[Effects of cancer treatments on gonads]

High dose cytotoxic drug combinations as well as radiotherapies to the whole body, the pelvic region and the head ovarian are associated with a risk of gonadal damage. In men, cells responsible for sperm production are most prone to damage, but testosterone production is usually preserved. In women, cancer treatments are known to accelerate the disappearance of primordial follicles, prevent ovarian follicle growth and increase fibrosis. This decreases the non-regenerable pool of oocytes. In young women, the ovaries may function well shortly after cancer treatments, whereby getting pregnant is possible. However they are in inreased risk of premature menopause.

Chronic medical conditions and reproducibility of self-reported age at menopause among community-dwelling women

OBJECTIVE

The aim of this study was to examine the association between chronic medical conditions and reproducibility of self-reported age at menopause among community-dwelling women.

METHODS

Age at menopause was assessed in a population-based longitudinal survey of 240 women twice, in 1993 and 2004. Women who recalled age at menopause in 2004 within 1 year or less of age at menopause recalled in 1993 (concordant) were compared with women who did not recall age at menopause in 2004 within 1 year of age at menopause recalled in 1993 (discordant). Type of menopause (surgical or natural) and chronic medical conditions were assessed by self-report.

RESULTS

One hundred forty-three women (59.6%) reported surgical menopause, and 97 (40.4%) reported natural menopause. In all, 130 (54.2%) women recalled age at menopause in 2004 within 1 year or less of recalled age at menopause in 1994, whereas 110 (45.8%) women did not recall age at menopause in 2004 within 1 year or less of recalled age at menopause in 1994. Among the women with surgical menopause, the women with three or more medical conditions were less likely to have concordant recall of age at menopause than the women with less than three chronic medical conditions (adjusted odds ratio, 0.36; 95% CI, 0.15-0.91) in multivariate models controlling for potentially influential characteristics including cognition and years since menopause.

CONCLUSIONS

Among women who underwent surgical menopause, the presence of three or more medical conditions is associated with decreased reproducibility of self-reported age at menopause.

Adverse health outcomes in women exposed in utero to diethylstilbestrol

BACKGROUND

Before 1971, several million women were exposed in utero to diethylstilbestrol (DES) given to their mothers to prevent pregnancy complications. Several adverse outcomes have been linked to such exposure, but their cumulative effects are not well understood.

METHODS

We combined data from three studies initiated in the 1970s with continued long-term follow-up of 4653 women exposed in utero to DES and 1927 unexposed controls. We assessed the risks of 12 adverse outcomes linked to DES exposure, including cumulative risks to 45 years of age for reproductive outcomes and to 55 years of age for other outcomes, and their relationships to the baseline presence or absence of vaginal epithelial changes, which are correlated with a higher dose of, and earlier exposure to, DES in utero.

RESULTS

Cumulative risks in women exposed to DES, as compared with those not exposed, were as follows: for infertility, 33.3% vs. 15.5% (hazard ratio, 2.37; 95% confidence interval [CI], 2.05 to 2.75); spontaneous abortion, 50.3% vs. 38.6% (hazard ratio, 1.64; 95% CI, 1.42 to 1.88); preterm delivery, 53.3% vs. 17.8% (hazard ratio, 4.68; 95% CI, 3.74 to 5.86); loss of second-trimester pregnancy, 16.4% vs. 1.7% (hazard ratio, 3.77; 95% CI, 2.56 to 5.54); ectopic pregnancy, 14.6% vs. 2.9% (hazard ratio, 3.72; 95% CI, 2.58 to 5.38); preeclampsia, 26.4% vs. 13.7% (hazard ratio 1.42; 95% CI, 1.07 to 1.89); stillbirth, 8.9% vs. 2.6% (hazard ratio, 2.45; 95% CI, 1.33 to 4.54); early menopause, 5.1% vs. 1.7% (hazard ratio, 2.35; 95% CI, 1.67 to 3.31); grade 2 or higher cervical intraepithelial neoplasia, 6.9% vs. 3.4% (hazard ratio, 2.28; 95% CI, 1.59 to 3.27); and breast cancer at 40 years of age or older, 3.9% vs. 2.2% (hazard ratio, 1.82; 95% CI, 1.04 to 3.18). For most outcomes, the risks among exposed women were higher for those with vaginal epithelial changes than for those without such changes.

