Menopause has been associated with vasomotor symptoms, vulvar-vaginal atrophy and osteoporosis. One of the goals in exploring the potential of selective estrogen receptor modulators (SERMs) was to determine if they could...Menopause has been associated with vasomotor symptoms, vulvar-vaginal atrophy and osteoporosis. One of the goals in exploring the potential of selective estrogen receptor modulators (SERMs) was to determine if they could prevent fractures, reduce menopausal symptoms and treat vaginal atrophy, while being neutral or protective on the uterus, breast and cardiovascular system. However, no SERM to date has achieved this goal. More recently, the idea of pairing a SERM with estrogen(s), known as a tissue-selective estrogen complex (TSEC), has been studied in postmenopausal women. A TSEC combines the complementary tissue-selective activities of a SERM and estrogen(s), in an attempt to gain the benefits of each with better overall tolerability. The Selective estrogen Menopause And Response to Therapy (SMART) trials were multicentre, randomized, double-blind, placebo- and active-controlled phase 3 studies evaluating the safety and efficacy of the SERM, bazedoxifene (BZA) paired with conjugated estrogens (CEs) in healthy postmenopausal women. In the first SMART trial, BZA/CE protected the endometrium from estrogenic stimulation, relieved hot flushes and maintained bone mass, with rates of amenorrhea, breast pain and overall adverse events similar to those with placebo in more than 3400 women over two years. BZA 20 mg was the lowest effective dose of BZA in BZA/CE to protect the endometrium and maintain bone mass when paired with CE 0.625 mg and CE 0.45 mg. In SMART-2, these BZA/CE doses significantly reduced the frequency and severity of hot flushes over 12 weeks. Collectively, these data support the TSEC containing BZA/CE as a new paradigm for treating menopausal symptoms and preventing osteoporosis while protecting the endometrium from unopposed estrogenic stimulation.
In spite of overwhelming evidence that vulvovaginal symptoms plague up to 46% of menopausal and perimenopausal women, and that there persists a reluctance to seek help among patients, adequate vulval and sexual histories...In spite of overwhelming evidence that vulvovaginal symptoms plague up to 46% of menopausal and perimenopausal women, and that there persists a reluctance to seek help among patients, adequate vulval and sexual histories are still woefully rare in general gynaecology clinics. This review aims to present the key points of an effective vulval history and an overview of the accepted current management of vulval disease postmenopause, in order that our patients feel encouraged to present with their problems.
This retrospective case-note study was performed to examine the ways in which an already established menopause clinic could improve service to its patients. The management of 151 patients was examined. Most were referred...This retrospective case-note study was performed to examine the ways in which an already established menopause clinic could improve service to its patients. The management of 151 patients was examined. Most were referred by their general practitioner and the most common reason for referral was to seek an alternative to hormone replacement therapy (HRT). The consultant saw 17% of the patients, and with the trainee was most likely to discharge the patient. Better information on alternatives to HRT, more consultant input and better use of telephone consultation for follow-up would enhance the service provided by the menopause clinic.
AIM: The purpose of this study is to confirm in our population the decreasing secular trend in the age of menarche (AAM) observed in other European countries. Another aim is to investigate the association between early m...AIM: The purpose of this study is to confirm in our population the decreasing secular trend in the age of menarche (AAM) observed in other European countries. Another aim is to investigate the association between early menarche and breast cancer, metabolic disorders risk or early menopause. MATERIALS AND METHODS: We conducted a nationwide population-based study of 1980 Caucasoid Spanish postmenopausal women from 2003 to 2006 to investigate the AAM, the duration of the fertile period and the relation of early menarche with breast cancer and some metabolic disorders. RESULTS: Regression analysis of AAM demonstrates a trend towards the younger AAM in our population during the past decades (P > 0.001). Parallel to this decrease we observe a significant increase in the fertility period and the height of our population (P < 0.001). In the women with AAM less than 11 years, there is an increased risk of hypercholesterolaemia, being overweight and obesity. However, early menarche does not raise the risk of adult onset diabetes, hypertension or breast cancer. CONCLUSIONS: These data indicate a decreasing secular trend of AAM in a Spanish population in the last decades. Furthermore, hypercholesterolaemia and obesity, but not breast cancer, appears to be influenced by younger AAM. Only women who have their menarche at the age of nine years or less are more likely to have an earlier menopause.
