[Inhibition of sexual desire associated with menopause]

Physicians or gynaecologists, specifically in their general practice or in the setting of a menopause clinic, are more and more frequently confronted to sexual complaints of menopausal women. Among these, decline in sexual desire is probably the most usually reported. The first study to evaluate a potential relationship between sexual functioning and menopause was conducted by Hallström in 1977. Thereafter, a review of the literature was able to show that there is nearly a consensus regarding the role of oestrogens in that condition. They effectively relieve vaginal atrophy and resulting dyspareunia. There is less agreement, however, regarding a direct effect of oestrogens on more complex sexual behaviour and motivation. When analyzing potential influence of sex hormones, oestrogens may exert a positive effect on the quality of the sexual relationship whereas androgens can definitely increase sexual "motivation" including sexual desire. In spite of the potentially important part played by androgens as promoters of libido and in the maintenance of sexual functioning in men and women, the exact role of the hormonal treatment in relieving sexual complaints still keeps controversial. In some women whose decline of sexual desire can be reasonably attributed to menopause, androgens in non-masculinizing adequate dosages, can be effectively included in the postmenopausal hormone replacement regimen. However, aetiology of diminished sexual motivation and desire is far from univocal particularly in the human being where psychological, social and cultural influences are endowed with a prominent importance. It is accordingly conspicuous that our sexual life is not reduced to hormonal fluctuations only. A short critical review of the literature devoted to the main aspects of changes of sexual desire associated with menopause is presented.

[Meno-metrorrhagia]

Menometrorrhagia is frequent. It consists in menorrhagia (excessive menstrual flow and duration) and metrorrhagia (irregular, excessive flow and duration). Three different types of aetiology occur: general extra-gynaecological causes, endocrine causes and organic causes. This last group is made of myomas, polyps, endometrial hyperplasia, adenomyosis and uterine cancers. Dysfunctional uterine bleedings do not find their cause in one of these three main causes. The diagnosis is based on three types of complementary investigations: endo-uterine cytological and histological samplings, medical imaging of which endovaginal echography is the most accurate, and diagnostic hysteroscopy. This triad allows to reach a very precise diagnosis in order to exclude a malignant lesion. Thanks to this precise diagnosis, the therapeutic decision is made according to the nature of the lesion to be treated, the desire to retain fertility, and age. Medical and surgical treatments are possible. In most cases of general extra-gynaecological and endocrine causes, medical treatment is efficient and etiological. When organic uterine lesions are present, several medical treatments are efficient by suppressing the cause of bleeding or by symptomatic action. Main medical treatments are: anti-fibrinolytic agents, nonsteroidal anti-inflammatory drugs, progestin, oral contraceptive pills, GnRH agonists and danazol. The surgical treatment consists in endoscopic techniques (operative hysteroscopy and laparoscopy) and hysterectomy performed by vaginal route with or without laparoscopic preparation, by laparoscopic approach only or by classical laparotomy. Currently, the classical D & C has become essentially a diagnostic method. Surgical treatment is necessary after failure of a medical treatment or in the presence of a lesion not directly accessible to medical therapy. The efficacy of conservative endoscopic techniques depends on the respect of the indications of these techniques. These allow to reduce the number of hysterectomies for benign lesions by up to 50%.

[Premenstrual tension syndrome or premenstrual dysphoria]

Premenstrual Tension Syndrome (PMS) has always existed: it has been first described by an endocrinologist from New York in 1931. It is responsible for significant and psychological disorders which justify the study of its pathogenesis. Hormonal dysfunction has been demonstrated among women who are at risk for PMS; nevertheless, it has been shown that neurological transducers are also affected, such as GABAergic, serotoninergic and endorphinic systems. Interactions between the two systems allow to raise the hypothesis of an inbalance between GABAergic and progesterone derived neurosteroids in a psychoneuroendocrinological model. Based on this hypothesis, psychological symptoms can be efficiently treated by anxiolytic or antidepressant treatment. On the other hand, progesterone derivatives and, sometimes, diuretics, are useful on physical symptoms. As far as we know there is so far no single treatment of demonstrated efficacy in the PMS.

[Hyperandrogenism: clinical aspects, investigation and treatment]

Androgen excess (AE) is one of the most common endocrine disorders, affecting 10% of adult women before the menopause. The clinical picture varies widely depending on the etiology of AE. Most of these women are suffering from hirsutism, acne, menstrual disturbances, anovulation and obesity. Virilization is unusual, except in patients with ovary or adrenal cancer. Polycystic ovary syndrome (PCOS) and idiopathic hirsutism (IH) are the most frequent causes of androgen excess, accounting for more than 90% of the cases. The pathogenesis of PCOS is still an unresolved problem. A hereditary predisposition has been suggested. Enzymatic deficiency is a less frequent cause of AE, the most common deficiency being the non classic 21-OH deficiency (NCAH). AE has been implicated as a side effect of many drugs. Ovary and adrenal tumours are unusual, however, they must be considered especially in case of severe hirsutism or virilization. Complementary investigations are selected based on the result of clinical examination. Pharmacologic therapy, usually with anti-androgens, is the most widely used treatment for PCOS, IH and NCAH. Surgical therapy should be considered only when there is a particular indication such as Cushing's syndrome, ovary or adrenal tumours.

[Surgical hysteroscopy or hysterectomy in the treatment of benign uterine lesions. What to choose in 1998?]

In the past, the treatment of benign uterine lesions required, in many instances, a hysterectomy. These days, most cases can be successfully treated by hysteroscopy. To be reliable, this technique must lead to a significant reduction in the number of hysterectomies performed for benign uterine lesions. The electroresection technique is preferred to that using the Nd-YAG laser because of its lower cost and its equivalent efficacy. By using the uterine perfusion pump device, the risk of resorption syndrome can be reduced to its minimum. Submucosal myomas < 1 cm, benign endometrial hyperplasia and adenomyosis are the commonest benign lesions treated. Dysfunctional uterine bleeding can also be treated by an endometrectomy. A preoperative workup includes a transvaginal ultrasound and a biopsy. This ensures that only benign lesions that are accessible to a hysteroscopy will be submitted to this technique and that no cases of endometrial cancer or atypical hyperplasia would be ignored. This study presents 270 cases of operative hysteroscopy with a follow-up to 4 years. 82.8% of myomatous lesions were treated with success. The results for patients with benign endometrial polyps or benign endometrial hyperplasia are also excellent with only 4.6% and 5.6% rate of secondary surgery respectively. Adenomyosis does not appear to be a good indication for hysteroscopy as only 37% of patients did not need a definitive hysterectomy. Rates of operative complications (post-operative bleeding, uterine perforation, resorption syndrome and difficulty of access) are acceptable and get less frequent as the surgeon experience increases.

[Risks, benefits and costs of hormone replacement therapy in menopause]

Hormone replacement therapy (HRT) acts both as an effective treatment of menopausal symptoms and genital atrophy, and as an effective prevention of osteoporosis. It is also probably cardioprotective and potentially preventing cerebrovascular disease. The risk of oestrogen-induced endometrial cancer is eliminated by the addition of a progestin. An increase in breast cancer risk is however possible after 10 years or more of HRT use. This multifactorial risk-benefit balance altogether with other variables (numerous and expensive hormonal therapies, low compliance of postmenopausal women, need for monitoring, therapy-related adverse events) explain why so few global pharmaco-economic appraisals have been devoted to HRT. Computer model studies have been set up to study hypothetical cohorts of menopausal women treated for 5-10 years or more, comprising hysterectomized women (receiving an estrogen alone) and non hysterectomized women (receiving an oestrogen-progestogen therapy) compared with untreated controls. Treatment of hysterectomized women as well as non hysterectomized symptomatic menopausal women appears relatively cost-effective. In terms of mortality and morbidity, a reduction in cardiovascular disease risk and, to a smaller extent, in osteoporosis has a strikingly greater impact than the small increase in breast cancer risk related to HRT use. A significant increase in life expectancy seems associated with long-term use and the quality-adjusted life years gain, is particularly impressive, as quality of life appears distinctly improved by HRT utilization. In the future, this beneficial cost-effectiveness equation will probably be optimized thanks to the introduction of alternative and innovative replacement therapies allowing longer treatment periods without increasing the risk of breast cancer.

Treatment of symptomatic pelvic varices by ovarian vein embolization

PURPOSE

Pelvic congestion syndrome is a common cause of chronic pelvic pain in women and its association with venous congestion has been described in the literature. We evaluated the potential benefits of lumbo-ovarian vein embolization in the treatment of lower abdominal pain in patients presenting with pelvic varicosities.

METHODS

Nineteen patients were treated. There were 13 unilateral embolizations, 6 initial bilateral treatments and 5 treated recurrences (a total of 30 procedures). All embolizations were performed with either enbucrilate and/or macrocoils, and there was an average clinical and Doppler duplex follow-up of 15.4 months.

RESULTS

The initial technical success rate was 96.7%. There were no immediate or long-term complications. Variable symptomatic relief was observed in 73.7% of cases with complete responses in 57.9%. All 8 patients who had partial or no pain relief complained of dyspareunia. The direct relationship between varices and chronic pelvic pain was difficult to ascertain in a significant number of clinical failures.

CONCLUSION

Transcatheter embolization of lumbo-ovarian varices is a safe technique offering symptomatic relief of pelvic pain in the majority of cases. The presence of dyspareunia seemed to be a poor prognostic factor, indicating that other causes of pelvic pain may coexist with pelvic varicosities.

Effect of transdermal 17 beta-estradiol and oral conjugated equine estrogens on biochemical parameters of bone resorption in natural menopause

OBJECTIVE

To evaluate and compare the effects or oral and transdermal estrogen replacement therapy on biochemical markers of bone resorption in early postmenopausal women.

DESIGN

Controlled, randomized group comparison.

SETTING

Outpatient clinic for menopausal women and research into osteoporosis.

SUBJECTS

Sixty healthy women menopausal for less than 5 years and who had never received any medications interfering with bone metabolism.

INTERVENTIONS

The 60 women were randomly allocated to 3 months therapy with either oral conjugated estrogens (0.625 mg/day) (n = 28) or transdermal estradiol (50 micrograms/day) (n = 32) in cyclical combination with medroxyprogesterone acetate (5 mg/day).

MAIN OUTCOME MEASURES

Traditional (urinary calcium/creatinine and hydroxyproline/creatinine) and the new specific (urinary pyridinoline/creatinine and deoxypyridinoline/creatinine) markers of bone resorption were determined before and after 3 months of treatment.

RESULTS

In both groups, circulating levels of estrone and estradiol were significantly (P < 0.001) increased during treatment. In women treated with oral conjugated equine estrogens, urinary calcium/creatinine and hydroxyproline/creatinine ratios were significantly (P < 0.05) reduced. Pyridinoline/creatinine ratio fell from 69.1 (4) [mean (SEM)] to 50 (4) mumol/mumol (P < 0.01) and deoxypyridinoline/creatinine ratio fell from 10.8 (1) [mean (SEM)] to 8.3 (0.8) mumol/mumol (P < 0.01). In the group treated with transdermal estradiol, urinary hydroxyproline/creatinine ratio was significantly (P < 0.05) reduced. Pyridinoline/creatinine ratio fell from 66.3 (4) [mean (SEM)] to 46.2 (3) mumol/mumol (P < 0.01) and deoxypyridinoline/creatinine ratio fell from 11.5 (1.5) [mean (SEM)] to 7.7 (0.6) mumol/mumol (P < 0.01). There were no differences between the evolution of the biochemical variables in the two groups.

CONCLUSION

These results suggest that oral conjugated equine estrogens and transdermal estradiol, in the given doses, are equally effective in reducing postmenopausal bone resorption.