CONCLUSIONS

In utero exposure of women to DES is associated with a high lifetime risk of a broad spectrum of adverse health outcomes. (Funded by the National Cancer Institute.).

Assessing osteoporosis risk factors in Spanish menopausal women

OBJECTIVES

(1) To assess the prevalence of osteoporosis risk factors in Spanish menopausal women; (2) to detect medical and lifestyle risk factor differences between perimenopausal and postmenopausal women; (3) and to identify the main factors responsible for osteoporosis.

METHODS

Cross-sectional descriptive study encompassing women aged 45-65 across Spain. The study population sample was collected through random sampling and a total of 10,514 women were included. Socio-demographic, medical history, and lifestyle data were assessed.

RESULTS

The prevalence of osteoporosis risk factors was 67.6%. The most common risk factors were physical inactivity (53.6%), use of medication related to osteoporosis risk (45.9%), and low calcium intake (30.1%). There were statistically significant differences between peri- and postmenopausal women in terms of smoking status, alcohol intake, personal history, poor dairy product intake, and medication use that could increase risk. Logistic regression analysis showed that osteoporosis was significantly associated with age, family history, age at onset of menopause, Kupperman Index, prolonged immobilization, weight loss, and other diseases that increase the probability of developing osteoporosis.

CONCLUSIONS

A high prevalence of women taking osteoporosis risk-related medication was observed in our study. There was correlation between the menopausal symptoms' degree of severity and the risk of suffering from osteoporosis.

Gametes or organs? How should we legally classify ovaries used for transplantation in the USA?

Ovarian tissue transplantation is an experimental procedure that can be used to treat both infertility and premature menopause. Working within the current legal framework in the USA, I examine whether ovarian tissue should be legally treated like gametes or organs in the case of ovarian tissue transplantation between two women. One option is to base classification upon its intended use: ovarian tissue used to treat infertility would be classified like gametes, and ovarian tissue used to treat premature menopause would be classified like organs. In the end, however, I argue that this approach will not work because it engenders too many legal, cultural and logistical concerns and that, at least for the near future, we should treat ovarian tissue like gametes.

Safety and tolerability of testosterone patch therapy for up to 4 years in surgically menopausal women receiving oral or transdermal oestrogen

Two clinical trials previously demonstrated the safety of 300 μg/day transdermal testosterone patch (TTP) treatment for up to 6 months in 1094 surgically menopausal women with hypoactive sexual desire disorder (HSDD). Adverse events (AE), clinical laboratory tests, vital signs, physical examinations and mammograms were evaluated in open-label extensions of these two trials for up to 4 years and are presented in this article. Nine hundred and sixty-seven patients received at least one application of the TTP resulting in 1092 patient-years of exposure. There was no increase over time in the rate of new occurrences or severity of AEs, serious AEs, or withdrawals due to AEs. The most common AEs associated with treatment were application site reactions and unwanted hair growth; however, most were mild and rarely resulted in study withdrawal. No clinically meaningful changes in serum chemistry, haematology, lipid profile, carbohydrate metabolism, renal and liver function or coagulation parameters were noted with up to 4 years of therapy. Consistent with age-appropriate expected rates, three cases of invasive breast cancer were observed. No important changes in the safety or tolerability profile of TTP were revealed with long-term use for up to 4 years in otherwise healthy oophorectomised women with HSDD on concomitant oestrogen.

[The peculiarities of adaptation of a woman organism to the conditions of the Altai medium height altitude zones]

A comparative analysis on the morphological features, the duration of the reproduction period and antioxidant activity of blood plasma of the female population living in the Altai low and medium height altitude zones has been conducted. As a result we have discovered that women living in the unfavorable conditions of medium height altitude zones have a tendency to raise the body mass index, a shorter reproduction period and lower level of blood plasma antioxidant activity.

Celiac disease and its effect on human reproduction: a review

Celiac disease is an intestinal inflammatory disease that is triggered by gluten in the diet. Patients present with a wide array of symptoms due to malabsorption that include diarrhea, abdominal pain, bloating and weight loss. In women, this disease may have implications on menstrual and reproductive health. The symptom complex includes delayed menarche, early menopause, secondary amenorrhea, infertility, recurrent miscarriages and intrauterine growth restriction. These women benefit from early diagnosis and treatment. Therefore, celiac disease should be considered and screening tests performed on women presenting with menstrual and reproductive problems and treated accordingly. The objective of this article is to review the current literature on celiac disease and its association with the above-mentioned disorders.

