The menopause: health implications and clinical management

Are the Diagnosis and Treatment of Acute Cystitis in the Premenopausal, Pregnant, and Postmenopausal Women the Same? A Review of the Literature

Importance

Acute cystitis is a common condition diagnosed in women. The diagnosis and treatment of this condition change throughout a woman's life. Understanding the differences in diagnosis and treatment in premenopausal, pregnant, and postmenopausal woman increases the likelihood of treatment success and decreases risk of complications from untreated or suboptimally treated infections.

Objective

The aim of this review is to describe the incidence, risk factor, pathophysiology, diagnosis, and management of acute cystitis and the similarities and differences of these aspects of the condition in the premenopausal, pregnant, and postmenopausal woman.

Evidence Acquisition

A PubMed, Web of Science, and CINAHL search was undertaken with the years 1990 to 2020 searched.

Results

There were 393 articles identified, with 103 being the basis of review. Multiple risk factors for acute cystitis have been identified and are largely consistent throughout a woman's lifetime with few exceptions. The diagnoses by group with common diagnostic tools, such as urinalysis, vary in specificity and sensitivity between these groups. Management also varies between groups, with pregnancy having specific limitations related to drug safety in regard to possible fetal effects posed by certain medications commonly used to treat acute cystitis.

Conclusions

Acute cystitis not only varies in presentation throughout a woman's lifespan, but also in appropriate diagnosis and treatment. Treatment of acute cystitis does have some commonalities between the groups; however, there are contraindications unique to each group. These differences are paramount to not only ensuring appropriate treatment but also treatment success.

Relevance

Acute cystitis is a common condition with different diagnostic and management recommendations throughout a woman's lifespan.

Update: The Clinical Role of Vaginal Lasers for the Treatment of the Genitourinary Syndrome of Menopause

OBJECTIVE

To educate providers on the emergence of vaginal lasers for the treatment of the genitourinary syndrome of menopause (GSM) and discuss the peer-reviewed literature regarding their use.

MATERIALS AND METHODS

A search of literature databases (PubMed and Medline) was performed for publications in February 2020. Keywords included genitourinary syndrome of menopause, urinary incontinence, overactive bladder, urgency, urinary tract infections, atrophy, laser, and vaginal. We reviewed the available published literature, identifying articles, guidance, and society statements on the use vaginal laser therapies.

RESULTS

The literature regarding vaginal laser therapy in the treatment of the GSM is primarily limited to prospective case series with small numbers and short-term follow-up. Nevertheless, these studies have demonstrated reductions in genitourinary syndrome of menopause symptoms. High quality data describing the safety, benefits, and appropriate use of vaginal laser therapy is lacking.

CONCLUSION

Vaginal laser treatment for the GSM is of interest as it provides patients with a nonhormonal treatment option. Further research to better outline the indications, efficacy, safety, and applications of this technology is needed before supporting its universal use for the management of the GSM.

Management of vaginal atrophy: a real mess. Results from the AGATA study

OBJECTIVES

To investigate the management of vaginal atrophy (VA) in a population-based study.

STUDY DESIGN

A sub-study of a cross-sectional multicenter study on 913 postmenopausal women.

MAIN OUTCOME MEASURES

Management of VA was investigated on the 274 women referring having received a previous diagnosis of VA.

RESULTS

Women had received, no therapy (9.8%), systemic hormones (9.2%), intra-vaginal estrogens (44.5%) or local non-hormonal (36.5%) therapy. There was heterogeneity of treatments. Local therapies were given in cycles, and used for a length of time ranging from 1 to 12 months. At the time of the investigation 59.5% of these women were not on treatment, either because following the physician's indication (31.1%) or because spontaneously withdrawing from treatment (68.9%). Reasons for withdrawing from therapy were insufficient symptom relief (46.6%), messiness (24.3%), difficulty in application (7.8%) and vaginal discharge (1.9%). At the time of investigation only 2.9% of treated women did not suffer from VA.

CONCLUSIONS

This study underlines the presence of a great confusion about the therapy used for VA, along with patients' dissatisfaction with actual treatments. The emerging evidence is that in real world VA remains untreated.

Evaluating the utility of syndromic case management for three sexually transmitted infections in women visiting hospitals in Delhi, India

Utility of syndromic case management (SCM) in women visiting obstetrics & gynecology department needs to be evaluated as it is subjective and imperfect. Consequently, antibiotic resistance has accelerated along with increased risk of infection to the partners. To understand the effectiveness and/or inadequacies of SCM, 11000 women were recruited and examined by clinicians for infection by Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV), Bacterial vaginosis (BV) and others. Amongst these patients, 1797 (16.3%) reported vaginal discharge (VD). Other symptoms included: vaginitis (97%), cervicitis (75%), genital ulcers (60%), abnormal vaginal discharge (55%) and lower abdominal pain (48%). The patients were treated for single or co-infections using pre-packed National Aids Control Program III STI/RTI Kits. However, based on PCR diagnostics, 1453/1797 (81%) subjects were uninfected for NG/TV/CT. Amongst 344 (19%) infected patients, 257 (75%) carried infection with single pathogen (TV/NG/CT) while 87/344 (25%) were co-infected with multiple pathogens. Prevalence of TV, NG & CT was 4%, 7% and 8% respectively. Co-infection with CT + NG was highest, 51% (44/87), whereas, co-infection with CT + TV was 21% and NG + TV was 18% while co-infection with all three pathogens was 1.3%. We conclude that SCM is imprecise and successful intervention requires accurate and confirmatory diagnostic approach.