Clinical tolerance of a combined monophasic contraceptive agent containing a low-dose of ethinyloestradiol and gestodene in adolescents

The clinical effects and the contraceptive effectiveness of a monophasic preparation containing 30 micrograms ethinyloestradiol and 75 micrograms gestodene per tablet were assessed in a study of 115 healthy adolescents (mean age 18.5 +/- 2 years) covering a total of 712 menstrual cycles (mean of 8 cycles per patient). There was a number of cases of discontinuation of the study (70/115), mainly due to poor discipline in tablet intake in this particular age group. Only 20 cases discontinued the study for medical reasons. No pregnancies occurred, in spite of the fact that tablets were frequently forgotten (11% of cycles). Eighty-eight percent of cycles presented a normal bleeding pattern from the second month of treatment on. Spotting was sporadic (less than 8% from the 2nd cycle) and was mainly associated with tablet omission. Intermenstrual bleeding (breakthrough bleeding) occurred in 19% of the first menstrual cycles but only in 5% of the second and following cycles. Tenderness of the breast was the most frequent subjective complaint (3.4% of cycles), followed by urogenital problems, headaches and digestive disorders. However, all complaints remained sporadic (13.4% of cycles). The systolic blood pressure showed little variation, with only a slight increase from 123 to 125 mmHg after 6 months of treatment. Though not clinically important, an increase in diastolic blood pressure was observed (from 76 to 82 mmHg after 6 months). The patients showed a tendency to increase weight (from 54.4 to 56.7 kg after 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Minimal levels of serum estradiol prevent postmenopausal bone loss

Biochemical parameters reflecting bone resorption [urinary calcium/creatinine (Ca/Cr) and hydroxyproline/creatinine (OH/Cr)] were related to serum estrogens [estrone (E1) and estradiol (E2)] in 262 healthy women including 158 patients receiving estrogen replacement therapy (ERT) for at least 6 months, 49 eugonadal women, and 55 untreated postmenopausal women. A significant (P < 0.001) correlation exists between serum E2 and Ca/Cr: Ca/Cr (mg/dl) = -0.00044 E2 (pg/ml) + 0.129 (n = 262; r = -0.37), serum E2 and OH/Cr: (OH/Cr (mg/g) = -0.049 E2 (pg/ml) + 18.76 (n = 262; r = -0.36), serum E1 and Ca/Cr: Ca/Cr (mg/dl) = -0.0003 E1 (pg/ml) + 0.127 (n = 261; r = -0.28) but not between serum E1 and OH/Cr. Women with circulating levels of E2 between 60 and 90 pg/ml have a significant (P < 0.01) reduction of Ca/Cr and OH/Cr when compared with those with lower levels of E2. Higher values of E2 do not provide additional benefit. We conclude that in postmenopausal women receiving an estrogen replacement therapy (ERT), a significant reduction of bone resorption is achieved when circulating levels of estradiol reach a value (60 pg/ml) corresponding to the one measured, in eugonadal women, during the last days of the early follicular phase of the menstrual cycle. We suggest that oral or percutaneous ERT should induce a minimal value of 60 pg/ml to prevent postmenopausal bone loss.

Exteroceptive silent period of temporalis muscle in menstrual headaches

The second exteroceptive silent period (ES2) of temporalis muscle was recorded on days 1 and 15 of the menstrual cycle in 17 women, 9 of whom suffered regularly from tension-type headaches during menstruation. Mean duration of temporalis ES2 was significantly shorter on day 1 of the cycle than on day 15. This difference was due to a marked menstrual reduction of ES2 in the headache subgroup. A positive correlation was found between ES2 durations and oestradiol/progesterone ratios. We hypothesize that the variations of ES2 during the ovarian cycle result from the modulatory effects of oestrogens on descending aminergic pathways that control excitability of inhibitory brainstem interneurons mediating exteroceptive suppression of jaw-closing motoneurons.