Hormone replacement after gynaecological cancer

Treatment of gynaecological cancer frequently results in the loss of ovarian function and menopausal symptoms. Symptoms of iatrogenic menopause are usually significantly more intense than those of natural menopause due to sudden onset of symptoms, younger age and its effects on common physical and psychological problems of cancer therapy like body image concerns and sexual dysfunction. The most effective treatment for menopausal symptoms is hormone replacement therapy (HRT). However, it is very controversial if HRT is safe in patients after a gynaecological malignancy. The main concerns are the potential stimulation of residual cancer and the induction of new hormone-dependent disease. However, the majority of the most common gynaecological malignancies like squamous cell carcinomas of the cervix, serous papillary epithelial ovarian carcinomas and squamous cell carcinomas of the vulva are not oestrogen dependent. Furthermore, current scientific evidence does not show HRT to adversely affect the outcome in patients after treatment for hormone sensitive cancers like early stage endometrioid adenocarcinomas of the endometrium. There are only a small number of gynaecological malignancies like low grade endometrial stromal sarcomas in which HRT is an absolute contraindication. Therefore, as maintaining quality of life and minimising the physical and psychological impact of treatment side effects is one of the most important factors in cancer care, it is imperative to give patients unbiased information about their individual cancer which in most cases will allow them to use HRT without any detrimental effect on their survival.

Cognitive behavioral therapy and physical exercise for climacteric symptoms in breast cancer patients experiencing treatment-induced menopause: design of a multicenter trial

BACKGROUND

Premature menopause is a major concern of younger women undergoing adjuvant therapy for breast cancer. Hormone replacement therapy is contraindicated in women with a history of breast cancer. Non-hormonal medications show a range of bothersome side-effects. There is growing evidence that cognitive behavioral therapy (CBT) and physical exercise can have a positive impact on symptoms in naturally occurring menopause. The objective of this study is to investigate the efficacy of these interventions among women with breast cancer experiencing treatment-induced menopause.

METHODS/DESIGN

In a randomized, controlled, multicenter trial, we are evaluating the effectiveness of CBT/relaxation, of physical exercise and of these two program elements combined, in reducing menopausal symptoms, improving sexual functioning, reducing emotional distress, and in improving the health-related quality of life of younger breast cancer patients who experience treatment-induced menopause. 325 breast cancer patients (aged < 50) are being recruited from hospitals in the Amsterdam region, and randomly allocated to one of the three treatment groups or a 'waiting list' control group. Self-administered questionnaires are completed by the patients at baseline, and at 12 weeks (T1) and 6 months (T2) post-study entry. Upon completion of the study, women assigned to the control group will be given the choice of undergoing either the CBT or physical exercise program.

DISCUSSION

Cognitive behavioral therapy and physical exercise are potentially useful treatments among women with breast cancer undergoing treatment-induced, premature menopause. For these patients, hormonal and non-hormonal therapies are contraindicated or have a range of bothersome side-effects. Hence, research into these interventions is needed, before dissemination and implementation in the current health care system can take place.

Menopausal age in relation to smoking

A population study of women revealed more smokers among 50-year-old postmenopausal women than among women of the same age who still menstruated. The difference was statistically significant. The postmenopausal smokers had on average smoked as long as or longer than the smokers who still menstruated. The higher number of smokers among postmenopausal women could thus not be explained by these women starting to smoke in connection with the menopause. Non-smoking women were on average heavier than smoking women. Previous studies indicate that an increased amount of adipose tissue might delay the menopausal age. It is therefore possible that the difference in menopausal age between smoking and non-smoking women might be explained either by a delayed menopause in non-smoking women due to an increased amount of adipose tissue in these women, or by a precocious menopause in smokers due to toxic effects from smoking. Probably both factors are of importance, but our results indicate that smoking per se is the main factor. The increased number of smokers among women with precocious menopause can probably explain part of the overrepresentation of women with precocious menopause among those who have myocardial infarction.

[Correlations between bone mass density and osteoporosis risk factors in postmenopausal women]

AIM

To analyse correlations between bone tissue mineral density (BMD) and risk factors of osteoporosis.

