Association of reproductive factors with dementia: A systematic review and dose-response meta-analyses of observational studies

Background Associations between endogenous estrogen exposure indicators and risk of subtypes of dementia have been unclear. Methods Databases (PubMed, EMBASE and Web of Science) were searched electronically on 1st July and updated regularly until 12nd November 2021. Observational studies of English language were selected if reported an effect estimate [e.g., odds ratio (OR), rate ratio (RR) or hazard ratio (HR)] and 95% CI for the association between any exposure (age of menarche, age at menopause, reproductive period, estradiol level) and any endpoint variable [all-cause dementia, Alzheimer's disease (AD), vascular dementia (VD), cognitive impairment (CI)]. Random-effects models and dose-response meta-analyses were used to calculate estimates and to show the linear/nonlinear relationship. PROSPERO CRD42021274827. Findings We included 22 studies (475 9764 women) in this analysis. We found no clear relationship between late menarche (>= 14 vs <14 years) and dementia, CI in categorical meta-analysis compared to a J-shape relationship in dose-response meta-analyses. Later menopause (>= 45 vs <45 years) was consistently associated with a lower risk of all-cause dementia (pooled RR: 0.87, 95%CI: 0.78-0.97, I-2 =56.0%), AD (0.67, 0.44-0.99, I-2 =78.3%), VD (0.87, 0.80-0.94) and CI (0.82, 0.71-0.94, I-2 =19.3%) in categorical meta-analysis, showing similar results in doseresponse meta-analyses. An inverse relationship between longer reproductive duration (>= 35 vs <35 years) and dementia was observed in dose-response meta-analysis. In addition, estradiol levels after menopause were inversely correlated with the risk of AD and CI. Interpretation In this study, later menopause and longer reproductive period were associated with a lower risk of dementia, while the relationship for menarchal age was J-shaped. There was an inverse relationship between higher postmenopausal estrogen levels and risk of AD and CI. Longitudinal study are needed to further explore the association between life-time estrogen exposure and risk of subtypes of dementia. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd.