Postmenopausal hormone replacement therapy

Health status of users of hormone replacement therapy by hysterectomy status in Western Australia

STUDY OBJECTIVES

To compare the demographic, behavioural, and biological correlates of use of hormone replacement therapy (HRT) in women with an intact uterus and women who have undergone hysterectomy.

DESIGN

Cross sectional analysis of data from the Busselton Health Study and the 1994 Healthway-National Heart Foundation Risk Factor Survey.

SETTING

Busselton and Perth, Western Australia, 1994.

PARTICIPANTS

2540 women aged 35-79 years.

MAIN OUTCOME MEASURES

Demographic, behavioural, and biological correlates of use of HRT by hysterectomy status.

RESULTS

In women with an intact uterus, after adjustment for age and place of residence, current use of HRT was significantly associated with having a professional level of occupation, ever use of alcohol, having a history of smoking, and a lower body mass index. Current users of HRT had significantly lower levels of total cholesterol and higher levels of triglycerides than non-users. In women who had undergone hysterectomy, the only non-biological characteristic associated with use of HRT was having a history of smoking. Current users of HRT had lower levels of systolic blood pressure, lower levels of LDL cholesterol, higher levels of HDL cholesterol, and higher levels of triglycerides. The association between use of HRT and participation in exercise, level of systolic blood pressure, level of HDL cholesterol, and total/HDL cholesterol ratio varied significantly by hysterectomy status. After adjustment for age and place of residence, the mean levels of systolic and diastolic blood pressure, body mass index, waist/hip ratio, LDL cholesterol, and total/HDL cholesterol ratio were highest in women who had undergone hysterectomy and were not using HRT.

CONCLUSIONS

Demographic/behavioural and biological correlates of use of HRT varied depending on hysterectomy status. Demographic and behavioural characteristics were more important as selection factors for use of HRT in women with an intact uterus than in women who had undergone hysterectomy. Women who had undergone hysterectomy and were not using HRT had a significantly worse profile for CHD than did women with an intact uterus. These results indicate that any bias in estimates of the protective effect of HRT on risk of CHD in observational studies is likely to depend on the prevalence of hysterectomy within the study population. Hysterectomy status needs to be taken into account in any studies that investigate the effect of HRT on risk of CHD.

Efficacy of a new 7-day transdermal sequential estradiol/levonorgestrel patch in women

OBJECTIVE

To investigate the efficacy and tolerability of a new 7-day transdermal sequential estradiol/levonorgestrel patch (Fem7 Combi; Merck KGaA; Germany), versus placebo, as hormone replacement therapy in menopausal women.

METHODS

A multicentre, randomized, clinical study consisting of a 3-week screening phase, a 12-week double-blind, placebo-controlled treatment phase, and a 12-week open, follow-up phase. Women aged 40-65 years with an intact uterus and menopausal complaints were randomized to either 2 weeks of an estradiol mono patch (50 microg per 24 h) followed by 2 weeks of an estradiol/levonorgestrel combination patch (50 microg/10 microg per 24 h), or a placebo patch, for three 28-day cycles. Changes in the Kupperman Index and the frequency of hot flushes were assessed.

RESULTS

The sequential use of a 7-day estradiol patch and a 7-day estradiol/levonorgestrel patch was superior to placebo in reducing menopausal symptoms, and was well tolerated. At the end of the treatment phase, there was a statistically significant reduction in the Kupperman Index score versus placebo (P<0.0001), and a statistically significant difference between groups in the proportion of patients with a reduction in the number of hot flushes (at least 50% versus baseline). During the open follow-up phase, there was a marked reduction in the Kupperman Index score and the number of hot flushes for patients switched from placebo to active study medication. The active medication was effective throughout the 1-week application period.

CONCLUSIONS

The new 7-day transdermal sequential estradiol/levonorgestrel patch was well tolerated, providing rapid and effective relief of menopausal symptoms. The addition of low-dose levonorgestrel did not influence the beneficial effects of estradiol.