MATERIAL AND METHODS

Correlation between bone mass density measured by dual-energy x-ray absorptionmetry (DEXA) and risk factors (RF) of osteoporosis (fractures in relatives, early menopause, fractures in patients, low weight and low food calcium consumption) was studied in 1115 postmenopausal women (mean age 64.24 +/- 3.92).

RESULTS

A decrease of BMD with age, even without RF leads to osteopenia at the age over 70 years. The presence of almost all RF (except low calcium consumption) often combines with osteopenia, two RF--fractures in the patients, low weight--are associated with osteoporosis.

CONCLUSION

The above correlation helps make decisions on treatment policy in outpatients.

Prophylactic oophorectomy in premenopausal women and long-term health

OBJECTIVE

To review the data on long-term outcomes in women who underwent prophylactic bilateral oophorectomy, a common surgical procedure that has more than doubled in frequency since the 1960s.

STUDY DESIGN

Literature review of the published data on the consequences of prophylactic bilateral oophorectomy. Special emphasis was given to the Mayo Clinic Cohort Study of Oophorectomy and Aging. Main outcome measures Overall mortality, cardiovascular disease, cognitive impairment and dementia, parkinsonism, osteoporosis, psychological wellbeing and sexual function.

RESULTS

There is a growing body of evidence suggesting that the premature loss of ovarian function caused by bilateral oophorectomy performed before natural menopause is associated with several negative outcomes. In particular, studies have revealed an increased risk of premature death, cardiovascular disease, cognitive impairment or dementia, parkinsonism, osteoporosis and bone fractures, decline in psychological wellbeing and decline in sexual function. The effects involve different organs (e.g. heart, bone, or brain), and different functions within organs (e.g. cognitive, motor, or emotional brain functions). Estrogen treatment may prevent some but not all of these negative outcomes.

CONCLUSION

The potential adverse effects of prophylactic bilateral oophorectomy on heart health, neurological health, bone health and quality of life should be carefully weighed against its potential benefits for cancer risk reduction in women at average risk of ovarian cancer.

Postmenopausal status and early menopause as independent risk factors for cardiovascular disease: a meta-analysis

OBJECTIVE

Loss of ovarian function and subsequent deficiency of endogenous estrogens is suggested to enhance cardiovascular disease risk and related death after menopause. The aim was to obtain valid estimates of the cardiovascular disease risk associated with postmenopausal status and early menopause.

DESIGN

A literature search of observational studies was performed using PubMed and EMBASE (1966 to May 1, 2004). Eighteen studies on postmenopausal status and age at menopause in relation to cardiovascular disease were selected. Six studies investigated menopausal status, nine studies investigated menopausal age, and three studied both. General variance-based methods were used to pool relative risk estimates and corresponding 95% confidence intervals. Stratification was performed for study design, type of menopause, outcome, and adjustment for age and smoking.

RESULTS

The pooled relative risk estimate for postmenopausal versus premenopausal status and cardiovascular disease was 1.36 (95% CI, 1.15-1.60). In the stratified analysis, the pooled effect was 0.96 (95% CI, 0.77-1.21) after controlling for age and smoking. The pooled effect of bilateral oophorectomy on cardiovascular disease was 2.62 (95% CI, 2.05-3.35). For early menopause and cardiovascular disease, with the menopausal age category containing 50 years as a reference, the pooled relative risk estimate was 1.25 (95% CI, 1.15-1.35). In the stratified analysis, the pooled effect was 1.38 (95% CI, 1.21-1.58) after controlling for age and smoking. The pooled effect of bilateral oophorectomy on cardiovascular disease was 4.55 (95% CI, 2.56-8.01).

CONCLUSIONS

Overall, there was no convincing relationship between postmenopausal status and cardiovascular disease. However, there was a modest effect of early menopause on cardiovascular disease. The effect was more pronounced for women with an artificial menopause than for women with a natural menopause.

[Anti-mullerian hormone in young women after chemotherapy and infradiaphragmatic radiotherapy for childhood cancer]

INTRODUCTION

Composed anticancer treatment leads to different late effects, such as ovarian failure, causing infertility or premature menopause.

AIM OF THE STUDY

was to analyse ovarian function, particularly anti-mullerian hormone levels, in young females after anticancer treatment.

