28. Sheikhansari G, Aghebati-Maleki L, Nouri M, Jadidi-Niaragh F, Yousefi M. Current approaches for the treatment of premature ovarian failure with stem cell therapy. Biomed Pharmacother 2018; 102: 254-62. doi: 10.1016/j.biopha.2018.03.056.
-
29. Zhang L, Sun Y, Zhang XX, Liu YB, Sun HY, Wu CT, et al. Comparison of CD146 +/- mesenchymal stem cells in improving premature ovarian failure. Stem Cell Res Ther 2022; 13: 267. doi: 10.1186/s13287-022-02916-x.
-
30. Wang Z, Wei Q, Wang H, Han L, Dai H, Qian X, et al. Mesenchymal Stem Cell Therapy Using Human Umbilical Cord in a Rat Model of Autoimmune-Induced Premature Ovarian Failure. Stem Cells Int 2020; 2020: 3249495. doi: 10.1155/2020/3249495.
-
31. Yin N, Zhao W, Luo Q, Yuan W, Luan X, Zhang H. Restoring Ovarian Function With Human Placenta-Derived Mesenchymal Stem Cells in Autoimmune-Induced Premature Ovarian Failure Mice Mediated by Treg Cells and Associated Cytokines. Reprod Sci 2018; 25: 1073-82. doi: 10.1177/1933719117732156.
-
32. Yamchi NN, Rahbarghazi R, Bedate AM, Mahdipour M, Nouri M, Khanbabaee R. Menstrual blood CD146+ mesenchymal stem cells reduced fibrosis rate in the rat model of premature ovarian failure. Cell Biochem Funct 2021; 39: 998-1008. doi: 10.1002/cbf.3669.
-
33. Vrachnis N, Zygouris D, Vrachnis D, Antonakopoulos N, Fotiou A, Panagopoulos P, et al. Effects of Hormone Therapy and Flavonoids Capable on Reversal of Menopausal Immune Senescence. Nutrients. 2021; 13: 2363. doi: 10.3390/nu13072363.
-
34. Kumru S, Godekmerdan A, Yilmaz B. Immune effects of surgical menopause and estrogen replacement therapy in peri-menopausal women. J Reprod Immunol 2004; 63: 31-8. doi: 10.1016/j.jri.2004.02.001.
-
35. Schneider AH, Kanashiro A, Dutra SGV, Souza RDN, Veras FP, Cunha FQ, et al. Estradiol replacement therapy regulates innate immune response in ovariectomized arthritic mice. Int Immunopharmacol 2019; 72: 504-10. doi: 10.1016/j.intimp.2019.04.048.
-
36. Averyanova M, Yureneva S, Kiseleva V, Yakushevskaya O, Iskusnykh M, Pavlova A, et al. Effect of Menopausal Hormone Therapy on Cellular Immunity Parameters and Cytokine Profile. Biomedicines 2024; 12(8): 1892. doi: 10.3390/biomedicines12081892.
-
37. Kiss O, Bahri R, Watson REB, Chike C, Langton AK, Newton VL, et al. The impact of irritant challenge on the skin barrier and myeloid-resident immune cells in women who are postmenopausal is modulated by hormone replacement therapy. Br J Dermatol 2024; 191: 746-59. doi: 10.1093/bjd/ljae226.
-
38. Salliot C, Nguyen Y, Gusto G, Gelot A, Gambaretti J, Mariette X, et al. Female hormonal exposures and risk of rheumatoid arthritis in the French E3N-EPIC cohort study. Rheumatology (Oxford) 2021; 60: 4790-4800. doi: 10.1093/rheumatology/keab101.
-
39. Kim JW, Kim HA, Suh CH, Jung JY. Sex hormones affect the pathogenesis and clinical characteristics of systemic lupus erythematosus. Front Med (Lausanne) 2022; 9: 906475. doi: 10.3389/fmed.2022.906475.
-
40. Itaborahy RM, de Medeiros SF. Influence of estrogen therapy on immune markers in postmenopausal women. Climacteric 2016; 19: 496-500. doi: 10.1080/13697137.2016.1212828.