Hormone Replacement Therapy (HRT) has received consistently bad press, despite re-analysis of previous data new studies and supporting Consensus Statements from leading national and international societies. Many women have been convinced by women's journals and the media not to even consider HRT as an option and, General Practitioners, still limit duration to 5 years or, will, arbitrarily, discontinue prescriptions in the early 50s. This article seeks to make sense of our current position. Previous and new evidence on the safety of HRT is reviewed. New data on the long-term consequences of non-treatment of women with Premature Ovarian Insufficiency (POI) is presented and the dichotomy of the older female workforce is explored. From this, a logical plan of management emerges.
Androgens are known to play a pivotal role in cardiovascular function. However, a definitive explanation as to how their impact differs between genders is yet to be provided. In this review, the existing studies on the link between androgens and cardiovascular disease have been analysed, with a particular focus on the gender-specific differences. Several studies agree that both direct and indirect effects of testosterone on cardiovascular function show a gender-related dimorphism. Consistently, men and women display different responses to androgen supplementation treatment. Post-menopausal women may particularly benefit from testosterone supplementation therapy. Future studies should further clarify the optimal dose and route of administration of testosterone, and more women should be included in clinical trials, in order to identify novel gender-specific targets, and finally to develop therapeutic strategies.
OBJECTIVE:The results of the Women's Health Initiative studies dramatically altered hormone therapy use around the world. In countries outside the United States, self-use in physicians remained unaltered while prescription use declined, implying that physicians may not concur with the findings. We wished to explore prevailing attitudes among American physicians by examining New York City obstetrician-gynaecologists' self-use and prescription use of hormone therapy.STUDY DESIGN:All board-certified obstetrician-gynaecologists in New York City were invited to complete and return a detailed, previously validated questionnaire concerning hormone therapy use.RESULTS:Two hundred and nine questionnaires were returned, for a response rate of 12% (209/1797). Gynaecologists agreed with the findings from the Women's Health Initiative studies regarding indications and contraindications to hormone therapy use. Even so, three-quarters of female gynaecologists and female partners of male gynaecologists (74%; 67/91) use or have previously used hormone therapy. However, only 27.3% (21/77) of male gynaecologists and 12.3% (14/114) of female gynaecologists recommend hormone therapy to all menopausal women regardless of contraindications. Gynaecologists remain divided in their attitude toward hormone therapy; 30% of gynaecologists felt that hormone therapy use generally prolonged women's lives, 36% felt it was not useful in prolonging women's lives, and 33% were unsure.CONCLUSION:Since the publication of the Women's Health Initiative findings, New York City gynaecologists prescribe hormone therapy to fewer patients. However, they continue to self-use hormone therapy at much higher rates, even as they seem to concur with Women's Health Initiative recommendations, contributing to the ongoing controversy surrounding the validity of the Women's Health Initiative findings.
As more women survive reproductive cancers, menopausal symptoms following treatment can be a significant problem affecting quality of life and wellbeing. Hormone replacement therapy may or may not be contraindicated. Women often receive conflicting information about their management from different specialists. The aim of this study, based in a regional menopause clinic, was to examine referral patterns and symptom profiles of women with cancer or at high risk of cancer; to identify areas of need where a more integrated approach to management might be required; and to reach a local consensus across disciplines involved in the care of these women regarding prescribing of hormonal therapies. A retrospective case record review of all women attending Edinburgh Menopause Clinic for one 12-month period in 2011/2012 for management of cancer-related menopausal symptoms was undertaken. The results of the review were discussed at a multidisciplinary meeting and regional guidance on the management of these women was agreed. There has been an immediate improvement in communication between departments and the quality of information received in referral letters.