Efficacy and tolerability of a new 7-day transdermal estradiol patch versus placebo in hysterectomized women with postmenopausal complaints

OBJECTIVES

To investigate the efficacy and tolerability of a continuously applied 7-day-Estradiol patch (Fem7, Merck KGaA, Germany) delivering 50 microg estradiol per day in the treatment of hysterectomized women with postmenopausal complaints compared with placebo.

DESIGN

A multicentre, randomized, double-blind study with an initial screening phase (phase I), a 3-month double-blind placebo-controlled phase (phase II) and a 3-month open follow-up phase (phase III).

METHODS

186 patients were randomized for a 3-cycle placebo-controlled study followed by a 3-cycle open follow-up (total duration; 6 months). The changes in Kupperman Index (primary efficacy variable), hot flushes and urogenital symptom score were studied from baseline to the end of the study. In addition, skin tolerability was assessed and patients were also asked to grade the subjective acceptance of therapy.

RESULTS

A reduction in Kupperman Index was observed in both groups, and at each cycle of the placebo-controlled treatment phase the 7-day-Estradiol patch was superior compared with placebo (last value vs. baseline P = 0.0006). From the second treatment week onwards a distinct difference was noted in the reduction of hot flushes from baseline between the 7-day-Estradiol patch group and the placebo group. The difference between the groups was statistically significant for each cycle and at the end of the controlled treatment phase (mean weekly hot flush reduction at the end of the placebo-controlled treatment phase: -32.5 for the 7-day-Estradiol patch vs. -22.0 for placebo, P = 0.0025). The efficacy of the 7-day-Estradiol patch within the application period did not show any difference between days 1-3 and 4-7. Subjective acceptance of the 7-day-Estradiol patch was good and 72.4% of patients who took active medication throughout the study were willing to consider continuing its use.

CONCLUSIONS

The 7-day-Estradiol patch is well tolerated and provides effective relief of moderate to severe vasomotor symptoms in hysterectomized women, with a rapid onset of action and 7-day duration of therapeutic effect. Although a placebo effect was observed, the 7-day-Estradiol patch significantly reduced hot flushes and other menopausal symptoms throughout the application period.

Evaluation of hormone replacement therapy use by the sales figures

Despite the efficiency of hormone replacement therapy (HRT) to prevent climacteric manifestations and possibly the long-term deleterious influences of menopause, the prevalence of HRT is relatively low, and quite variable, depending on the population studied. Presently, there is no information regarding HRT in Switzerland and in the region of Geneva, which have particularly aged populations, with a life expectancy among the longest in the Western world. In this study, the number of women treated per year in 1993 and 1996, as well as the prevalence of HRT were estimated, based on the total amount of hormone preparations sold for HRT. In Switzerland, for a female population older than 45 years of about 1.45 million, the number of women on HRT was approximately 166,000 in 1993 and 202,000 in 1996. For Geneva, the female population was more than 86,000, and the number of treated women was about 14,000 and 21,000 in 1993 and 1996, respectively. Depending on the age class considered as susceptible of receiving HRT, the prevalence of this therapy may vary between 15 and 20% for Switzerland, and between 21 and 27% for Geneva in 1993. It was estimated between 17 and 24%, and 31 and 41% in 1996. These values are quite comparable to those reported for other countries with a similar socioeconomic level and obtained using different methods of evaluation.

Persistence with estrogen therapy in a postmenopausal Medicaid population

We evaluated rates of persistence with estrogen replacement therapy in postmenopausal Georgia Medicaid recipients adjusted for age and race. Data files for 1992-1994 were examined to estimate 3-year conditional survival probabilities using the Kaplan-Meier model, and 3800 subjects were identified. Over 54% of women remained compliant over 29 months, and 17% continued therapy for the entire 35 months of observation. Kaplan-Meier predictors indicated that white women have a 70% chance of being compliant for 3 years, whereas black women have a 60% chance. Monthly discontinuation rates ranged from 1-1.5% after the second month of therapy. Younger, white women were the most likely to maintain and comply with therapy.