Study of pruritus vulvae in geriatric age group in tertiary hospital

BACKGROUND

According to the World Health Organization criteria, geriatric population is people above 60 years of age. In this phase of life, a woman has already gone through menopause and its associated emotional, physical, and hormonal changes. These changes are due to gradual loss of estrogen that comes with menopause which results in dramatic changes in the appearance of vulva and vagina. With age, skin of vulva becomes thin, loses elasticity, and moisture so that the patient starts feeling burning and itchy sensation. The normal acidic pH changes to basic which alters the flora and makes the person prone to other bacterial infections. Apart from infections, there are many other dermatological and nondermatological causes of vulvar itching in this age group such as eczema, contact dermatitis, lichen planus (LP), lichen sclerosus atrophicans, lichen simplex chronicus (LSC), prolapse, incontinence, and carcinoma. The aim is to diagnose the causes of pruritus vulvae in the geriatric age group to decrease the misery of these patients.

METHODS

We selected 40 consecutive females of age group ranging from 60 to 75 years coming to skin OPD with the complaint of pruritus of vulvar region over a period of 1 year. Clinical examination, complete blood count, fasting blood sugar, wet mount, pap smear, and skin biopsy were done in every case.

RESULTS

Out of the forty patients who were included in this study, 17 (42.5%) were diagnosed as a case of LSC and 11 (27.5%) patients had atrophic vaginitis. Three (7.5%) patients presented with tinea. Three (7.5%) cases were clinically diagnosed as scabies. Another 2 (5%) cases were diagnosed as LP and Candida was seen in other 2 (5%) cases. 1 (2.5%) case was diagnosed as bacillary vaginosis and 1 (2.5%) patient was of lichen sclerosus.

CONCLUSION

Pruritus vulvae of geriatric age group are of diverse etiology, therefore, treatment based on precise diagnosis is of prime importance.

Menopause Research and The Dominance of the Biomedical Model 1984-1994

Popular images and stereotypes of women in the menopausal age range are overwhelmingly negative. Because these stereotypes are likely both to influence and to be influenced by published scholarship, it is particularly important to examine conventional knowledge as it has been represented in science-based journals. In an effort to examine the extent and nature of the accepted knowledge base regarding menopause, a survey of both medical and psychological journal articles was conducted for the years 1984-1994. Publication trends revealed a predominance of articles based on a biomedical paradigm and the virtual absence of articles presenting alternative perspectives on midlife. Ten serious methodological problems common to this literature are delineated, including such fundamental errors as failure to acquire baseline data, lack of control groups, vague operational definitions, and blatantly pejorative language. We also discuss conceptual flaws implicit in the predominant paradigm, including the messages that women are different, sicker, and weaker than a normal, male, ideal. Finally, we consider the implications of these social constructions for the political, social, and psychological status of women.

Effects of dioxin-related compounds on bone mineral density in patients affected by the Yusho incident

Exposure to dioxin-related compounds results in many adverse health effects. Several studies have examined the effects of dioxin-related compounds on human bone metabolism with inconsistent results. In Japan in 1968, accidental human exposure to rice oil contaminated with dioxin-related compounds led to the development of Yusho oil disease. The aim of this study was to determine whether exposure to dioxin-related compounds was associated with bone mineral density in Yusho patients. In 2010, 262 women and 227 men underwent dual-energy X-ray absorptiometry bone scans as part of the nationwide Yusho health examination. Serum levels of polychlorinated dibenzo-p-dioxin, polychlorinated dibenzofurans, and non-ortho polychlorinated biphenyls were measured using high-resolution gas chromatography and high-resolution mass spectrometry. When adjusted for prefecture, 1,2,3,4,7,8-HxCDD and 2,3,7,8-TCDF were significantly positively associated with Z-scores in men. No congeners were positively associated with Z-scores in women. After adjustment for prefecture and body mass index, one congener, 1,2,3,4,6,7,8-HpCDD, was negatively associated with Z-scores in women. In contrast, no congeners remained significant in men after adjusting for body mass index. This may suggest that 1,2,3,4,6,7,8-HpCDD has a negative effect on bone mineral density in women; however, the findings should be interpreted carefully, because no increase in the serum level of this congener was observed in patients with Yusho disease.

Menopausal hormone therapy and cancer: changing clinical observations of target site specificity

Menopausal hormone therapy with estrogen plus progestin or estrogen alone (for women with prior hysterectomy) is still used by millions of women for climacteric symptom management throughout the world. Until 2002, hormone therapy influence on cancer risk and other chronic diseases was determined through observational study reports. Since then, results from the Women's Health Initiative randomized, placebo-controlled hormone therapy trials have substantially changed concepts regarding estrogen plus progestin and estrogen alone influence on the most common cancers in postmenopausal women. In these trials, estrogen plus progestin significantly increased breast cancer incidence and deaths from breast cancer, significantly increased deaths from lung cancer, significantly decreased endometrial cancer, and did not have a clinically significant influence on colorectal cancer. In contrast, estrogen alone use in women with prior hysterectomy significantly reduced breast cancer incidence and deaths from breast cancer without significant influence on colorectal cancer or lung cancer. These complex results are discussed in the context of known potential mediating mechanisms of action involved in interaction with steroid hormone receptors.