These words were written several centuries ago at a time when there were cultural and religious restrictions. However, da Vinci was prepared to discuss and create anatomical diagrams of male genitalia in spite of such curbs. Many generations later there still seems to be a taboo concerning men’s health care, which is underutilised and less well provided for when compared with that of women. This article looks at how women can play an important role in ‘standing by their man’ and encouraging him to seek appropriate medical attention. Leonardo da Vinci (1452–1519) surely must have been one of the most influential and intelligent renaissancemen.He designed prototypes for the chain link used on bicycles, a rudimentary helicopter, as well as being a superb artist, architect and anatomist. Her Majesty the Queen has a private collection of his anatomical diagrams including various anatomical drawings of the penis. His jottings often appeared alongside such diagrams andwere sometimes difficult to decipher as they were written ‘mirror-image cursive’ from right to left. This was probably because he was left-handed, although others say it was in order to protect his thoughts from prying eyes. When looking at men’s health it is first necessary to ascertain what is involved:
Objective To understand the physical and emotional impact of postmenopausal vaginal discomfort on relationships between women and their male partners. Study design In a quantitative, Internet-based survey, 8200 individuals from the UK, Denmark, Sweden, Norway, Finland, France, Italy, US and Canada (postmenopausal, married/cohabiting women, aged 55–65 years, who had experienced vaginal discomfort, and male partners of such women) completed a structured questionnaire. Main outcome measures Results for respondents from the UK (500 men, 500 women), expressed as percentages of women/men describing particular answers, are reported. Results Avoiding physical intimacy because of vaginal discomfort was reported by 69% of women and 76% of male partners, mainly due to concern about sex being painful (women 63%; men 61%); 18% of women considered vaginal discomfort had created emotional distance between them and their partners. Local estrogen treatment was used by 21% of women, among whom 58% subsequently reported less painful sex. Following such treatment, 33% of women and 30% of male partners reported an improved sex life, while 33% of women and 34% of male partners described becoming emotionally closer. Although 73% of women did not consider enough information about vaginal discomfort to be available, 60% would consult a physician to obtain this. Conclusions Although vaginal discomfort has a substantial impact on postmenopausal women and their partners, improvements in sexual and emotional relationships can follow use of local estrogen therapy. Not all women may be aware of therapeutic options; healthcare providers can improve outcomes by more openly communicating and initiating discussion with patients.
In this paper we describe potential reasons for the discrepancies between data from basic sciences and observational studies and those of large treatment studies investigating the association between brain function and sex steroids. Observational studies which often showed positive associations between hormone use and cognition can be affected by 'recall bias' and 'healthy user bias', while outcomes of treatment studies were hypothesized to be modified by age at treatment, age at or type of menopause, health status, addition of a progestogen or type of estrogen treatment. However, meta-analyses of data from treatment studies negate many of these hypotheses showing at best mainly short-term (up to 6 months) positive effects of estrogen treatment on cognition regardless of age. This positive effect may reverse, particularly in older women with prolonged hormone treatment, which was predominantly seen after addition of progestogen. Medroxyprogesterone acetate seemed to have worse effects on cognition than other types of progestogen in these long-term studies. Estradiol with or without a progestogen was three times more likely to have positive effects on cognition than conjugated equine estrogens. However, two-thirds of studies showed no associations at all which may be an underestimate given the possibility of publication bias. We briefly review alternative treatments, such as testosterone and soy-derived supplements, but currently insufficient data are available for conclusive comments. Women who have undergone surgical menopause or who undergo natural menopause before age 47 may benefit most from hormone treatment and a special case may need to be made for this group. Long-term safety studies for this group are urgently needed.