Prevention and treatment of postmenopausal osteoporosis

The purpose of the review is to outline the interventions, both pharmacological and non-pharmacological, available to prevent postmenopausal osteoporosis (PMO) and treat the established disease. Current suggested guidelines for the most cost-effective treatment and prophylactic strategies are included following a consideration of the available options. As life expectancy has increased so has the incidence of PMO which has major quality of life implications for the sufferers and economic implications for the authorities responsible for their treatment. PMO represents a significant public health problem and although more effective treatments are becoming available prevention of the disease by taking account of existing risk factors is preferable. Indeed, a population approach to prevention may be more cost effective than screening for the disease. Attention to dietary calcium intake and exercise regimes have been shown to be effective prophylactic measures premenopausally, while the treatment of choice is hormone replacement therapy (HRT). HRT treats other postmenopausal symptoms in addition to PMO and is available in many presentations, containing different hormones, at different doses intended for different routes of administration. The optimum treatment duration is controversial and may contribute to some of the risks associated with HRT such as endometrial and breast carcinoma and venous thromboembolism (VTE). Newer effective treatments include the bisphosphonates and novel formulations of calcitonin, but older approaches such as vitamin D, anabolic steroids and fluoride are still utilised in some circumstances. However, most promise has been shown by synthetic hormonal modulators currently being trialled.

Is hormone replacement therapy a risk factor for low back pain among postmenopausal women?

STUDY DESIGN

Cross-sectional study with two age cohorts.

OBJECTIVE

To assess whether women receiving hormone replacement therapy after menopause have a higher prevalence of back problems than women who do not receive such treatment.

BACKGROUND

Back pain is a common medical problem throughout life and especially during pregnancy. Hormonal factors have been proposed as a possible contributor.

PATIENTS AND METHODS

A validated postal questionnaire was sent in early 1995 to all 1324 women of 55 years and 56 years of age residing in Linköping, Sweden. This questionnaire included questions about current hormone replacement treatment, previous and current back problems, medical care for back problems, parity, exercise and smoking habits, and occupation.

RESULTS

The questionnaire was returned by 84.7% of the women. There was a significant, albeit weak, positive association between current use of hormone replacement treatment and low back pain. Previous back problems during pregnancy was a strong risk factor for current back pain, whereas neither current smoking nor regular physical exercise was a risk factor according to multiple logistic regression analysis. The interaction of smoking and an occupation involving heavy lifting significantly affected back pain.

CONCLUSIONS

Women receiving hormone replacement treatment had a slightly, but significantly, higher prevalence of current back pain than nonusers (48% vs. 42%, respectively, P < 0.05), which could not be explained by differences in occupation, smoking habits, or current physical activity. Although the association between hormone replacement therapy and back problems is weak and probably of minor clinical importance, it is speculated that hormonal effects on joints and ligaments may be involved.

Prescribing patterns for nursing home residents in the US. The reality and the vision

The study of prescribing for the elderly in the US is in its infancy. Nursing home studies provide some of the most reliable data. In US nursing homes, each resident is prescribed an average of between 7.2 and 8.1 medications, with gastrointestinal agents being the most frequent. The vision for prescribing in the US involves avoidance of polypharmacy and specific groups of medications. Approaches to treatment in the US for certain conditions that can be prevented are addressed, specifically pain control, osteoporosis, stroke, cardiovascular disease, cognitive impairment and infection.