The effect of hormones on the lower urinary tract

The female genital and lower urinary tracts share a common embryological origin, arising from the urogenital sinus and both are sensitive to the effects of the female sex steroid hormones throughout life. Estrogen is known to have an important role in the function of the lower urinary tract and estrogen and progesterone receptors have been demonstrated in the vagina, urethra, bladder and pelvic floor musculature. In addition estrogen deficiency occurring following the menopause is known to cause atrophic change and may be associated with lower urinary tract symptoms such as frequency, urgency, nocturia, urgency incontinence and recurrent infection. These may also co-exist with symptoms of urogenital atrophy such as dyspareunia, itching, vaginal burning and dryness. Epidemiological studies have implicated estrogen deficiency in the aetiology of lower urinary tract symptoms with 70% of women relating the onset of urinary incontinence to their final menstrual period. Whilst for many years systemic and vaginal estrogen therapy was felt to be beneficial in the treatment of lower urinary and genital tract symptoms this evidence has recently been challenged by large epidemiological studies investigating the use of systemic hormone replacement therapy as primary and secondary prevention of cardiovascular disease and osteoporosis. The aim of this paper is to examine the effect of the sex hormones, estrogen and progesterone, on the lower urinary tract and to review the current evidence regarding the role of systemic and vaginal estrogens in the management of lower urinary tract symptoms and urogenital atrophy.

Obesity: Friend or foe for osteoporosis

Osteoporosis and obesity are worldwide health problems. Interestingly, both are associated with significant morbidity and mortality. Both the diseases have common linkage as bone marrow mesenchymal stromal cells are the common precursors for both osteoblasts and adipocytes. Aging may shift composition of bone marrow by increasing adipocytes, osteoclast activity, and decreasing osteoblast activity, resulting into osteoporosis. Adipocytes secret leptin, adiponectin, adipsin, as well as proinflammatory cytokines, that contributes in pathogenesis of osteoporosis. This new concept supports the hypothesis, that the positive correlation of weight and body mass index (BMI) with bone mineral density (BMD) is not confirmed by large population-based studies. Thus, the previous concept, that obesity is protective for osteoporosis may not stand same as bone marrow fat deposition (adipogenesis) seen in obesity, is detrimental for bone health.

K, K. J, D. D, T.V. S, Dinesh P. Evaluation of Salivary Flow Rate, pH and Buffer in Pre, Post & Post Menopausal Women on HRT

BACKGROUND

Climateric is considered to be a natural phase of life which by definition is the period of life starting from decline in ovarian activity until after the end of ovarian function. It is accompanied by various health consequences that include the changes in saliva too. This study was carried out to evaluate the salivary flow rate, pH, buffering capacity in pre-menopausal, post-menopausal and post-menopausal women on HRT.

AIMS AND OBJECTIVES

(1) To evaluate the salivary flow rate, pH of resting saliva and stimulated saliva and buffer capacity of stimulated saliva in pre-menopausal, post-menopausal and post-menopausal women on Hormone Replacement Therapy (HRT). (2) To compare the above salivary findings between pre-menopausal, post-menopausal and post-menopausal women on HRT.

MATERIALS AND METHODS

The study was carried out on 60 patients. These patients were divided into three groups of 20 patients: Group 1: Pre-menopausal women (control), Group 2: post-menopausal women (case), Group 3: post-menopausal women on HRT (case). The control group consisted of 20 women volunteers, having regular ovulatory menstrual cycles with no known systemic illness and deleterious habits and Group 2 consists of 20 post-menopausal women and Group 3 will consist of 20 post-menopausal women on HRT. After clearing the mouth by swallowing, stimulated saliva was collected after chewing paraffin for 10 mins in to a glass centrifuge tube graded in 0.1 mL increments up to 10mL.in rare cases the collection time will be reduced or extended (5-15 min), salivary flow rate will be determined as ml/min, immediately after collection, pH was determined by dipping pH test paper directly into the sample of oral fluid, salivary buffer capacity was determined by using saliva check buffer kit (GC corporation). The data obtained was statistically evaluated using chi-square test, fisher exact test ANOVA analysis.

RESULTS

In our study we found salivary flow rate significantly lower in the post-menopausal women in comparison with the menstruating women and also there was improvement in the flow rate in individuals who were on HRT, it was also observed that salivary pH of the post-menopausal group was significantly lower than that of the control group, statistically significant difference in buffer capacity values was found between the groups however buffer capacity values were higher in the post-menopausal group than the control group.

CONCLUSION

From the above study it is clear that post-menopausal women will present with oral discomfort, while HRT can improve the same. Hence our role as physicians and health care providers is to incorporate preventive dental health care in post-menopausal women and clearly inform patients about both the benefits and the limitations of HRT.

Symptomatic menopausal transition increases the risk of new-onset depressive disorder in later life: a nationwide prospective cohort study in Taiwan

INTRODUCTION

The role of the menopausal transition and associated menopausal symptoms in the occurrence of depressive disorders has been discussed and debated for a long time. Most previous clinical studies had limited case samples, and did not control the attributable risk of medical comorbidities.

METHODS

Patients with a diagnosis of symptomatic menopausal transition and without a psychiatric history were enrolled in 2000 in Taiwan, and compared with age-matched controls (1∶4). These subjects were followed to the end of 2010 to investigate the association between symptomatic menopausal transition and new-onset depressive disorder; the effect of medical comorbidities was also assessed.

RESULTS

A total of 5,837 women with symptomatic menopausal transition were identified, and compared with 23,348 age-matched controls in 2000. The follow-up showed that symptomatic menopausal transition was an independent risk factor for major depression (hazard ratio[HR]: 2.18, 95%CI: 1.79∼2.65) and any depressive disorder (HR: 2.34, 95%CI: 2.08∼2.63) after adjusting age at enrollment, monthly income, residence location, level of urbanization, and comorbid medical diseases. In addition, medical comorbidities, including cerebrovascular disease (HR: 1.77, 95% CI: 1.52∼2.07), cardiovascular diseases (HR: 1.35, 95% CI: 1.15∼1.57), congestive heart failure (HR: 1.35, 95% CI: 1.04∼1.75), and liver diseases (HR: 1.19, 95% CI: 1.03∼1.36) increased the risk of developing any depressive disorder.

