1. Risk of Severe Fibrosis is Associated with Time from Menopause
in Nonalcoholic Fatty Liver Disease (NAFLD)
Jagpal S. Klair1), Ju Dong Yang1), Manal F. Abdelmalek2), Cynthia D. Guy3), Ryan M. Gill4), Katherine Yates5), Aynur Unalp-Arida6), Joel Lavine7), Anna Mae Diehl2), Ayako Suzuki1)2)8), for NASH CRN
1) Dept. of Medicine, University of Arkansas for medical Sciences, Little Rock, AR, 2) Gastroenterology, Duke University, Durham, NC, 3) Dept. of Pathology, Duke University, Durham , NC, 4) Dept. of Pathology, University of California San Francisco, San Francisco, CA , 5) NASH CRN Data Coordinating Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 6) National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, MD, 7) Dept. of Pediatrics, Columbia University, New York, NY, 8) Gastroenterology, Central Arkansas Veterans Healthcare System, Little Rock, AR
RESULTS
ABSTRACT
BACKGROUND
Background /Aims
We recently reported that pre-menopausal women have less severe fibrosis than men and post-menopausal women among patients with nonalcoholic steatohepatitis (NASH), suggesting a protective effect of estrogens. We hypothesized that among postmenopausal women, those who had menopause at an earlier age are at an increased risk of hepatic fibrosis and that time after menopause positively correlates with fibrosis severity. In this analysis we aimed to investigate the associations of premature menopause (age at menopause of <40years) and the time from menopause with fibrosis severity among women with NAFLD.
Methods
We analyzed data from 491 post-menopausal women enrolled in the NASH CRN with 1) a histologic diagnosis of NAFLD and 2) self-reported information on age at menopause. Premature menopause was defined as age at menopause of <40 years (yrs). Time difference between age at menopause and age at study enrollment was calculated as yrs. Liver biopsies were read and scored according to NASH CRN scoring system. The associations of premature menopause and the time from menopause with fibrosis severity (stage 0-4) were assessed using ordinal logistic regression models with and without adjusting for age at enrollment, race/ethnicity, waist circumference, current smoking/alcohol use, hypertension, diabetes, HOMA-IR, and hormone replacement therapy (HRT).
Results
Mean age ± SD at menopause was 44 ± 9 yrs. 29.5% women had premature menopause. This group was younger at enrollment (55 ± 9 vs. 59 ± 7 yrs, p<0.001, t-test) and used HRT more often (32% vs. 19%, p<0.003, Chi-square test). Premature menopause was associated with a higher stage of fibrosis (p<0.05, Wilcoxon rank-sum test). No significant differences were noted in other histologic features or above listed clinical variables. After adjusting for age at enrollment, premature menopause was associated with an increased likelihood of having more severe fibrosis; cumulative odds ratio and 95% confidence interval (COR[95%CI]) was 1.8 [1.3, 2.6] (p< 0.002), which remained similar after adjusting for the other variables. Time from menopause was also directly associated with an increased likelihood of having more severe fibrosis (COR[95%CI] for 5-year unit=1.2 [1.1, 1.3], p<0.003), which also remained the same after adjusting for the other variables.
Conclusion
Age at menopause was significantly associated with a risk of fibrosis among post-menopausal women with NAFLD. This finding, together with our previous reports, underscores the significance of reproductive information for risk stratification among female patients with NAFLD.
Pre-menopausal women are protected from severe fibrosis compared to men and post-menopausal women among patients with nonalcoholic steatohepatitis (NASH), suggesting estrogen’s anti-fibrotic effect (Yang, JD, Hepatology, 2013)
However, how time from menopause affects severity of fibrosis among post-menopausal women remains unknown.
Length of time without the estrogen’s protective effect may impact severity of fibrosis among women with NAFLD.
Premature menopause and risk of Fibrosis
Clinical Characteristics of the Study population
Univariate
COR(95%Cl), p-value
Model 1
Model2
COR (95%Cl), p-value
Premature menopause No -
Yes
1.4 [ ], p=0.04
1.8 [ ], p<0.002
1.5 [ ], p=0.03
Premature Menopause
(N = 145)
Natural Menopause
(N = 346)
P value**
Age at enrollment, years
54.8  8.8
58.6  6.6
<0.001
Race, %
0.8389
White
115 (79.31%)
270 (78.49%)
Others
30 (20.69%)
74 (21.51%)
Ethnicity - Hispanics, %
14 (9.66%)
29 (8.43%)
0.6515
BMI, kg/m2
34.5  6.2
34.3  6.8
0.7505
Waist, cm
107.6  13.8
106.6  13.9
0.4568
Diabetes/impaired glucose tolerance, %
79 (54.48%)
208 (60.12%)
0.2490
HOMA-IR
7.04  6.32
6.99  7.72
0.3760
Hypertension, %
119 (82.1%)
275(79.5%)
0.5079
Current smokers, %
18 (12.4%)
28 (8.1%)
0.1432
Alcohol consumption*, %
56 (38.6%)
142 (41.0%)
0.8532
Treatment with HRT, %
46 (31.7%)
66 (19.1%)
0.0028
Time from menopause and risk of Fibrosis
Univariate
COR(95%Cl), p-value
Model 1
Model2
COR (95%Cl), p-value
Time from Menopause
5 years
1.2 [ ], <0.001
1.2 [ ], p<0.003
1.1 [ ], p=0.06
HYPOTHESIS
Among postmenopausal women, women who had premature menopause are at a higher risk of severe hepatic fibrosis and time from menopause directly correlates with fibrosis severity.
