Practice patterns with hormone therapy after surgical menopause

Excess morbidity and mortality associated with underuse of estrogen replacement therapy in premenopausal women who undergo surgical menopause

BACKGROUND

Contrary to clinical guidelines, there has been a decrease over time in estrogen therapy use in premenopausal women undergoing bilateral oophorectomy for benign indications.

OBJECTIVE

This study aimed to estimate the excess morbidity and mortality associated with current patterns of estrogen therapy use in women who undergo bilateral oophorectomy with hysterectomy for benign indications.

STUDY DESIGN

We developed 2 Bayesian sampling Markov state-transition models to estimate the excess disease incidence (incidence model) and mortality (mortality model). The starting cohort for both models were women who had undergone bilateral oophorectomy with hysterectomy for benign indications at the age of 45 to 49 years. The models tracked outcomes in 5-year intervals for 25 years. The incidence model estimated excess incidence of breast cancer, lung cancer, colorectal cancer, coronary heart disease, and stroke, whereas the mortality model estimated excess mortality due to breast cancer, lung cancer, coronary heart disease, and all-other-cause mortality. The models compared current rates of estrogen therapy use with optimal (100%) use and calculated the mean difference in each simulated outcome to determine excess disease incidence and death.

RESULTS

By 25 years after bilateral oophorectomy with hysterectomy, there were an estimated 94 (95% confidence interval, -158 to -23) fewer colorectal cancer cases, 658 (95% confidence interval, 339-1025) more coronary heart disease cases, and 881 (95% confidence interval, 402-1483) more stroke cases. By 25 years after bilateral oophorectomy with hysterectomy, there were an estimated 189 (95% confidence interval, 59-387) more breast cancer deaths, 380 (95% confidence interval, 114-792) more coronary heart disease deaths, and 759 (95% confidence interval, 307-1527) more all-other-cause deaths. In sensitivity analyses where we defined estrogen therapy use as a duration of >2 years of use, these differences increased >2-fold.

CONCLUSION

Underuse of estrogen therapy in premenopausal women who undergo oophorectomy is associated with substantial excess morbidity and mortality.

Insufficient use of menopausal hormone therapy in Swedish women with early or premature menopause caused by bilateral oophorectomy: a register-based study

OBJECTIVE

To investigate the use of menopausal hormone therapy (MHT) in premenopausal women after bilateral oophorectomy.

DESIGN

Retrospective register-based cohort study.

SETTING

Sweden.

POPULATION

Swedish women aged 35-44 years without malignancy who underwent bilateral oophorectomy in 2005-2020 were identified using The Swedish National Quality Register of Gynaecological Surgery (GynOp).

METHODS

Data from GynOp were cross-linked with data on dispensed drugs extracted from the Swedish Prescribed Drug Register.

MAIN OUTCOME MEASURES

Proportion of women dispensed MHT at least once within 1 year after surgery. Repeated treatment episodes were defined, and the proportion of 'person time' covered by dispensations was analysed.

RESULTS

In total, 1231 of all women (n = 1706) were dispensed MHT at some point after surgery, with 1177 women dispensed MHT within 1 year. This proportion increased from 64% in 2005 to 84% in 2019 (p < 0.001). In the total population, 4537 'treatment years' transpired, corresponding to 43% of the mean time covered. In women dispensed MHT within 1 year, the proportion of time covered was 63%.

CONCLUSIONS

Only 69% of all women without malignancy of any kind who underwent bilateral oophorectomy were dispensed MHT within 1 year after surgery, and the duration of treatment was limited. It is important to study further the reasons behind the low dispensation rate in this group to increase adherence to current treatment guidelines, improve quality of life, and avoid increased morbidity and mortality.

The Menopause Management Vacuum

ABSTRACT

The burden of untreated menopause symptoms in midlife women is substantial and can result in reduced quality of life as well as lost work productivity, lost opportunities for advancement at work, and increased health care costs. Unfortunately, the health care system is largely unprepared to help women manage these symptoms, which have a mean duration of 7 to 9 years. Hormone therapy usage rates have plummeted following publication of the results of the Women's Health Initiative trials due to safety concerns. In addition, postgraduate medical training programs include minimal to no training on menopause management. These and other factors have contributed to what is essentially a menopause management vacuum. This vacuum created a market opportunity, particularly given the fact that midlife women are potent drivers of the global economy. In this review, we outline the menopause management gaps and discuss a multipronged approach to close these gaps and improve the care of midlife women.