CONCLUSION

Our population cohort study, with the largest study sample and medical record diagnosis thus far, supports an association between symptomatic menopausal transition and depressive disorder in midlife women, and an increased risk of depressive disorder with medical comorbidities.

Changing concepts: Menopausal hormone therapy and breast cancer

Hormone therapy is still used by millions of women for menopausal symptoms. Concerns regarding hormone therapy and breast cancer were initially based on case reports and retrospective case-control studies. However, recent results from large prospective cohort studies and the Women's Health Initiative (WHI) randomized placebo-controlled hormone therapy trials have substantially changed concepts regarding how estrogen alone and estrogen plus progestin influence breast cancer. The preponderance of observational studies suggested that estrogen alone and estrogen plus progestin both increased the risk of breast cancer, with cancers commonly diagnosed at an early stage. However, substantially different results emerged from the WHI randomized hormone therapy trials. In the WHI trial evaluating estrogen plus progestin in postmenopausal women with an intact uterus, combined hormone therapy statistically significantly increased the risk of breast cancer and hindered breast cancer detection, leading to delayed diagnosis and a statistically significant increase in breast cancer mortality. By contrast, estrogen alone use by postmenopausal women with prior hysterectomy in the WHI trial did not substantially interfere with breast cancer detection and statistically significantly decreased the risk of breast cancer. Differential mammography usage patterns may explain differences between observational study and randomized trial results. In clinical practice, hormone therapy users have mammograms more frequently than nonusers, leading to more and earlier stage cancer detection. By contrast, in the WHI randomized trials, mammogram frequency was protocol mandated and balanced between comparison groups. Currently, the different effects of estrogen plus progestin vs estrogen alone on breast cancer are not completely understood.

Conjugated equine oestrogen and breast cancer incidence and mortality in postmenopausal women with hysterectomy: extended follow-up of the Women's Health Initiative randomised placebo-controlled trial

BACKGROUND

By contrast with many observational studies, women in the Women's Health Initiative (WHI) trial who were randomly allocated to receive oestrogen alone had a lower incidence of invasive breast cancer than did those who received placebo. We aimed to assess the influence of oestrogen use on longer term breast cancer incidence and mortality in extended follow-up of this cohort.

METHODS

Between 1993 and 1998, the WHI enrolled 10,739 postmenopausal women from 40 US clinical centres into a randomised, double-masked, placebo-controlled trial. Women aged 50-79 years who had undergone hysterectomy and had expected 3-year survival and mammography clearance were randomly allocated by a computerised, permuted block algorithm, stratified by age group and centre, to receive oral conjugated equine oestrogen (0·625 mg per day; n=5310) or matched placebo (n=5429). The trial intervention was terminated early on Feb 29, 2004, because of an adverse effect on stroke. Follow-up continued until planned termination (March 31, 2005). Consent was sought for extended surveillance from the 9786 living participants in active follow-up, of whom 7645 agreed. Using data from this extended follow-up (to Aug 14, 2009), we assessed long-term effects of oestrogen use on invasive breast cancer incidence, tumour characteristics, and mortality. We used Cox regression models to estimate hazard ratios (HRs) in the intention-to-treat population. This study is registered with ClinicalTrials.gov, number NCT00000611.

FINDINGS

After a median follow-up of 11·8 years (IQR 9·1-12·9), the use of oestrogen for a median of 5·9 years (2·5-7·3) was associated with lower incidence of invasive breast cancer (151 cases, 0·27% per year) compared with placebo (199 cases, 0·35% per year; HR 0·77, 95% CI 0·62-0·95; p=0·02) with no difference (p=0·76) between intervention phase (0·79, 0·61-1·02) and post-intervention phase effects (0·75, 0·51-1·09). In subgroup analyses, we noted breast cancer risk reduction with oestrogen use was concentrated in women without benign breast disease (p=0·01) or a family history of breast cancer (p=0·02). In the oestrogen group, fewer women died from breast cancer (six deaths, 0·009% per year) compared with controls (16 deaths, 0·024% per year; HR 0·37, 95% CI 0·13-0·91; p=0·03). Fewer women in the oestrogen group died from any cause after a breast cancer diagnosis (30 deaths, 0·046% per year) than did controls (50 deaths, 0·076%; HR 0·62, 95% CI 0·39-0·97; p=0·04).

INTERPRETATION

Our findings provide reassurance for women with hysterectomy seeking relief of climacteric symptoms in terms of the effects of oestrogen use for about 5 years on breast cancer incidence and mortality. However, our data do not support use of oestrogen for breast cancer risk reduction because any noted benefit probably does not apply to populations at increased risk of such cancer.

FUNDING

US National Heart, Lung, and Blood Institute; Wyeth.

Effects of intravaginal estriol and pelvic floor rehabilitation on urogenital aging in postmenopausal women

PURPOSE

To assess the effects of the combination of pelvic floor rehabilitation and intravaginal estriol administration on stress urinary incontinence (SUI), urogenital atrophy and recurrent urinary tract infections in postmenopausal women.

METHODS

Two-hundred-six postmenopausal women with urogenital aging symptoms were enrolled in this prospective randomized controlled study. Patients were randomly divided into two groups and each group consisted of 103 women. Subjects in the treatment group received intravaginal estriol ovules, such as 1 ovule (1 mg) once daily for 2 weeks and then 2 ovules once weekly for a total of 6 months as maintenance therapy plus pelvic floor rehabilitation. Subjects in the control group received only intravaginal estriol in a similar regimen. We evaluated urogenital symptomatology, urine cultures, colposcopic findings, urethral cytologic findings, urethral pressure profiles and urethrocystometry before, as well as after 6 months of treatment.