The female genital and lower urinary tracts share a common embryological origin, arising from the urogenital sinus and both are sensitive to the effects of the female sex steroid hormones throughout life. Estrogen is known to have an important role in the function of the lower urinary tract and estrogen and progesterone receptors have been demonstrated in the vagina, urethra, bladder and pelvic floor musculature. In addition estrogen deficiency occurring following the menopause is known to cause atrophic change and may be associated with lower urinary tract symptoms such as frequency, urgency, nocturia, urgency incontinence and recurrent infection. These may also co-exist with symptoms of urogenital atrophy such as dyspareunia, itching, vaginal burning and dryness. Epidemiological studies have implicated estrogen deficiency in the aetiology of lower urinary tract symptoms with 70% of women relating the onset of urinary incontinence to their final menstrual period. Whilst for many years systemic and vaginal estrogen therapy was felt to be beneficial in the treatment of lower urinary and genital tract symptoms this evidence has recently been challenged by large epidemiological studies investigating the use of systemic hormone replacement therapy as primary and secondary prevention of cardiovascular disease and osteoporosis. The aim of this paper is to examine the effect of the sex hormones, estrogen and progesterone, on the lower urinary tract and to review the current evidence regarding the role of systemic and vaginal estrogens in the management of lower urinary tract symptoms and urogenital atrophy.
The case report discusses a very serious interaction between red clover and methotrexate not previously documented. It highlights the potential pitfalls of concomitant use of herbal remedies and conventionally prescribed drugs and the importance of advising our patients about OTC drugs. A 52-year-old woman attended her general practitioner for advice on menopausal flushing. She was on methotrexate weekly injections for severe psoriasis and was not keen to consider anything that would possibly affect her skin. Alternative therapies were discussed and red clover was suggested. This was bought OTC. After the third day of taking red clover capsules (430 mg), the patient developed severe vomiting and epigastric pain. She contacted the dermatology clinic that administers the methotrexate injection and was thought to have symptoms suggestive of methotrexate toxicity even though her liver function tests remained within normal levels. She had been receiving methotrexate injections for nearly two years with no adverse effects. The only new drug that had been started was red clover and this was thought to be the probable cause of the toxicity. It was withdrawn. The patient made a full recovery and received her next injection of methotrexate with no adverse effects. The interaction was reported to the MHRA with a yellow card.
Premature ovarian insufficiency (POI) can have significant health implications for the affected patient population, but remains a largely under researched area. There is lack of evidence from randomised controlled trials to guide clinical practice, regarding the optimal hormone replacement therapy regimens, dose and route of administration. Furthermore, little research has addressed the effect of the various progestogens used on health parameters in women with POI. Here we describe an ongoing randomised clinical trial looking at the effects of micronized progesterone and medroxyprogesterone acetate, both used in combination with transdermal oestradiol on the cardiovascular system, lipid profile and coagulation cascade in women with POI as a step towards better understanding of the implications of hormone treatment in this cohort of women.
Cardiovascular disease remains a leading cause of morbidity and mortality in menopausal women in spite of the overall reduction in age-adjusted mortality from the disease in the last few years. It is now clear that mechanisms of cardiovascular disease in menopausal women are similar to men and rather than midlife acceleration of cardiovascular disease in women, the final impact of cardiovascular disease in later life may be a reflection of cardiovascular changes during reproductive years as a result of woman's obstetric history. A decade after the Women's Health Initiative trial, there is upcoming evidence to suggest that hormone replacement therapy in young recently menopausal women has a cardioprotective effect. Cardiovascular changes during normal pregnancy or pregnancy complications such as preeclampsia may affect a woman's long-term cardiovascular health. Therefore, it is plausible that the cardioprotective benefit of hormone replacement therapy depends on occult pre-existing cardiovascular risks in women in relation to their previous obstetric history. In this review, we describe the cardiovascular changes during and after pregnancy in obstetric complications such as recurrent miscarriage, preeclampsia, intrauterine growth restriction, preterm labour and gestational diabetes; existing evidence regarding their association with cardiovascular disease later in life, and hypothesize possible mechanisms. Our aim is to improve the understanding and highlight the importance of including obstetric history in risk assessment in menopausal women and individualizing their risks before prescribing hormone replacement therapy. Future research in risk benefit assessment of hormone replacement therapy should also account for a woman's background cardiovascular risk in the light of her obstetric history.