Model 1: Adjusted for age at enrollment, race/ethnicity, waist circumference, current smoking/alcohol use, hypertension, diabetes, HOMA-IR, and HRT.
Model 2: Adjusted for the above covariates, hepatocyte ballooning grades, and portal inflammation grades.
SPECIFIC AIM
SUMMARY
To investigate the associations of premature menopause
(age at menopause of <40years) and the time from
menopause with fibrosis severity among women with
NAFLD.
Continuous variables are expressed as mean ± SD while categorical variables are expressed as %.
*: Alcohol intake was defined as <7 servings/week for women and <14 servings/week for men
**: p-values from Chi-square test, Student’s t-test or Wilcoxon rank sum test
After adjusting for the covariates, premature menopause was associated with 80% increased risk of having more severe fibrosis vs. natural menopause.
After adding hepatocyte ballooning and portal inflammation to the model, premature menopause was still associated with 50% increased risk, suggesting that majority of the risk may be explained by effects on ‘fibrogenesis’.
Time from menopause was also directly associated with an increased likelihood of having more severe fibrosis (COR[95%CI] for 5-year unit=1.2 [ ] (p<0.0001).
METHODS AND MATERIALS
Design
A hypothesis-driven descriptive analysis
Data source
Data from NASH CRN Database I project (DBI), the Pioglitazone versus Vitamin E versus Placebo for the Treatment of Non-diabetic Patients with Nonalcoholic Steatohepatitis (PIVENS) trial at baseline, and Database II project (DBII, before Nov 2013) were analyzed in this study.
Study population
A total of 491 women
Enrolled in any of the above studies
Had histologic diagnosis of NAFLD
Self-reported menopause and information on age at menopause
Study variable
Primary predictors: premature menopause (age at menopause of <40years ) and time from menopause
Primary outcome: fibrosis stage (0 to 4) according to NASH CRN scoring system
Covariates: age at enrollment, race/ethnicity, waist circumference, current smoking/alcohol use, hypertension, diabetes, HOMA-IR, hormone replacement therapy (HRT), and grades of hepatocyte ballooning and portal inflammation.
Statistical analyses
Univariate: Wilcoxon signed-rank test, Student’s t-test or Chi-square tests
Multiple ordinal logistic regression model:
Outcome: fibrosis stage
Predictors: premature menopause (yes, no), time from menopause
Other variables: above-listed covariates
Cumulative odds ratio and 95%CI
Histologic Features of the Study population
Premature Menopause
(N = 145)
Natural Menopause
(N = 346)
P value*
Steatosis
0.2543
Grade 0
9 (6.21%)
15 (4.34%)
Grade 1
63 (43.45%)
140 (40.46%)
Grade 2
43 (29.66%)
108 (31.21%)
Grade 3
30 (20.69%)
83 (23.99%)
Lobular inflammation
0.2492
1 (0.29%)
75 (51.72%)
195 (56.36%)
51 (35.17%)
115 (33.24%)
19 (13.1%)
35 (10.12%)
Hepatocyte ballooning
0.0834
35 (24.14%)
107 (30.92%)
87 (25.14%)
152 (43.93%)
Mallory Body
0.1941 No
84 (57.93%)
222 (64.16%)
Yes
61 (42.07%)
124 (35.84%)
Portal inflammation
0.1102
10 (6.94%)
36 (10.4%)
84 (58.33%)
211 (60.98%)
50 (34.72%)
99 (28.61%)
Fibrosis
0.0469
Stage 0
24 (16.55%)
85 (24.64%)
Stage 1
34 (23.45%)
84 (24.35%)
Stage 2
32 (22.07%)
63 (18.26%)
Stage 3
78 (22.61%)
Stage 4
20 (13.79%)
35 (10.14%)
LIMITATIONS
Cross-sectional setting precludes from addressing causality.
Potential selection bias due to enrollment in tertiary academic centers needs to be considered.
CONCLUSIONS
Premature menopause (at age of <40 years) was associated with a significantly increased risk of fibrosis among post-menopausal women with NAFLD.
Time from menopause was directly associated with severity of fibrosis among post-menopausal women with NAFLD.
This finding, together with our previous reports, underscores the significance of reproductive information for risk stratification among female patients with NAFLD.
REFERENCES
Yang JD, Abdelmalek MF, Pang H, et. al. Gender and menopause impact severity of fibrosis among patients with nonalcoholic steatohepatitis. Hepatology Apr;59(4):
*: p-valued from Wilcoxon rank sum tests.