RESULTS

After therapy, the symptoms and signs of urogenital atrophy significantly improved in both groups. 61/83 (73.49%) of the treated patients, and only 10/103 (9.71%) of the control patients referred a subjective improvement of their incontinence. In the patients treated by combination therapy with estriol plus pelvic floor rehabilitation, we observed significant improvements of colposcopic findings, and there were statistically significant increases in mean maximum urethral pressure (MUP), in mean urethral closure pressure (MUCP), as well as in the abdominal pressure transmission ratio to the proximal urethra (PTR).

CONCLUSIONS

Our results showed that combination therapy with estriol plus pelvic floor rehabilitation was effective and should be considered as a first-line treatment for symptoms of urogenital aging in postmenopausal women.

Confronting the challenges of postmenopausal urogenital health

The global population is aging, especially in Western industrialized nations. In the USA, 38% of adults are over the age of 45 and 13% of adults are over the age of 65 years. Moreover, postmenopausal women now comprise 60% of adults aged over 65 years of age, a proportion that will rise as the population ages. This article reviews some of the more common urogenital health issues among older women. Changes to urogenital morphology and physiology are discussed, highlighting the impact on tissue atrophy, sexuality, prevalence of certain vulvar dermatoses, susceptibility to infection and urinary continence. We review treatment approaches, challenge some of the current paradigms and discuss the need for future research.

Drospirenone and estradiol: a new option for the postmenopausal woman

The efficacy of estrogen with or without a progestogen as hormone replacement therapy (HRT) for menopausal symptoms is well-established. Recent large-scale randomized studies with combined estrogen/progestogen therapy (EPT) have raised a number of safety issues, specifically the potential risk for coronary heart disease. Subsequent analyses and other studies have indicated that HRT may be cardioprotective in younger postmenopausal women. A new continuous EPT combines natural 17beta-estradiol (E2) 1 mg with the novel progestin, drospirenone (DRSP) either 0.5 or 2 mg. DRSP has a physiological profile closer to that of natural progesterone than any other synthetic progestin. This paper reviews recent clinical trial data demonstrating the efficacy and safety of combined DRSP/E2 therapy as EPT in postmenopausal women. DRSP/E2 provides symptomatic relief of vasomotor symptoms and improvement in genitourinary atrophy. DRSP/E2 protects against endometrial hyperplasia and reduces the risk of osteoporosis. Combined DRSP/E2 therapy has a favorable impact on cholesterol and triglyceride levels, and decreases blood pressure in women with elevated blood pressure. The favorable efficacy and safety profile of DRSP/E2, and potential for long-term health benefits, represents a new option for the effective management of menopause and its clinical sequelae.

The Relationship Between Menopausal Status, Phase of Menstrual Cycle, and Replacement Estrogen on Cognition in Healthy Women Without Dementia

The authors examined the effect of menopausal status on several aspects of cognition in 4 groups of women (young premenopausal women, middle-aged premenopausal women, naturally postmenopausal women not using hormone therapy, and postmenopausal women using hormone replacement therapy). Participants (N = 48) completed questionnaires designed to assess psychological and physical health. The authors administered a test battery consisting of 10 neuropsychological tests to assess cognitive functioning. Using multivariate analyses of covariance with age as the covariate, the authors found a significant main effect of menopausal status on attention and complex processing abilities. Postmenopausal women using hormone replacement therapy significantly outperformed postmenopausal women not using hormone therapy on the Trail Making Test, Part B of the Halstead-Reitan (R. M. Reitan, 1958). This effect was significant even when the authors controlled for the effects of age, vocabulary levels, and education. Results are consistent with previous findings and may provide further evidence for an ameliorative effect of estrogen replacement therapy on specific cognitive functions.

Dehydroepiandrosterone, androgens and the mammary gland

Mainly through the transformation of dehydroepiandrosterone (DHEA) into androgens in peripheral tissues by intracrine mechanisms, women synthesize at least two-thirds of the androgens found in men. Such data strongly suggest that androgens exert very important but so far underestimated physiological functions in women, including in the breast. In fact, the mammary gland possesses all the enzymatic machinery required to transform DHEA into both androgens and estrogens, although androgens are the predominant steroids synthesized from DHEA in the mammary gland. Early clinical studies have shown beneficial effects of androgens on breast cancer which are comparable to those observed with other hormonal therapies. In fact, a long series of preclinical and clinical data clearly indicate that proliferation of both the normal mammary gland and breast cancer results from the balance between the stimulatory effect of estrogens and the inhibitory effect of androgens. Moreover, the data showing the additive inhibitory effects of antiestrogens and androgens suggest that taking advantage of the inhibitory effect of androgens on breast cancer proliferation could well improve the efficacy of the currently used estrogen deprivation therapies for the treatment and prevention of breast cancer, the best and most physiological candidate being DHEA that limits the androgenic exposure to the tissues which possess the required enzymatic intracrine machinery.

Effect of estradiol valerate and levonorgestrel on vaginal health

OBJECTIVES

To evaluate the effect of the combined hormone replacement therapy (HRT) estradiol valerate/levonorgestrel on vaginal symptoms, vaginal health index, vaginal pH, and vaginal cytology.

STUDY DESIGN

A prospective, open-label study involving 32 postmenopausal women was performed in Ramathibodi Hospital, Mahidol University, Bangkok, Thailand. All the subjects received sequential oral estrogen-progestogen hormone replacement therapy, which contains 2 mg estradiol valerate and 0.15 mg levonorgestrel, for 6 months. The results in terms of vaginal health index, vaginal pH, and vaginal cytology before and after treatment were analyzed.