Impact of Global Consensus Statement on compliance with hormonal therapy for surgical menopause

OBJECTIVE

Initiation of and compliance with menopausal hormonal therapy (MHT) have been dropping due to the 2002 Women's Health Initiative (WHI) publication. We evaluated the change in practice of MHT for surgical menopause after implementing the 2013 'Global Consensus Statement on MHT' to our institutional guideline.

METHODS

A retrospective study was conducted in surgically menopausal women newly registering at the Siriraj Menopause Clinic in a university hospital, Thailand, from 1995 to 2013. The patients were categorized into four groups according to periods of MHT initiation: 1995-1998 (control), 2000-2003 (WHI affected), 2005-2008 (post WHI) and 2010-2013 (Global Consensus Statement affected). Their 3-year compliance with MHT was compared using forward stepwise regression analysis.

RESULTS

There were 288, 156, 107 and 104 cases in the 1995-1998, 2000-2003, 2005-2008 and 2010-2013 groups. Their mean age at surgery was 42.8 ± 4.7 years. After the first, second and third years, overall compliance was 82.4%, 70.9% and 61.2%, respectively. The 3-year compliance drastically dropped in the 2000-2003 group, and then improved to control level in the 2010-2013 group (51.9% vs. 77.9%, p = 0.035).

CONCLUSION

The initiation of MHT continuously dropped during 2000-2013; however, compliance with MHT initiated during 2010-2013 improved after implementing the 2013 'Global Consensus Statement on MHT' to our institutional guideline. Each institute should have a strategy to encourage the initiation of and compliance with MHT for surgical menopause to achieve long-term health benefits.

Premature or early bilateral oophorectomy: a 2021 update

In this invited review, we discuss some unresolved and controversial issues concerning premature (<40 years) or early (40-45 years) bilateral oophorectomy. First, we clarify the terminology. Second, we summarize the long-term harmful consequences of bilateral oophorectomy. Third, we discuss the restrictive indications for bilateral oophorectomy in premenopausal women to prevent ovarian cancer that are justified by the current scientific evidence. Fourth, we explain the importance of estrogen replacement therapy when bilateral oophorectomy is performed. Hormone replacement therapy is indicated after bilateral oophorectomy until the age of expected natural menopause like in premature or early primary ovarian insufficiency. Fifth, we discuss the relationship between adverse childhood experiences, adverse adult experiences, mental health, gynecologic symptoms and bilateral oophorectomy. The acceptance and popularity of bilateral oophorectomy over several decades, and its persistence even in the absence of supporting scientific evidence, suggest that non-medical factors related to sex, gender, reproduction, cultural beliefs and socioeconomic structure are involved. We discuss some of these non-medical factors and the need for more research in this area.

Developing and evaluating a patient decision aid for hormone therapy to manage symptoms of surgical menopause: the story behind the "SheEmpowers" patient decision aid

OBJECTIVES

To develop and evaluate an evidence-based patient decision aid (PDA) that can support women making decisions on hormone therapy (HT) for the management of early surgical menopause.

METHODS

The PDA development was guided by the Ottawa Decision Support Framework and the International Patient Decision Aid Standards and involved three phases: an exploratory phase to identify women's decisional needs; a development phase to identify evidence related to treatment options and draft initial prototype; and an evaluation phase to evaluate the prototype and elicit views on acceptability in women (N = 12). All phases were driven by a multidisciplinary group of researchers, clinicians, and patient stakeholders to ensure women's priorities were met.

RESULTS

A prototype PDA was drafted based on needs identified from the exploratory phase. The PDA has five domains: information on surgical menopause and HT; HT outcome probabilities; patient stories; values clarification; and guidance in deliberation. Participants in the evaluation phase perceived the tool as acceptable and offered suggestions for modifications.

CONCLUSION

Through our adopted, systematic approach the SheEmpowers PDA was developed to help women overcome deterrents to decision-making related to lack of knowledge, decision-making skills, and involvement in therapy decisions. The decisional effectiveness of the tool is to be assessed in future studies.

Gynecologic Considerations for the Urologic Surgeon

While gynecologic malignancy is uncommon in women with conditions such as pelvic organ prolapse and bladder cancer, urologists should be acquainted with the relevant gynecologic literature as it pertains to their surgical care of female patients. While taking the patient history, urologists should be aware of prior cervical cancer screening and ask about vaginal bleeding, which can be a sign of uterine cancer. Urologic surgeons should also discuss the role of concomitant prophylactic oophorectomy and/or salpingectomy for ovarian cancer risk reduction at the time of pelvic surgery. An understanding of basic tests, such as a transvaginal sonogram, can help urologists provide comprehensive care.

Hormone Replacement Therapy Prescription after Premature Surgical Menopause

STUDY OBJECTIVE

To assess hormone replacement therapy (HRT) prescription pattern in patients undergoing premature surgical menopause on the basis of surgical indication.

DESIGN

Retrospective cohort study.

SETTING

Academic tertiary care center.

PATIENTS

Surgically menopausal patients aged ≤45 years who underwent a minimally invasive hysterectomy with salpingo-oophorectomy.

INTERVENTIONS

HRT prescription in the 6-week postoperative period.

MEASUREMENTS AND MAIN RESULTS

A total of 63 patients met inclusion criteria. Of these, 52% (n = 33) were prescribed HRT in the 6-week postoperative period. Indications for surgical menopause included pelvic pain or endometriosis (31.7%), gynecologic malignancy (20.6%), BRCA gene mutation (17.4%), breast cancer (9.5%), Lynch syndrome (4.8%), and other (15.8%). In total, 80% of patients with pelvic pain, 25% with gynecologic malignancies, 45% with BRCA gene mutations, 33.3% with breast cancer, and 66.6% with Lynch syndrome used HRT postoperatively. In patients who used HRT postoperatively, 76% were offered preoperative HRT counseling. This is in contrast with those patients who did not use HRT postoperatively, of whom only 33% were offered HRT counseling (p <.001). Perioperative complications were not predictive of HRT use postoperatively. In patients who did not use HRT postoperatively, 13.3% used alternative nonhormonal therapy.

CONCLUSION

In patients who underwent premature surgical menopause, 52% used HRT postoperatively. Patients with pelvic pain and Lynch syndrome were more likely to use HRT, whereas those with gynecologic or breast malignancies and BRCA gene mutations were less likely to use HRT. Preoperative HRT counseling was associated with postoperative HRT use.

Menopausal Estrogen-Alone Therapy and Health Outcomes in Women With and Without Bilateral Oophorectomy: A Randomized Trial

BACKGROUND

Whether health outcomes of menopausal estrogen therapy differ between women with and without bilateral salpingo-oophorectomy (BSO) is unknown.

OBJECTIVE

To examine estrogen therapy outcomes by BSO status, with additional stratification by 10-year age groups.

DESIGN

Subgroup analyses of the randomized Women's Health Initiative Estrogen-Alone Trial. (ClinicalTrials.gov: NCT00000611).

SETTING

40 U.S. clinical centers.

PARTICIPANTS

9939 women aged 50 to 79 years with prior hysterectomy and known oophorectomy status.

INTERVENTION

Conjugated equine estrogens (CEE) (0.625 mg/d) or placebo for a median of 7.2 years.

MEASUREMENTS

Incidence of coronary heart disease and invasive breast cancer (the trial's 2 primary end points), all-cause mortality, and a "global index" (these end points plus stroke, pulmonary embolism, colorectal cancer, and hip fracture) during the intervention phase and 18-year cumulative follow-up.

RESULTS

The effects of CEE alone did not differ significantly according to BSO status. However, age modified the effect of CEE in women with prior BSO. During the intervention phase, CEE was significantly associated with a net adverse effect (hazard ratio for global index, 1.42 [95% CI, 1.09 to 1.86]) in older women (aged ≥70 years), but the global index was not elevated in younger women (P trend by age = 0.016). During cumulative follow-up, women aged 50 to 59 years with BSO had a treatment-associated reduction in all-cause mortality (hazard ratio, 0.68 [CI, 0.48 to 0.96]), whereas older women with BSO had no reduction (P trend by age = 0.034). There was no significant association between CEE and outcomes among women with conserved ovaries, regardless of age.

LIMITATIONS

The timing of CEE in relation to BSO varied; several comparisons were made without adjustment for multiple testing.

CONCLUSION

The effects of CEE did not differ by BSO status in the overall cohort, but some findings varied by age. Among women with prior BSO, in those aged 70 years or older, CEE led to adverse effects during the treatment period, whereas women randomly assigned to CEE before age 60 seemed to derive mortality benefit over the long term.

PRIMARY FUNDING SOURCE

The WHI program is funded by the National Heart, Lung, and Blood Institute; National Institutes of Health; and U.S. Department of Health and Human Services. Wyeth Ayerst donated the study drugs.

Determinants of hormone therapy uptake and decision-making after bilateral oophorectomy (BO): A narrative review

Objective Early surgical menopause (≤45 years) can have significant short- and long-term health consequences. Hormone therapy (HT) is recommended for women with no contraindications. However, HT is greatly underutilized among these women due to their fear of the associated risks. The objective of this study is to identify and describe determinants of HT uptake and decision-making in women after surgical menopause. Methods We searched Medline, EMBASE, and CINAHL, from inception to April 2018, to identify relevant literature. Inclusion criteria included studies that assessed factors affecting the uptake of HT and decision-making about HT after surgical menopause. Studies including both women with natural and surgical menopause were included. Search terms were derived from 3 main concepts: surgical menopause, hormone therapy, and decision-making. Papers included in the review had to be in the English language and to report human studies. Results Of the 1952 articles identified, 23 were eligible for inclusion. Studies were mostly published before the WHI (61%) and had a quantitative cross-sectional study design. Only 22% focused on surgical menopause per se. The mean age at time of surgical menopause was 43.6 years (range 29-68). HT uptake was associated with younger age, higher level of education, higher income and adopting positive lifestyle behaviors. Factors affecting decision-making were mostly perceptions, beliefs, and values women associate with HT, as well as knowledge of and experiences with HT and surgical menopause. External factors related to physicians' recommendations and information sources also influenced HT decision-making. Conclusion Our review highlights the complex nature of decision-making about HT after surgical menopause and the numerous factors involved. Women tend to rely on subjective perceptions and inferences from information sources, which may hamper the ability to make informed treatment decisions. There is a need for tailored decision-aid interventions to help support women and guide informed treatment decisions.

Sex Differences in Insomnia: from Epidemiology and Etiology to Intervention

PURPOSE OF REVIEW

Insomnia is approximately 1.5 times more common in women than in men. To date, research has advanced our knowledge about why women report significantly more sleep problems than men despite not being reflected in objective sleep measures. Precisely understanding the symptomatology and pathological mechanisms underlying sex differences is important for prevention and providing appropriate interventions.

RECENT FINDINGS

Sex differences found in insomnia goes beyond simple explanations and have been proven to be a complicated interplay of biological, psychological, and social factors that play different roles throughout the life span. This paper will review sex differences in insomnia based on risk factors, mechanisms, and consequences, as well as treatment response. In addition, we will also discuss treatment recommendations when working with female populations at different stages in the life span that may be more vulnerable to insomnia. Future studies utilizing prospective, longitudinal designs are needed to understand the interactions of various factors that can explain existing sex differences in insomnia.

NAMS 3rd Utian Translational Science Symposium, October 2016, Orlando, Florida A conversation about hormone therapy: is there an appropriate dose, route, and duration of use?