In July 2011, the Royal College of Obstetricians and Gynaecologists published the Expert Advisory Group Report High Quality Women’s Health Care: A Proposal for Change. This landmark publication highlighted a new concept – the continuum of important aspects of women’s health through puberty, the reproductive years, menstruation, pregnancy, contraception and fertility, through to the menopause and postreproductive health. We feel the concept of a life-course approach to healthcare should be widely adopted with an emphasis on the fluid and changing challenges in women’s health. Healthcare providers need to be reminded that many conditions and disease processes evolve during the process of aging. This means that the same condition may have different manifestations depending upon her age and consequently her endocrinological status. For example, a history of polycystic ovarian syndrome increases the risk of endometrial cancer and so would influence the threshold for investigation of increased perimenopausal bleeding or postmenopausal bleeding; pregnancy-related problems such as pre-eclampsia increase the risk of cardiovascular disease in later life; the use of hormonal contraceptives may influence a woman’s views, and those of her doctor, on the use of hormone replacement therapy (HRT); diabetes influences the use of contraception, pregnancy and management of the menopause as clearly outlined in this issue in the review paper by Morling. So has this concept been applied to the care of women experiencing the menopause, and to the management of postmenopausal health? There has certainly been a broadening of interest in postmenopausal health and focus has moved away simply from ‘the menopause’ and the pros and cons of HRT, but it appears that the concept of changing health as life progresses after the point of the menopause has not been widely adapted. When women attend gynaecology clinics with postmenopausal bleeding, is full assessment taken of the number of years since the menopause, i.e. since she became estrogen deficient, whether or not she is still experiencing vasomotor symptoms, what has been the effect of estrogen deficiency on her vagina and bladder, how healthy are her bones and what is her cardiovascular risk? The same can be applied to women attending with prolapse, continence problems, and even when asymptomatic and attending for cervical or breast screening after the age of 50. If these assessments of the effects of estrogen deficiency are not being made, then surely opportunities are being lost? While cognisance has to be made of time limitations and what is realistically achievable, surely at least gynaecologists should take on the broader, life-course view of women’s health and of the continuum of estrogen deficiency in particular and address the possible effects in any woman attending their clinics who is in an estrogen-deficient state. How can this message be adapted? It is time that primary care doctors and nurses, gynaecologists, physiotherapists, physicians, indeed all healthcare professionals caring for estrogen-deficient women had a broad understanding of the consequences of estrogen deficiency not only in the short term but throughout the years after periods stop and understood the life-course of women’s health. How? Education, education, education!
Currently, 25% of women seek the advice of a medical professional for symptoms related to the menopause. However, with an increasingly ageing and medically aware population, it is likely this proportion will grow. The main symptoms related to the menopause are systemic vasomotor and localized urogenital symptoms. Numerous forms of estrogen have been used to alleviate these symptoms. Further problems that increase during the menopause include incontinence, pelvic organ prolapse and recurrent urinary tract infections. This article reviews the process by which estrogen affects the tissues of the urogenital tract, what symptoms occur during this period and what modalities of treatments are available.
The increasing prevalence of diabetes in combination with an aging population and increasing female longevity means that it is important to understand the effects of diabetes on women's health. Both type 1 and type 2 diabetes influence health outcomes throughout the life-course. This review article provides a summary of sex differences in diabetes epidemiology and covers specific aspects of the life-course in women including: the menarche, pregnancy and the menopause. It also discusses the associations with other conditions: cardiovascular disease, osteoporosis and cancer.
The British Menopause Society (BMS) recommendations on hormone replacement therapy (HRT) are designed to complement the BMS Observations and Recommendations on menopause management, submitted to the Department of Health in the UK and published in full in Menopause International, The Journal of the British Menopause Society and in the Royal College of Obstetricians and Gynaecologists Expert Advisory Group Report, High Quality Women’s Health Care. Our key recommendation is that all women should be able to access advice on how they can optimise their menopause transition and beyond, with particular reference to lifestyle and diet and an opportunity to discuss the pros and cons of complementary therapies andHRT. The following information based on the latest available evidence can be used to provide guidance to prescribers of HRT and alternatives. An extensive reference section and links to useful websites provide an opportunity to access extensive evidence based information in each key area.