RESULTS

The mean age of these postmenopausal women was 52.56 +/- 3.33 years (range: 46-60 years). The mean time since the last menstrual period was 3.41 +/- 2.95 years (range: 1-15 years). The vaginal health index, which indicates vaginal health by means of scores for vaginal moistness, vaginal fluid volume, vaginal elasticity, vaginal mucosa, and vaginal pH rose significantly in all the women. The mean vaginal pH became significantly lower. The vaginal cytology showed an estrogenic effect on the karyopyknotic index (KPI) and the maturation value (MV) after 3 and 6 months of treatment.

CONCLUSION

During estradiol valerate and levonorgestrel treatment, there were demonstrable improvements in the objective signs of vaginal atrophy: atrophic vaginal epithelium became thicker and vaginal pH lower, and the morphology of the vaginal cells was better.

Efficacy of low-dose intravaginal estriol on urogenital aging in postmenopausal women

OBJECTIVE

To assess the efficacy and safety of intravaginal estriol administration on urinary incontinence, urogenital atrophy, and recurrent urinary tract infections in postmenopausal women.

DESIGN

Eighty-eight postmenopausal women with urogenital aging symptoms were enrolled in this prospective, randomized, placebo-controlled study. Participants were randomly divided into two groups, with each group consisting of 44 women. Women in the treatment group received intravaginal estriol ovules: 1 ovule (1 mg) once daily for 2 weeks and then 2 ovules once weekly for a total of 6 months as maintenance therapy. Women in the control group received inert placebo vaginal suppositories in a similar regimen. We evaluated urogenital symptomatology, urine cultures, colposcopic findings, urethral cytologic findings, urethral pressure profiles, and urethrocystometry before as well as after 6 months of treatment.

RESULTS

After therapy, the symptoms and signs of urogenital atrophy significantly improved in the treatment group in comparison with the control group. Thirty (68%) of the treated participants, and only seven (16%) of the control participants registered a subjective improvement of their incontinence. In the treated participants, we observed significant improvements of colposcopic findings, and there were statistically significant increases in mean maximum urethral pressure, in mean urethral closure pressure as well as in the abdominal pressure transmission ratio to the proximal urethra. Urethrocystometry showed positive but not statistically significant modifications.

CONCLUSIONS

Our results show that intravaginal administration of estriol may represent a satisfactory therapeutic choice for those postmenopausal women with urogenital tract disturbances who have contraindications or refuse to undergo standard hormone therapy.

Breast cancer and hormonal replacement therapy

Understanding the association between hormone replacement therapy (HRT), the diagnosis of breast cancer, and the clinical outcome of women who develop breast cancer in the setting of HRT continue to present important challenges for health professionals and the public. The general impression in the medical community is that breast cancer is diagnosed more frequently after prolonged HRT; however, whether a causative relationship exists between HRT and breast cancer remains uncertain. Despite the increase in breast cancer diagnosis, clinical outcome of the disease appears favorable for women who develop breast cancer after HRT; HRT users tend to present with more localized tumors that exhibit favorable histology, and overall death from breast cancer appears reduced. The history of breast cancer constitutes a contraindication for HRT as a general rule, based on the concern that HRT may activate dormant cancer cells. Direct evidence for this practice is very limited; available studies are small and mostly retrospective, but do not indicate an adverse effect of HRT on breast cancer recurrence. In reaching a clinical decision regarding HRT, the expected benefits (largely improvement of menopausal symptoms) must be weighed against the potential risks of HRT (especially breast cancer) for each individual woman.

Low-dose (0.3 mg) synthetic conjugated estrogens A is effective for managing atrophic vaginitis

OBJECTIVE

Estrogen or combined hormone (estrogen-progestin) therapy is highly efficacious for managing the signs and symptoms of urogenital atrophy. A low, effective estrogen dose may enhance patient acceptance and reduce side effects.

METHODS

In this randomized, double-blind, multicenter clinical trial, 71 healthy postmenopausal women with vaginal atrophy (Vaginal Maturation Index < or =55) received either low-dose synthetic conjugated estrogens, A tablets (Cenestin) (SCE-A), 0.3 mg once daily, or placebo for 16 weeks.

RESULTS

Treatment with SCE-A for 16 weeks resulted in a highly significant (P<0.0001) mean increase of 17.7 in the Vaginal Maturation Index compared to a mean increase of 4.1 with placebo treatment. A significant estrogenic improvement was detected as early as 4 weeks (mean increase 14.6). Superficial cells were significantly increased from 2.1% at baseline to 15.9% at week 16 with SCE-A, and parabasal cells were significantly reduced from 23.0% at baseline to 1.6% at week 16 (P<0.01 between treatments for both). Vaginal pH was significantly decreased from 6.2 at week -2 to 5.2 at week 16 with SCE-A compared to placebo (P<0.0001). There were no significant differences between treatment groups in the incidence of treatment-emergent side effects or other measures of safety, except for urinary tract infection, which occurred more frequently in the placebo group.

CONCLUSIONS

These results confirm the relatively rapid estrogenic effect and safety of a low-dose (0.3 mg/day) of slow-release SCE-A (Cenestin) in the treatment of vaginal atrophy in postmenopausal women.