The North American Menopause Society (NAMS) held the 3rd Utian Translational Symposium on October 4, 2016, in Orlando, Florida, to answer questions about the benefits and risks of hormone therapy (HT) for postmenopausal women. This report is a record of the proceedings of that symposium.The maxim about HT for the past 15 years since the publication of the initial results of the Women's Health Initiative (WHI) has been to prescribe the "lowest dose for the shortest period of time." With new clinical trials, observational data, and further analysis of the WHI and the cumulative 13 years' follow-up, it was time to hold a conversation about the state of the evidence and recommendations for HT dose, route, and duration of use.The symposium brought together experts in the field of HT to speak on these topics, organized by session, after which working groups gathered to synthesize the presentations into areas of what still needs to be known and how to proceed with areas of needed research. After the presentations, there was consensus that postmenopausal women aged younger than 60 years or within 10 years of menopause onset without contraindications and who desire to take HT for relief of vasomotor symptoms or prevention of bone loss if at elevated risk can safely do so.The working groups raised the possibility that the use of "Big Data" (pharmacy and cancer databases) would allow answers that cannot be found in clinical trials. This could lead to more appropriate FDA labeling and patient package inserts reflecting the true risks associated with various types and formulations of HT, with differences among estrogen alone, estrogen with a progestogen, and estrogen plus a selective estrogen-receptor modulator for the younger women most likely to initiate these therapies for symptom relief. Differences were found for potential risk among estrogen alone, estrogen with synthetic progestins contrasted to progesterone, lower doses, nonoral doses, and low-dose vaginal estrogen.With all of the available routes and dosages, including vaginal estrogen alone for genitourinary symptoms, there are many options when considering the most appropriate type, dose, formulation, route of administration, and duration of use, taking into account the age of the woman at initiation of HT and the time from menopause.

Perspectives and decision-making about menopausal therapies in women who had bilateral oophorectomy

OBJECTIVE

The aim of the study was to explore the process of decision-making about menopausal treatments in women who have had surgical menopause as a result of bilateral oophorectomy (≤50 y).

METHODS

We used a descriptive qualitative research design. Women who had a surgical menopause were purposefully selected from the Edmonton Menopause Clinics. Focus groups were held, each with six to nine participants. All sessions were audio-recorded and transcribed verbatim. Data were analyzed using qualitative content analysis.

RESULTS

We conducted five focus groups from June 30 to July 21, 2016 (N = 37). One-third of the women had the surgery within the last 5 years. Almost all women had a concurrent hysterectomy (97%) and were current users of hormone therapy (70%). Four main themes identified were "perceptions of surgical menopause," "perceptions of received support," "being my own advocate," and "concept of adequate support." Women shared that the experience was worse than their expectations and did not believe they were given adequate support to prepare them to make therapy decisions. Women had to "be their own advocates" and seek support from within the healthcare system and outside to cope with their health issues. To make an informed decision about treatments postsurgery, women expressed a need to learn more about the symptoms of surgical menopause, treatment options, resources, avenues for support, and stories of similar experiences, preferably before the surgery.

CONCLUSIONS

We identified several modifiable deterrents to decision-making in early surgical menopause which can help inform the development of a patient decision aid for this context.

Efficacy of Postoperative Hormone Replacement Therapy on Prognosis of Patients with Serous Ovarian Carcinoma

Background:

Ovarian cancer is the most common cause of gynecological cancer-associated death. Iatrogenic menopause might adversely affect the quality of life and health outcomes in young female cancer survivors. We evaluated whether postoperative hormone replacement therapy (HRT) had a negative influence on the progression-free survival (PFS) of patients with papillary serous ovarian cancer (SOC).

Methods:

We retrospectively reviewed the medical records of patients with papillary SOC, treated from January 1980 to December 2009, who suffered from menopause with or without HRT. Clinical characteristics of patients were compared between the two groups (HRT and non-HRT). Blood samples were collected from all the participants to detect serum cancer antigen (CA) 125. Hazard ratios with 95% confidential intervals for each variable were calculated by univariable and multivariable conditional Logistic regression analyses.