OBJECTIVE: To assess the metabolic syndrome (METS) and its components in postmenopausal women using updated diagnostic criteria and explore their relation to menopausal symptom severity. METHOD: Medical records of the fi...OBJECTIVE: To assess the metabolic syndrome (METS) and its components in postmenopausal women using updated diagnostic criteria and explore their relation to menopausal symptom severity. METHOD: Medical records of the first visit of 574 postmenopausal Caucasian Spanish women attending a menopause clinic were retrospectively reviewed. Recorded information included general demographic data, type of menopause, menopausal symptom intensity (Kupperman index) and baseline hormonal and metabolic parameters. METS was established if three or more of the following criteria were met: body mass index (BMI) >28.8 kg/m(2), fasting glycaemia ≥100 mg/dL, high-density lipoprotein cholesterol (HDL-C) <50 mg/dL, triglycerides ≥150 mg/dL and blood pressure ≥130/85 mmHg. RESULTS: Mean ± SD age of the whole cohort was 49.9 ± 6.1 years, 66% had natural menopause and 38.9% were obese. In all, 23.1% met diagnostic criteria for METS who were significantly older and displayed higher rates of being married, obesity and abnormal glucose, triglyceride, HDL-C, low-density lipoprotein cholesterol and blood pressure values, when compared with those without the syndrome. The mean Kupperman index score for the whole sample was 26.4±10.6, with 73.8% displaying moderate to severe scores (20 or more). Logistic regression analysis determined that obesity and marriage status were independent risk factors related to more severe menopausal symptoms (Kupperman index scores of 20 or more). CONCLUSION: Although METS was observed in a lower frequency than previous reports, obesity was associated with more severe menopausal symptoms among postmenopausal Spanish women.
BACKGROUND: Excess visceral adipose tissue accumulation after menopause is closely associated with decreased insulin sensitivity and adiponectin levels. OBJECTIVE: The purpose of this study was to determine the effect of...BACKGROUND: Excess visceral adipose tissue accumulation after menopause is closely associated with decreased insulin sensitivity and adiponectin levels. OBJECTIVE: The purpose of this study was to determine the effect of ovariectomy and estrogen replacement on visceral fat and serum adiponectin levels in ovariectomized (OVX) rats. METHOD: Forty 11-week-old female Wistar rats were divided into the four following groups (n = 10 rats per group): sham-operated control (SHAM); sedentary OVX (OVX-SED); OVX with estrogen replacement (OVX-ER); and OVX with sesame oil treatment (OVX-C). Rats in OVX-ER and OVX-C groups received 17β-estradiol valerate (30 µg/kg, subcutaneously) and sesame oil as vehicle, five days a week, respectively. All animals were sacrificed after eight weeks of intervention. RESULTS: Ovariectomy after eight weeks increased body weight and visceral fat (P < 0.05) in OVX-SED and OVX-C groups compared with SHAM rats with no change in plasma adiponectin levels. Estrogen replacement in OVX animals decreased body weight (13.4%, P < 0.05) and visceral fat (10.4%). Although they were not statistically significant, adiponectin, insulin sensitivity and lipid profile of OVX rats were ameliorated with estrogen treatment. CONCLUSION: We conclude that ovarian hormone withdrawal leads to higher body weight and visceral adipose tissue in rats, but surprisingly does not change adiponectin levels. Although a substantial decrease in body weight was achieved by estrogen replacement therapy in OVX animals, the beneficial metabolic effects of weight loss seems to be only mechanical, having a tendency to improve insulin sensitivity without elevating adiponectin production.
Menopause Int
· 2010 Jun · PMID 20729501
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Approximately 18,000 women are diagnosed with a gynaecological cancer in the UK each year. Predisposing risk factors for some of these gynaecological cancers include an early menarche/late menopause and hormone replaceme...Approximately 18,000 women are diagnosed with a gynaecological cancer in the UK each year. Predisposing risk factors for some of these gynaecological cancers include an early menarche/late menopause and hormone replacement therapy (HRT). Furthermore, treatment of gynaecological malignancies often induces an iatrogenic menopause, which may be more severe than a natural onset. HRT is an extremely effective treatment that may dramatically improve physical and psychological symptoms and ultimately quality of life in patients with cancer. However, the safety of using HRT in patients with gynaecological cancer is a controversial issue and not entirely clear. The main concern is the theoretical risk of the stimulation of residual cancer cells by estrogen replacement. The review of the evidence in this article found that for most gynaecological cancers this hypothesis was not proven. No study to date has found HRT to have a detrimental effect on survival in patients with early stage endometrial cancer, epithelial ovarian cancer, cervical cancer and vulval tumours. HRT is only an absolute contraindication in low-grade endometrial stromal sarcomas and is best avoided in granulosa cell ovarian tumours. Therefore, HRT should not be withheld in the majority of patients with gynaecological cancer. If quality of life is being adversely affected by symptoms of the menopause, then patients with cancer should be counselled regarding the known risks and benefits of HRT to enable them to make an informed decision on their treatment.
Menopause Int
· 2010 Jun · PMID 20729500
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Hot flushes are the most common indication for the prescription of hormone replacement therapy (HRT) since it is effective in over 80% of cases. In 1995, 37% of American women took HRT, principally for this purpose. Howe...Hot flushes are the most common indication for the prescription of hormone replacement therapy (HRT) since it is effective in over 80% of cases. In 1995, 37% of American women took HRT, principally for this purpose. However, over the last five years, publications such as those from the Women's Health Initiative (WHI) have caused concern among women since they perceive that the risks outweigh the benefits. Following this publication, half of the women taking HRT in the UK, USA and New Zealand discontinued HRT. With the discontinuation of estrogen many women re-developed hot flushes; however only a small number (18%) of women report restarting hormone therapy. The majority of these (76%) for the recurrence of severe hot flushes or night sweats. Alternatives are available, but limited knowledge on aetiology and mechanisms of hot flushing represents a major obstacle for the development of new, targeted, non-hormonal treatments, and no current alternatives are as effective as estrogen.
Menopause Int
· 2010 Jun · PMID 20729499
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The bladder and its surrounding structures are rich in estrogen receptors and there are demonstrable physiological and anatomical changes that occur around and immediately after the menopause. The prevalence of many blad...The bladder and its surrounding structures are rich in estrogen receptors and there are demonstrable physiological and anatomical changes that occur around and immediately after the menopause. The prevalence of many bladder symptoms, such as frequency, urgency and incontinence, does seem to increase around the menopause, but there is continuing debate over whether these effects are due to ageing, menopause or a combination of the two. The impact of the menopause varies with individual symptoms; stress urinary incontinence being associated more with estrogen deficiency than urge incontinence which seems to be more age-related. Both estrogen and progesterone have a variety of effects on the urogenital tract which are reviewed. Based on these effects, it could be anticipated that estrogen replacement would have a positive effect on bladder symptoms. However, the data are far from clear cut on this issue. It seems that topical estrogens do have some positive effects, particularly on symptoms of urgency, frequency and urge incontinence, the prevention of urogenital atrophy and in the prevention of recurrent urinary tract infections. The role of systemic estrogens is less clear cut with some studies even suggesting they can be associated with a worsening of some symptoms. The possible explanations for this apparent contradiction are explored, but based on current evidence, it would appear preferable to use vaginal estrogens rather than systemic as part of the management of menopause-related bladder problems.
Menopause Int
· 2010 Jun · PMID 20729498
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Vaginismus is generally described as an involuntary contraction of the vaginal musculature, which usually results in the failure of penetration. Despite a lack of consensus as to the exact definition, prevalence rates va...Vaginismus is generally described as an involuntary contraction of the vaginal musculature, which usually results in the failure of penetration. Despite a lack of consensus as to the exact definition, prevalence rates vary between 4.2% and 42%. It is commonly diagnosed at both gynaecological and psychosexual clinics. The majority of studies and treatment options concentrate on the premenopausal age group. It is accepted that even within this age group, the diagnosis is often incorrect as symptoms can be confused with dyspareunia and other sexual pain disorders. There is no literature discussing vaginismus in the postmenopausal patient, despite evidence that an active sex life is important to the majority of women, irrespective of age. It is known that the majority of women do not report difficulties in their sex life and it may be that the older patient is more embarrassed at disclosing any such difficulties. This review aims to highlight the possible causes of vaginismus in this older age group and to aid the clinician in asking the appropriate questions, performing the appropriate examination and suggesting possible treatment options.
Menopause Int
· 2010 Jun · PMID 20729497
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Following diagnosis of premature ovarian failure (POF), few women become pregnant spontaneously and the only fertility treatment that can be offered is oocyte donation. With advances in fertility technology, timely prese...Following diagnosis of premature ovarian failure (POF), few women become pregnant spontaneously and the only fertility treatment that can be offered is oocyte donation. With advances in fertility technology, timely preservation of female fertility in the form of egg freezing is a topical area, and one of which patients are increasingly aware. Women with a family history of POF may be especially concerned about future fertility. We describe a case where a consultation was sought in the POF clinic for this issue.
Menopause Int
· 2010 Jun · PMID 20729495
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OBJECTIVE: To quantify compliance with using estrogen-only hormone replacement therapy (HRT) up until the time of mean age of natural menopause in women undergoing either bilateral oophorectomy or removal of one remainin...OBJECTIVE: To quantify compliance with using estrogen-only hormone replacement therapy (HRT) up until the time of mean age of natural menopause in women undergoing either bilateral oophorectomy or removal of one remaining ovary at the time of hysterectomy for benign disease. DESIGN: Prospective study. Annual questionnaire follow-up for ten years of women undergoing hysterectomy and bilateral oophorectomy for benign disease aged 46 or less at the time of surgery. SETTING: Gloucestershire Royal Hospital. PARTICIPANTS: Five hundred and twenty-one women recruited over a four-year period from 1994 to 1997. MAIN OUTCOME MEASURES: Compliance with HRT use, changes in HRT preparations and reasons for discontinuation. RESULTS: The median age of women at the time of hysterectomy was 42 (range 22-46) years; 4.9% (n = 24) stopped HRT within the first two years and 16.5% (n = 86) by the end of the study. The majority of women were prescribed HRT tablets (253, 48%) and the next most common being patches. In total, there were 1271 episodes of changing HRT, with the range between 0 and 18 changes per woman over the ten-year period. In all, 32% of changes were to a different route of HRT, 19% were to a different preparation of the same route, 18% were to an increased dose of the same preparation and 7% were to a decreased dose of the same preparation. CONCLUSIONS: Compliance with HRT use was high throughout the study, although responses decreased after five years. Change to HRT preparations was consistently high across all preparations. Women requiring HRT after surgical menopause need to be supported in finding the right preparation for them.