Endocrine and intracrine sources of androgens in women: inhibition of breast cancer and other roles of androgens and their precursor dehydroepiandrosterone

Serum androgens as well as their precursors and metabolites decrease from the age of 30-40 yr in women, thus suggesting that a more physiological hormone replacement therapy at menopause should contain an androgenic compound. It is important to consider, however, that most of the androgens in women, especially after menopause, are synthesized in peripheral intracrine tissues from the inactive precursors dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEA-S) of adrenal origin. Much progress in this new area of endocrine physiology called intracrinology has followed the cloning and characterization of most of the enzymes responsible for the transformation of DHEA and DHEA-S into androgens and estrogens in peripheral target tissues, where the locally produced sex steroids are exerting their action in the same cells in which their synthesis takes place without significant diffusion into the circulation, thus seriously limiting the interpretation of serum levels of active sex steroids. The sex steroids made in peripheral tissues are then inactivated locally into more water-soluble compounds that diffuse into the general circulation where they can be measured. In a series of animal models, androgens and DHEA have been found to inhibit breast cancer development and growth and to stimulate bone formation. In clinical studies, DHEA has been found to increase bone mineral density and to stimulate vaginal maturation without affecting the endometrium, while improving well-being and libido with no significant side effects. The advantage of DHEA over other androgenic compounds is that DHEA, at physiological doses, is converted into androgens and/or estrogens only in the specific intracrine target tissues that possess the appropriate physiological enzymatic machinery, thus limiting the action of the sex steroids to those tissues possessing the tissue-specific profile of expression of the genes responsible for their formation, while leaving the other tissues unaffected and thus minimizing the potential side effects observed with androgens or estrogens administered systemically.

The menopause and HRT. Urogenital effects of hormone therapy

The urogenital tract and lower urinary tract are sensitive to the effects of oestrogen and progesterone throughout adult life. Epidemiological studies have implicated oestrogen deficiency in the aetiology of lower urinary tract symptoms occurring following the menopause. Although to date the role of oestrogen replacement therapy in the management of post-menopausal urinary incontinence remains controversial, its use in the management of women complaining of urogenital atrophy is now well established. This aim of this chapter is to review the recent evidence regarding the urogenital effects of hormone therapy with a particular emphasis on the management of post-menopausal urinary incontinence, recurrent lower urinary tract infections and urogenital atrophy.

The role of ovarian hormones in preserving cognition in aging

Hormone replacement therapy is now the standard of care for amelioration of the symptoms of menopause and prevention of osteoporosis. More recently, it has been appreciated that hormone replacement may also have beneficial effects on the brain. This review will contrast the biologic data showing that estrogen has significant neuroprotectant effects on the brain, with data from cross-sectional and epidemiologic studies of women showing that hormone replacement may have beneficial effects for cognition in aging. Together, studies suggest that the temporal pattern of hormone replacement may be critical for maintaining cognitive health in aging.

Special considerations in premenopausal and postmenopausal women with symptoms of overactive bladder

The term overactive bladder (OAB) is used to describe the symptoms of urinary frequency and urgency with or without urge incontinence. Commonly reported symptoms are nocturia, urgency, frequency, and urge incontinence. However, some of these symptoms may be because of other lower urinary tract conditions or may simply represent a variant of normal physiologic function. Consequently, special considerations need to be made when diagnosing OAB in women. In women of all ages, lower urinary tract infection is the most common cause of irritative urinary symptoms, and midstream urine microscopy and culture should be performed. A chronic urinary residual secondary to voiding difficulties may also result in symptoms of frequency and overflow incontinence and may be diagnosed using a postmicturition ultrasound scan. In premenopausal women, pregnancy should also be excluded. In postmenopausal women, urogenital atrophy can cause irritative symptoms that may be improved with hormone replacement therapy. Vaginal administration has been shown to be most effective and may be used to supplement systemic replacement therapy. In addition, estrogen replacement may be beneficial in the management of OAB as an adjunct to anticholinergic therapy. When investigating elderly women with OAB, special consideration should be given to comorbidities, such as constipation and fecal impaction, mobility problems, and the loss of independence. Concomitant medication, such as diuretics and alpha-adrenergic blockers, should also be noted and the need for therapy reviewed. In conclusion, OAB is a subjective diagnosis that should only be made when other lower urinary tract conditions have been excluded.

Atrophic vulvovaginitis in women aged 50 years and above, both current and non-users of hormone replacement therapy, attending a genitourinary medicine clinic

INTRODUCTION

In women aged 50 years and over attending a genitourinary medicine (GUM) department the commonest presentation was with symptoms of vulval soreness, irritation or dryness. Atrophic vulvovaginitis (AVV) was the commonest diagnosis made. This study was undertaken to determine if the presence of AVV was related to the use, or not, of systemic hormone replacement therapy (HRT).

METHOD

A prospective study was made of all women aged 50 years and over attending a GUM department over a 3-month period.

RESULTS

Of the 124 women seen in this age group, 60 (40%) had AVV and 28 (23%) had vaginal candidiasis. No difference was found in current users or non-users of HRT.

CONCLUSION

Accurate diagnosis is essential in women with vulval symptoms to ensure that appropriate therapy is given. In the present study symptomatic women aged 50 years and over were more likely to have AVV than candidiasis irrespective of their use of systemic HRT.

Psychosocial aspects of selected issues in women's reproductive health: current status and future directions

Emphasizing research published in the past decade, this article presents a summary and evaluation of psychosocial investigations of women's reproductive health, with a focus on selected aspects of menstruation, pregnancy and birth, infertility, and menopause. In some areas, studies have focused on negative physical and psychological concomitants of these health issues. However, research reveals substantial individual variability, with most women adapting well to reproductive health changes. Although methodological and conceptual shortcomings have limited firm conclusions, research has advanced our understanding of the multivariate biological, psychological, and social influences on women's reproductive health and associated outcomes. Understanding and promoting women's reproductive health across the lifespan requires biopsychosocial approaches to research.