PATIENTS AND METHODS

We analysed FSH, LH, estradiol and anti-mullerian hormone (AMH) levels on days 3-5 of a menstrual cycle in thirty three cancer survivors in mean age 19.1+/-4.7 years treated in age 12.0+/-5.6 years for Hodgkin Lymphoma (HL) (n=16), nephroblastoma (n=7), soft tissue sarcoma (n=4), germinal tumor (n=3), neuroblastoma (n=2), histiocytosis (n=1). Infradiaphragmatic radiotherapy was needed in 16 patients (10 treated for HL). Results were compared with healthy girls of the same age.

RESULTS

The mean values of FSH, LH, E2 and AMH did not differ in all survivors comparing to controls. Patients treated for HL with chemo- and radiotherapy presented higher FSH levels than controls (8.53+/-3.25 vs. 5.8+/-2.03 mIU/ml; p=0.045). Mean AMH levels were lower in all patients that received radiotherapy for the infradiaphragmatic region (17.19+/-14.84 pmol/l) than in controls (29.40+/-13.2 pmol/l; p=0.037). Particular analysis of all cases showed higher (>2 SD) FSH levels in 8 patients: 5 patients treated for HL with radiotherapy and higher total doses of procarbazine, nitrogen mustard and vinblastine; 2 patients treated for soft tissue sarcoma and one patient for Wilms tumor (all received radiotherapy). Lowered AMH levels were found in 8 patients treated with chemo- and radiotherapy (4 - for HL, 2 - for Wilms tumor and 2 - for soft tissue sarcoma).

CONCLUSION

Composed anticancer treatment, especially radiotherapy, leads to ovarian failure. Decreased AMH values at young adulthood suggest a lower ovarian reserve. All causes and first symptoms of ovary damage should be known to the doctors who take care of the patients after anticancer treatment.

[Ovarian dysfunction after anticancer treatment - possibilities of diagnosis and fertility preservation]

Due to composed anticancer treatment more than 70% of children and adolescents are cured. The long-term side effects deteriorating quality of life have a great importance. The influence of chemo- and radiotherapy on ovary function, the causes of premature menopause, actual possibilities of diagnosis and fertility preservation are presented.

Treatment-related risk factors for premature menopause following Hodgkin lymphoma

We conducted a cohort-study among 518 female 5-year Hodgkin lymphoma (HL) survivors, aged 14 to 40 years (median: 25 years) at treatment (1965-1995). Multivariable Cox regression was used to quantify treatment effects on risk of premature menopause, defined as cessation of menses before age 40 years. After a median follow up of 9.4 years, 97 women had reached menopause before age 40 years. Chemotherapy was associated with a 12.3-fold increased risk of premature menopause compared with radiotherapy alone. Treatment with MOPP (mechlorethamine, vincristine, procarbazine, prednisone)/ABV (doxorubicine, bleomycine, vinblastine) significantly increased the risk of premature menopause (hazard ratio [HR]: 2.9), although to a lesser extent than MOPP treatment (HR: 5.7). Alkylating agents, especially procarbazine (HR: 8.1) and cyclophosphamide (HR: 3.5), showed the strongest associations. Ten years after treatment, the actuarial risk of premature menopause was 64% after high cumulative doses (> 8.4 g/m2) and 15% after low doses (≤ 4.2 g/m2) of procarbazine. The cumulative risk of menopause at age 40 years did not differ much according to age, but time to premature menopause was much longer in women treated at early ages. As long as alkylating agents will be used for curing HL, premature menopause will remain a frequent adverse treatment effect, with various clinical implications.

Variations on hormone replacement therapy: an answer to the 'one dose fits all' Women's Health Initiative study

The Women's Health Initiative study worked on the assumption that one dose would fit all asymptomatic postmenopausal women. The investigators therefore often used the wrong dose, of the wrong hormones, on the wrong patients and therefore came to many wrong conclusions. Different combinations of different hormones are necessary for different symptoms and different age groups. Hormone replacement therapy may be commenced in the perimenopausal phase, the early postmenopause, the late postmenopause or after hysterectomy and bilateral salpingo-oophorectomy or a premature menopause. These all require different treatments. Similarly, various indications such as vasomotor symptoms, sexual problems, depression or the treatment/prevention of osteoporosis all need different combinations of estradiol and possibly progestogen and testosterone, according to the specific requirements of the patient.