Results:

Among 112 identified patients, 31 were HRT users and 81 were not. The two groups did not significantly differ in median age at diagnosis (t = 0.652, P = 0.513), International Federation of Gynecology and Obstetrics (FIGO) stage (χ² = 0.565, P = 0.754), differentiation (χ² = 1.728, P = 0.422), resection status (χ² = 0.070, P = 0.791), relapse (χ² = 0.109, P = 0.741), chemotherapy course (t = −1.079, P = 0.282), follow-up interval (t = 0.878, P = 0.382), or PFS (t = 0.580, P = 0.562). Median Kupperman score at the onset of HRT was 30.81 and 12.19 after the therapy (t = 3.302, P = 0.001). According to the analysis, the strongest independent variables in predicting PFS were FIGO stage and disease that was not optimally debulked.

Conclusions:

Postoperative HRT is not a prognostic factor for PFS of patients with papillary SOC. However, multicenter studies are needed to verify and extend our findings.

Hormone replacement therapy in young women with surgical primary ovarian insufficiency

Bilateral oophorectomy performed in women before they are menopausal induces surgical primary ovarian insufficiency, an acute and chronic deficiency of the hormones normally produced by the ovaries. Without hormone replacement therapy (HRT) most of these women develop severe symptoms of estrogen (E) deficiency and are at increased risk for osteoporosis, cardiovascular disease, cognitive decline, dementia, and the associated increases in morbidity and mortality. In cases in which a hysterectomy has been performed at the time of bilateral oophorectomy transdermal or transvaginal E2 replacement therapy without cyclic progestin replacement is the optimum hormonal management for these women. There is substantial evidence this approach even reduces the risk for breast cancer. Unfortunately, unwarranted fear of all menopausal HRTs has become widespread following the reports of the Women's Health Initiative studies. This fear has led to a steep decline in use of E therapy, even in women in whom HRT is clearly indicated. Discussion of possible ovarian conservation in women who are premenopausal is an integral part of the preoperative planning for any women undergoing hysterectomy. Timely and effective HRT for women who will experience surgical primary ovarian insufficiency is clearly indicated.

Examining the relationship between subjective sleep disturbance and menopause: a systematic review and meta-analysis

OBJECTIVE

The purpose of this study was to conduct a systematic review and meta-analysis of the relationship between menopausal stages and sleep disturbance reported using subjective methods. Secondary aims included examining the influence of culture/ethnicity on the relationship between menopausal stages and sleep disturbance.

METHODS

Multiple electronic databases were searched from the first available year to November 2013, and a manual search of the reference lists of review articles identified was also conducted. Twenty-four studies with a total of 63,542 midlife women were identified, coded, and analyzed.

RESULTS

The crude and adjusted odds of experiencing sleep disturbance were small but statistically significant for perimenopausal and postmenopausal women, using premenopause as the reference group. The ethnicity of the samples influenced effect sizes; Asian and white women both experienced an increased rate of sleep disturbance at the perimenopausal and postmenopausal stages compared with the premenopausal stage, whereas Hispanic women experienced no change in sleep disturbance across the menopausal transition.

CONCLUSIONS

The prevalence of sleep disturbance is higher in perimenopausal, postmenopausal, and surgical menopausal women than in premenopausal women. There is an independent relationship between menopausal stages and sleep disturbance beyond the effects of aging and other confounders, although the magnitude of the relationship is small. Culture, ethnicity, or both might affect the levels of sleep disturbance at various menopausal stages.

Neonatal stress affects the aging trajectory of female rats on the endocrine, temperature, and ventilatory responses to hypoxia

Human and animal studies on sleep-disordered breathing and respiratory regulation show that the effects of sex hormones are heterogeneous. Because neonatal stress results in sex-specific disruption of the respiratory control in adult rats, we postulate that it might affect respiratory control modulation induced by ovarian steroids in female rats. The hypoxic ventilatory response (HVR) of adult female rats exposed to neonatal maternal separation (NMS) is ∼30% smaller than controls (24), but consequences of NMS on respiratory control in aging female rats are unknown. To address this issue, whole body plethysmography was used to evaluate the impact of NMS on the HVR (12% O2, 20 min) of middle-aged (MA; ∼57 wk old) female rats. Pups subjected to NMS were placed in an incubator 3 h/day for 10 consecutive days (P3 to P12). Controls were undisturbed. To determine whether the effects were related to sexual hormone decline or aging per se, experiments were repeated on bilaterally ovariectomized (OVX) young (∼12 wk old) adult female rats. OVX and MA both reduced the HVR significantly in control rats but had little effect on the HVR of NMS females. OVX (but not aging) reduced the anapyrexic response in both control and NMS animals. These results show that hormonal decline decreases the HVR of control animals, while leaving that of NMS female animals unaffected. This suggests that neonatal stress alters the interaction between sex hormone regulation and the development of body temperature, hormonal, and ventilatory responses to hypoxia.