Menopause Int
· 2010 Jun · PMID 20729494
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OBJECTIVE: To test the hypothesis that premenopausal hysterectomy compromises ovarian function and accelerates ovarian failure. DESIGN: Longitudinal prospective cohort study. Annual follow-up with serum follicle-stimulat...OBJECTIVE: To test the hypothesis that premenopausal hysterectomy compromises ovarian function and accelerates ovarian failure. DESIGN: Longitudinal prospective cohort study. Annual follow-up with serum follicle-stimulating hormone levels with all women being 46 years of age or less at the time of hysterectomy for benign disease. SETTING: Gloucestershire Royal Hospital, Gloucester, UK. PARTICIPANTS: Five hundred and thirty-one women recruited over a four-year period from 1994 to 1997. RESULTS: The median age of women in the study was 37 (range 22-46). Women had earlier ovarian failure after unilateral oophorectomy (hazard ratio 2.41, 95% confidence interval (CI) 1.44-4.04) and after vaginal hysterectomy (hazard ratio 2.04, 95% CI 1.33-3.14) compared with abdominal hysterectomy. The mean age of ovarian failure across all groups was 45.87 (+/-3.58), and 59 (11%) women remained in the study at the end of 10 years who had not yet entered the menopause. CONCLUSION: This is the largest number of cases collected prospectively looking at ovarian failure after hysterectomy. Earlier ovarian failure occurred in those women having unilateral oophorectomy or vaginal hysterectomy. Early ovarian failure was not confirmed across the study group with only 2% of women having confirmed ovarian failure by Kaplan-Meier estimate one year after surgery and 14% at five years.
Menopause Int
· 2010 Jun · PMID 20729493
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OBJECTIVE: To evaluate an online digital story aimed to empower women suffering from urogenital atrophy to seek health professional advice. STUDY DESIGN: A questionnaire evaluating a digital story on the UK-based menopau...OBJECTIVE: To evaluate an online digital story aimed to empower women suffering from urogenital atrophy to seek health professional advice. STUDY DESIGN: A questionnaire evaluating a digital story on the UK-based menopause website www.menopausematters.co.uk. Main outcome measure Answers to questions on empowerment. RESULTS: A total of 539 responses were obtained over the 62 weeks that the questionnaire was online. In women who had not previously sought help for urogenital atrophy, 145 were too embarrassed and 105 did not want to bother the health professional. Having watched the video, 73% (n = 105/143) of women who had been too embarrassed to discuss their symptoms with their doctor would now do so and 87% (n = 89/102) of women who had not wanted to bother their doctor would also make an appointment. Ninety-six percent (n = 138/144) of women would be willing to try treatment. Over two-thirds of women favoured webcast information to written information; however, postmenopausal women were less likely than peri- or premenopausal to favour this method of presenting health information. CONCLUSION: Using digital stories for health promotion is a new area for research. Our data provide preliminary evidence that women can feel more empowered to seek help for urogenital atrophy using digital storytelling.
Menopause Int
· 2010 Mar · PMID 20424287
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In spite of the negative press reports following the 2002 Women's Health Initiative (WHI) publication, women can be reassured that in the correct circumstances, hormone replacement therapy (HRT) is beneficial and safe, p...In spite of the negative press reports following the 2002 Women's Health Initiative (WHI) publication, women can be reassured that in the correct circumstances, hormone replacement therapy (HRT) is beneficial and safe, particularly if treatment is started below the age of 60. Transdermal estradiol is probably safer than oral estrogens as coagulation factors are not induced in the liver and HRT is safer if a minimal duration and dose of progestogen is used. HRT is effective for the treatment of estrogen-deficiency symptoms of flushes, sweats and vaginal dryness. Estrogens prevent osteoporotic fractures and should be first-choice therapy, rather than bisphosphonates. Similarly, HRT protects the intervertebral discs in a way that non-hormonal preparations do not. Estrogens perhaps with the addition of testosterone help certain sorts of reproductive depression, as well as improving energy and libido. There is new evidence to support the previous observational studies that HRT reduces the incidence of heart attacks. Estrogen therapy has a beneficial effect upon collagen, thus improving the texture of the skin, the nails, the intervertebral discs and bone matrix. Discussion of side-effects should not be avoided, particularly the 1% extra lifetime risk of breast cancer. This should be balanced against the fewer heart attacks, fewer deaths and less osteoporotic fractures in those who start HRT below the age of 60.