Patient managed clinical trial

We describe a trial design of postmenopausal hormone therapy. Our goal was to design a trial that allows more patient management than usual, would include placebo effect in the therapy, would imitate the normal practices of health care as much as possible, and would be based on ordinary health services. We gave women a randomized recommendation to use or not use hormone therapy, invited them to two discussion groups, and sent them two questionnaires. They were asked to consult their own physician and to pay for the therapy themselves. The design worked well regarding recruitment, but compliance after 6 months was not satisfactory. The main problems were the women's aversion to randomization, the attitudes of the women's own physicians, and the difficulty in stopping the use of hormone therapy. The last-mentioned problem could be avoided by different inclusion criteria. Unless societal perception of research can be changed, most solutions to improve compliance would lead toward traditional trial designs.

Drug-induced disorders of glucose metabolism. Mechanisms and management

Glucose homeostasis is maintained by a balance between the release and action of insulin, and the counterregulatory responses mediated principally by glucagon, catecholamines, growth hormone and cortisol. Hence, the effects of a drug on glucose metabolism may be mediated by any of these agents singly or in combination. Host factors, such as inherent glucoregulatory mechanisms, concurrent diseases, organ function and concomitant medications also increase the risk of drug-induced disturbances of glucose homeostasis in susceptible individuals. By far the most important agents causing hypoglycaemia are insulin and the sulphonylureas. Alcohol (ethanol), over-zealous glycaemic control, hypoglycaemic unawareness, detective counterregulation especially in insulin-dependent diabetes mellitus (IDDM), and renal and liver impairment are all important predisposing factors. Although antihyperglycaemic agents such as metformin and alpha-glucosidase inhibitors do not cause hypoglycaemia alone, they may enhance the hypoglycaemic effects of potent hypoglycaemic agents such as insulin and sulphonylureas. On the other hand, the potential hypoglycaemic effects of ACE inhibitors, alpha-blockers, lipid-lowering agents and recombinant human insulin-like growth factor demonstrated in experimental settings, are of potential therapeutic interest. Iatrogenic hypoglycaemia and intensive insulin treatment are associated with hypoglycaemic unawareness which may be obviated by meticulous avoidance of hypoglycaemia. Effective patient education remains an important preventive measure. Oral glucose is used to treat mild hypoglycaemic episodes while more severe episodes are treated by intravenous glucose or glucagon. Nasal glucagon and theophylline are other experimental measures to improve recovery from hypoglycaemia. In refractory hypoglycaemia due to hyperinsulinaemia such as during sulphonylurea overdosage or quinine treatment, the long-acting somatostatin, octreotide, may suppress insulin release and restore euglycaemia. Diuretics, beta-blockers, sympathomimetics, corticosteroids and sex hormones are commonly prescribed drugs which may have adverse effects on carbohydrate metabolism especially in patients with diabetes mellitus or those who are at risk of developing glucose intolerance. Pentamidine was frequently associated with dysglycaemia due to its pancreatic beta-cell cytotoxic effects but is now used less often to treat Pneumocystis carinii pneumonia in immunosuppressed patients. Despite the large number of anecdotal reports of drug-induced disturbances of glucose metabolism, many of the so-called adverse drug reactions were either idiosyncratic or coincidental. Nevertheless, they emphasise the complex nature of glucose homeostasis and its potential interactions with drugs, host factors and disease states. An understanding of these relationships may allow more critical interpretation of these clinical observations, better prediction of drug induced adverse effects on carbohydrate metabolism and the implementation of more rational therapy. Hence, the hypoglycaemic effects of a drug may be turned to a therapeutic advantage in patients with glucose intolerance. Similarly, the hyperglycaemic effect of a drug may help to treat refractory hypoglycaemia.

Vitamin D treatment and bone mineral density in the aged

The purpose of this study was to investigate whether long-term vitamin D treatment increased bone mineral density in the aged. The bone mineral density in the distal forearm and femoral neck did not differ between nine residents (mean age 81.0 years) of an old peoples' home who had received an annual injection of 150,000 IU ergocalciferol during the foregoing 2-7 years (mean 5.1 years) and nine age-, weight- and height-matched control subjects who had subnormal 25 hydroxyvitamin D level. The alkaline phosphatase and parathyroid hormone levels were clearly higher when the 25 hydroxyvitamin D level was below 10 nmol/1. The authors suggest that the ability of vitamin D treatment to diminish fracture incidence may derive from improved bone quality, not measurable by the standard dual energy X-ray absorptiometry, and/or improved nervous and muscular control of movements to counter the tendency to fall.