The mortality toll of estrogen avoidance: an analysis of excess deaths among hysterectomized women aged 50 to 59 years

OBJECTIVES

We examined the effect of estrogen avoidance on mortality rates among hysterectomized women aged 50 to 59 years.

METHODS

We derived a formula to relate the excess mortality among hysterectomized women aged 50 to 59 years assigned to placebo in the Women's Health Initiative randomized controlled trial to the entire population of comparable women in the United States, incorporating the decline in estrogen use observed between 2002 and 2011.

RESULTS

Over a 10-year span, starting in 2002, a minimum of 18 601 and as many as 91 610 postmenopausal women died prematurely because of the avoidance of estrogen therapy (ET).

CONCLUSIONS

ET in younger postmenopausal women is associated with a decisive reduction in all-cause mortality, but estrogen use in this population is low and continuing to fall. Our data indicate an associated annual mortality toll in the thousands of women aged 50 to 59 years. Informed discussion between these women and their health care providers about the effects of ET is a matter of considerable urgency.

Premature menopause or early menopause and risk of ischemic stroke

OBJECTIVE

The general consensus has been that estrogen is invariably a risk factor for ischemic stroke (IS). We reviewed new observational studies that challenge this simple conclusion.

METHODS

This was a review of observational studies of the association of premature or early menopause with stroke or IS published in English from 2006 through 2010.

RESULTS

Three cohort studies showed an increased risk of all types of stroke in women who underwent bilateral oophorectomy compared with women who conserved their ovaries before age 50 years. The increased risk of stroke was reduced by hormone therapy in one of the studies, suggesting that estrogen deprivation is involved in the association. Four additional observational studies showed an association of all types of stroke or IS with the early onset of menopause or with a shorter life span of ovarian activity. In three of the seven studies, the association was restricted to IS. Age at menopause was more important than type of menopause (natural vs induced).

CONCLUSIONS

The findings from seven recent observational studies challenge the consensus that estrogen is invariably a risk factor for IS and can be reconciled by a unifying timing hypothesis. We hypothesize that estrogen is protective for IS before age 50 years and may become a risk factor for IS after age 50 years or, possibly, after age 60 years. These findings are relevant to women who experienced premature or early menopause or to women considering prophylactic bilateral oophorectomy before the onset of natural menopause.

Predictors of intentions to use hormone replacement therapy in clinical postmenopausal women

OBJECTIVES

To investigate the contribution of components of the Health Beliefs Model (perceived susceptibility, perceived severity, health motivation, perceived risk and benefits of hormone replacement therapy (HRT) use), sociodemographic variables (age, duration of postmenopause, hysterectomy and social class) and psychological stress to intentions to use HRT for the first time.

METHODS

A quasi-experimental design was used to recruit a clinical sample of 180 postmenopausal women, attending a menopause clinic, with a mean age of 50.74 years (standard deviation 4.75 years). Data were collected using self-report questionnaires. A regression analysis was carried out to establish what predicts intentions to use HRT in this sample; sociodemographic variables were entered in the first step of the regression, followed by health motivation and perceived stress in step two, the third step involved the addition of perceived severity measures, and in the final step susceptibility and perceived risks and benefits were added.

RESULTS

The main predictor of intentions to use HRT, after controlling for all other variables, was the belief that the benefits outweigh the risks associated with taking HRT.

CONCLUSIONS

This information should be used to develop interventions and health awareness materials about HRT in clinical postmenopausal women.