Hormone replacement therapy at the threshold of 21st century

The management of postmenopausal women has become a major focus for the medical profession. The menopause era should progress from a period of "chaos" to an orderly understanding of the many issues related to the menopause and hormone replacement therapy (HRT). Although HRT has beneficial clinical effect and positive benefit/risk ratio, understanding of the side effects and weight gain, and, especially, a fear of cancer limit compliance. New data from long-term, controlled, prospective studies on the effects of different HRT schedules on cancer, cardiovascular disease and osteoporotic fracture risk are needed. HRT should be considered either as for prevention or for individualized care since women experience menopause as individuals, care should be taken not to make inappropriate generalizations. The priority should be the administration of appropriate medication to women with the best result in order to improve health care and quality of life. New therapeutic options will offer substantial medical advancement for the treatment of postmenopausal women.

Topical alprostadil in the treatment of Female Sexual Arousal Disorder: a pilot study

This study evaluated the efficacy and safety of three doses of topical alprostadil USP (prostaglandin E1) cream in 8 patients with Female Sexual Arousal Disorder (FSAD). Each patient was administered a single intravaginal dose of placebo followed by escalating intravaginal doses of the active drug at 2-week intervals. Alprostadil's effectiveness in enhancing subjective and physiological arousal during visual sexual stimulation was supported by patient ratings and physician assessments of vaginal erythema and transudate volume. Photoplethysmography measurement of vaginal pulse amplitude was not able to demonstrate treatment sensitivity in the present study. Adverse events included mild cases of vaginal itching and burning. The data support further investigation of the use of alprostadil for FSAD.

Clinical approach to dyspareunia

Dyspareunia needs to be addressed from an integrated patient-centered perspective. This review analyzes the organic causes of pain during intercourse. Factors that are often underevaluated in the clinical setting include hormonal, inflammatory, muscular, iatrogenic, neurologic, vascular, connective, and immunitary causes. Psychosexual factors, such as vaginismus, loss of libido, arousal disorders and sexual pain-related disorders, often overlap. A preliminary clinical approach aimed at integrating different biological and psychosexual etiologies in a comprehensive manner is discussed in this article.

Dimensions of sexuality in the perimenopausal transition: a model for practice

A biopsychosocial-cultural model of the sexuality of women during the perimenopausal transition includes dimensions related to physiology, psychosocial issues, and culture. It is an amalgam of biomedical and psychosocial models, yet has the added focus on culture. This holistic approach to sexual health is recommended by researchers and clinicians engaged in the study of midlife women. Clinicians can use this model to guide assessment and interventions, examining all of the dimensions of sexuality during the perimenopausal transition.

Prevention of bone loss by EM-800 and raloxifene in the ovariectomized rat

Some undesirable effects are associated with chronic estrogen and progestin administration used to prevent bone loss in postmenopausal women, thus leading to poor compliance and the need for improved therapeutic and preventive agents. We have thus studied the ability of the new antiestrogen EM-800 (SCH 57050) to prevent bone loss and lower serum cholesterol levels and compared its effects with those of raloxifene. Ovariectomized (OVX) female rats were treated by oral gavage for 37 weeks with increasing daily doses (0.01, 0.03, 0.1, 0. 3 or 1 mg/kg) of EM-800 or raloxifene. At 35 weeks after OVX, lumbar spine bone mineral density (BMD) was 19% lower than in intact animals (P<0.01), while the OVX animals given EM-800 or raloxifene had 90-93 and 85-90%, respectively, of the BMD values observed in intact rats. Similar effects were observed on femoral BMD. Bone histomorphometry measurements were performed on proximal tibia. At the 0.01 mg/kg dose, EM-800 prevented the effect of OVX on TBV by 34% (P<0.01), while raloxifene had no detectable effect. Treatment with 1 mg/kg EM-800 and raloxifene resulted in, respectively, 68% (P<0.01) and 64% (P<0.01) prevention of the OVX-induced decrease in TBV. In addition, the administration of 0.01 and 0.03 mg/kg EM-800 caused, respectively, 54% (P<0.01) and 56% (P<0.01) inhibitions of serum cholesterol levels, while raloxifene administered at the same doses caused, respectively, 24% (P<0.01) and 41% (P<0.01) decreases of the value of the same parameter. At the highest doses used (0.1-1 mg/kg), both compounds lowered serum cholesterol levels by approximately 65% (P<0.01). No stimulatory effect of EM-800 was observed on the endometrial epithelial cells at doses up to 1 mg/kg, while hypertrophy of uterine epithelium was observed with raloxifene. EM-800 and raloxifene achieve the same degree of effectiveness on bone and serum cholesterol at higher doses, but EM-800 is at least three to ten times more potent than raloxifene at lower concentrations and has no stimulatory effect on uterine epithelium. The present data show the potent effect of EM-800 preventing bone loss and lower serum cholesterol levels without the negative effect on the endometrium, thus suggesting the particular interest of this new fully tissue-specific selective estrogen receptor modulator.

Swimming eliminates the weight gain and abdominal fat associated with ovariectomy in the retired breeder rat despite high-fat diet selection

The effects of swim-training on choice of dietary fat, carbohydrate or protein, weight gain, energy intake, and energy efficiency were examined in ovariectomized and sham-operated retired breeder rats. After a 3 week training period of increased duration, rats swam for 75 min per session (5 days per week) for 4 weeks. Ovariectomized rats gained more weight than sham rats, while swimming reduced weight gain and abdominal fat. As a percentage of total intake, macronutrient choices (weight and energy) were similar for all groups, ovariectomized animals consumed more food and more energy, compared with sham animals. All rats freely chose the majority of their food (g) as carbohydrate and the majority of energy (kJ) as fat. Results indicate that a moderate intensity training program of swimming prevented the weight gain following ovariectomy in older rats despite their excessive caloric intake of fat.