Hormone replacement therapy in the aged. A state of the art review

The use of hormone replacement therapy (HRT) in the immediate postmenopause for the relief of menopausal symptoms and for the prevention of osteoporosis and cardiovascular disease is well established. The continuation of treatment beyond the age of 60 years is likely to maximise these long term benefits and there is now increasing evidence to suggest that commencing treatment de novo in women of this age is likely to be beneficial. Many women remain symptomatic well into their sixties and the introduction of HRT at this stage will not only relieve these symptoms but will also conserve bone density and reduce future osteoporotic fracture risk. Furthermore, HRT appears to reduce the risk of cardiovascular disease, even in those women with pre-existing heart disease. The possible association between HRT and breast cancer remains controversial. Overall, there seems to be a slight increase in risk with long term HRT usage (longer than 10 years) but certain subgroups of women may be more at risk. This review discusses the merits and potential problems of prescribing HRT to the elderly and gives some guidance on the type, dose and route of administration of estrogen and progestogen to be used. Poor compliance with HRT is a major problem and the more widespread use of pretreatment counselling together with a wider range of products should have a positive impact in this area. The final decision about whether to continue or commence HRT in the elderly should be an informed one made by the woman and her clinician together.

Hormone replacement therapy in a risk-benefit perspective

The relative cost-effectiveness of different treatment strategies for hormone replacement therapy (HRT) was assessed within the framework of a computer model. Where data were lacking, it was necessary to make assumptions about the effects of HRT, particularly in relation to combined oestrogen-progestogen therapy and cardiovascular disease; however, sensitivity analyses were performed to assess the impact of changing these assumptions on the cost-effectiveness equation. It appears that net expenditure by the NHS will depend critically on the direct costs of treatment, rather than on any indirect costs incurred or saved as a result of side-effects. In terms of mortality, a reduction in cardiovascular disease risk would have greatest impact and would overshadow any small increase in breast cancer risk which may be associated with long-term use. If the cardioprotective effect of oestrogen is real, our results suggest that long-term prophylactic treatment of hysterectomised women would be relatively cost-effective. Treatment of symptomatic menopausal women for any period of time appears to offer very good value for money. The lack of data relating to combined oestrogen-progestogen therapy and cardioprotection, and the major importance of the latter in the equation of benefits and risks, make it more difficult to draw conclusions about the cost-effectiveness of treating non-hysterectomised asymptomatic women for prophylactic reasons.

A comparative study of prescribing of hormone replacement therapy in USA and Europe

OBJECTIVES

The use of hormone replacement therapy (HRT) has been shown to vary from one country to another through international studies of sample populations and by comparison of data obtained from comparable national studies. Drawing international prescribing comparisons is very difficult as data sources are few, incomplete and of uncertain accuracy and comparability. As an alternative to direct prescribing information, pharmaceutical sales information indicates medication used. This paper sought to demonstrate international differences in the use of HRT using an economic analysis methodology based on national pharmaceutical sales statistics.

METHODS

A recognised economic analysis methodology was used to translate 1991/1992 pharmaceutical sales data into women treatment years of HRT used in each country. From this was calculated the percentage of the female population in each country, eligible for HRT, who would have been taking HRT.

RESULTS

The results show a wide variance in the percentage of the eligible female population in each country calculated to have been taking HRT, from <1%-20%. The results indicated that HRT usage fell into three groupings: USA being the greatest user with UK and Scandinavian countries in the middle group and continental Europe having the lowest usage.

CONCLUSIONS

National patterns of HRT usage, as calculated by this study, correlate well with those of other studies. Since similar morbidity could be expected as menopause is a naturally occurring event, not a disease, possible reasons for the variance in national prescribing patterns are discussed. The study indicates the need for further research on health beliefs and physicians' and women's attitudes to HRT in different countries to explain the variance in HRT usage, also considering access to healthcare, in particular women's health services. It confirms the validity of using economic analysis of pharmaceutical sales data as a proxy for prescribing data in the arena of prescribing research.

Hormone replacement therapy and cardiovascular disease

Coronary heart disease is the principal cause of death in postmenopausal women. Postmenopausal women have an elevated cardiovascular risk profile in the form of android obesity (increased waist/hip ratio), hyperinsulinemia, impaired glucose tolerance, increased insulin resistance and elevated plasma LDL, VLDL, serum triglyceride and lipoprotein (a). A significant decrease in the relative risk of cardiovascular disease is observed with estrogen replacement therapy. The addition of progestogens commonly used in hormone replacement regimes does not, based on present evidence, seem to affect cardiovascular protection adversely. The literature on this subject has been reviewed and recommendations made with implications for the future.

Do older women use estrogen replacement? Data from the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE)

OBJECTIVES

The primary purpose of this study was to determine the prevalence of current and past estrogen use among older, community-dwelling, postmenopausal women. The secondary purpose was to describe factors associated with estrogen use in this population.

DESIGN

A survey.

SETTING

The Piedmont region of North Carolina.

PARTICIPANTS

The sample included 2602 community-dwelling women over the age of 65 who were interviewed for the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE).

MEASUREMENTS

Current and past use of estrogen.

RESULTS

Of the women surveyed, 6.1% reported current estrogen use, and 18.5% reported past use. Approximately half of the participants reported using estrogen for more than 2 years. Multivariate analysis demonstrated that current estrogen users were younger, more affluent, had smaller families, and were more likely to be white and to live in an urban area than were never users. Current users were also more likely to drink alcohol and to take calcium supplements; and compared with past estrogen users, they were more likely to be white, have smaller families, and to drink alcohol.

CONCLUSION

Estrogen replacement therapy is used by a small minority of older women, especially blacks. Moreover, although women with some risk factors for osteoporosis are more likely to use estrogen, the chief determinants of estrogen utilization are socioeconomic.

Prevention of osteoporosis: cost-effectiveness of different pharmaceutical treatments

The cost-effectiveness of different pharmaceutical programmes to prevent osteoporosis has been compared. The following pharmaceutical treatments were analysed and compared: calcium supplementation, etidronate and calcitonin. As a benchmark for comparison, oestrogen replacement therapy, in the form of both pills and plaster, was also included in the analysis. The cost-effectiveness of different strategies for particular age groups was analysed. Finally, the cost-effectiveness of population-based prevention programmes was compared with the cost-effectiveness of programmes based on screening followed by treatment of women with low bone mineral density (BMD). A cost-effectiveness analysis (CEA) was carried out. The cost/effectiveness ratio computed was net costs per hip fracture avoided. The evaluation was based on a simulation model in which 1000 women were followed from the age of 50 years. The model was based on Danish epidemiological data and Danish health care cost figures. Assumptions concerning the health effect of the pharmaceutical methods of prevention were based on results from existing studies. As different results have been reported, 'optimistic' and 'pessimistic' alternatives were simulated in the model. The analysis revealed large differences in the cost-effectiveness of different pharmaceutical methods; however, the cost-effectiveness is highly sensitive to the treatment effect assumed. Treatment will be more cost-effective the higher the fracture risk of the group treated, so cost-effectiveness will therefore increase the later in life the intervention takes place, and if only women screened for low BMD are treated. However, the overall effect from a general screening programme will be low and highly sensitive to compliance. As compliance with pharmaceutical treatment seems to be low, and as the effectiveness--and thereby the cost-effectiveness--is encumbered with much uncertainty, prevention of osteoporosis through screening for low BMD should not be recommended at present.

Australian women's perceptions of hormone replacement therapy over 10 years

The knowledge, beliefs and experience of 60 women with HRT was studied when the women were premenopausal, and 10 years later when they were postmenopausal. Thirty-eight women had taken HRT by 1993. In 1993 women no longer considered clinics and self help groups to be the most useful sources of information about the menopause. They were more likely to think that doctors' knowledge of HRT was not adequate and to favour the use of HRT. Their reservations about all postmenopausal women receiving HRT continued. The women's understanding of long-term use of HRT varied. The women continued to maintain a desire not to experience withdrawal bleeding with HRT. More than 60% of women considered that HRT helped hot flushes, non-specific emotional changes and vaginal dryness. Women in 1993 were more likely to consider that HRT would help the menopausal symptoms of osteoporosis, insomnia and loss of muscle tone while fewer considered anxiety and depression would be relieved by HRT. Only one third believed HRT would reduce the incidence of heart disease. Women were more likely to take or have taken HRT if they were working and had achieved a higher work status (professional), considered reading material as the most useful source of information about menopause, had experienced menopause symptoms as distressing, considered menopause made relationships with husband and children more difficult and supported the universal use of HRT for all women.

The climacteric, osteoporosis and hormone replacement; views of women aged 45-49

We report climacteric symptoms among women aged 45-49, and their attitudes towards HRT and osteoporosis prevention. Semi-structured questionnaires were administered to 481 women attending for bone density screening after random invitation. We recorded social class, menopausal status, history of HRT exposure and climacteric symptoms, awareness of HRT and osteoporosis, and potential willingness to consider HRT before and after bone densitometry. In total, 294 (61%) were from non-manual social classes; 338 (70%) were premenopausal, 68 (14%) postmenopausal and 75 (16%) uncertain; 101 (21%) were current/previous HRT users. Three or more climacteric symptoms were experienced by 189 (56%) of premenopausal women, compared to 64 (94%) of postmenopausal women. Most women had heard of HRT (96%) and osteoporosis (84%), usually from women's magazines or friends. HRT was usually prescribed for climacteric symptoms and, in one case, for osteoporosis prevention. Side effects were reported with most HRT preparations and affected 38% of all users. Of the 380 (79%) women who had never taken HRT, half had concerns about such treatment, and few wanted it at the menopause. However, 364 (96%) said they would consider HRT if their bone scan suggested increased osteoporosis risk. In conclusion, women around the menopause experience considerable climacteric morbidity, but are often anxious about HRT use. Better health education might improve HRT uptake, while long-term compliance might be enhanced by disclosure of fracture risk.

Non-surgical management of early breast cancer in the United Kingdom: follow-up. Clinical Audit Sub-committee of the Faculty of Clinical Oncology, Royal College of Radiologists, and the Joint Council for Clinical Oncology

Follow-up of operable breast cancer patients takes up a significant proportion of British oncologists' time, with 90% seeing 5-50 patients each week. Procedures vary greatly, but, in patients treated by surgery and radiotherapy, care is usually shared, with alternating visits to see each team. Currently, the general practitioner has sole responsibility for follow-up in less than 3% of patients. They tend to be followed up in general, rather than specialist, clinics. There is almost universal agreement that routine blood tests, radiographs and scans are not indicated as part of routine follow-up, but the role of mammography in evaluating an irradiated breast remains a source of debate. Just over a half of the oncologists surveyed order baseline mammography of both treated and contralateral breasts, usually between 6 and 12 months after local excision and radiotherapy, with further follow-up 1-3-yearly thereafter. Ten per cent of the participating oncologists never suggest follow-up mammography. Patients tend to be followed in oncology clinics at 3-4-monthly intervals for the first 2 years, 6-monthly in the third and fourth years and, thereafter, yearly. Fifteen per cent of oncologists discharge patients at 5 years, with the discharge rate rising to 43% at 10 years; around one-third modify follow-up according to the age of the patient. The aims of follow-up were seen to include detection of curable disease, but other goals were perceived as equally important (e.g. detection of iatrogenic problems, audit, counselling, education and the provision of early palliation of incurable and metastatic disease. Breast cancer is no longer seen as an absolute contraindication to either pregnancy or the use of hormone replacement therapy (HRT); however, oncologists are uncertain about the appropriate use of HRT, either alone or with tamoxifen. This audit highlights a number of research areas: the identification of the appropriate site and skill-mix for follow-up of patients; clarification of the aims and attitudes to follow-up by both patients and health care professionals; the use of breast imaging; and the role of HRT.

Efficacy of a 3-substituted versus 17-substituted chemical delivery system for estradiol brain targeting

Brain-targeted delivery of estrogens has been achieved by a chemical delivery system (CDS) in which a molecular targetor (1-methyl-1,4-dihydronicotinate) was attached to the 17-alcohol of estradiol. Optimization of this effect was attempted with the isomeric 3-phenol ester. Estradiol 3-nicotinate was prepared with nicotinic anhydride, which selectively acylated the phenol position. Methylation and reduction gave estradiol 3-(1-methyl-1,4-dihydronicotinate) of the 3-E2-CDS. Theoretical and electrochemical investigation indicated that the 3-E2-CDS was more stable to oxidation than was the prototype 17-ester (17-E2-CDS). Systemic administration of the 17-E2-CDS produced high levels of the corresponding quaternary salt in the brain of rats, which disappeared with an estimated half-life of > 2 days, but 3-E2-CDS dosing resulted in no significant quaternary salt trapping. Pharmacological activity was potent and sustained after 17-E2-CDS dosing but transient after 3-E2-CDS administration. Thus, the 3-E2-CDS reduced the rate of weight gain in male rats but to a lesser extent and for a shorter duration than did the 17-E2-CDS. Similar effects were seen on pituitary hypertrophy, reduction in serum androgen concentrations, and involution of prostate and seminal vesicles. The results of these studies suggest that placement of the targeting ester at the phenol position increases dihydropyridine stability but, at the same time, reduces brain sequestration.

Pharmacological management of back pain syndromes

The symptom of back pain may be the result of many different pathologies. As such, patients with back pain require careful assessment to determine whether the cause is from the spine or other systems. For acute mechanical back pain, treatment is often symptomatic. Symptomatic treatment may include analgesics, anti-inflammatories and/or muscle relaxants. Patients may also need hypnotics in the short term to help them sleep at night. However, drug therapy should be reduced and stopped as soon as possible. Furthermore, too much bedrest may be counterproductive. Paracetamol (acetaminophen) is the standard treatment for transient back pain. More severe pain may require the addition of an opioid, such as codeine or dextropropoxyphene. Morphine and pethidine (meperidine) may be necessary in patients with back pain due to neoplastic disease or osteoporotic fracture. However, the opioid analgesics are associated with dependence, tolerance and adverse effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) have analgesic efficacy comparable with paracetamol. Individual patients respond differently to different NSAIDs, and several agents may have to be tried. Long term therapy with NSAIDs is necessary in diseases with an inflammatory component such as ankylosing spondylitis. Calcitonin reduces bone resorption and bone blood flow, and has been suggested to have central analgesic effects. As such, it has been used successfully in patients with Paget's disease, osteolytic bone disease and osteoporosis. Bisphosphonates also inhibit osteoclastic bone resorption and may be useful in Paget's disease, osteolytic metastases and osteoporotic fractures. Other drugs which may be useful in relieving back pain associated with specific circumstances include the tricyclic antidepressants, anxiolytics, antiepileptic agents, corticosteroids, colchicine and chymopapain.

Do women taking hormone replacement therapy have a higher uptake of screening mammograms?

All British women in the 50-64 age group are now offered three yearly screening mammograms. A study was undertaken to compare the uptake of three yearly screening mammograms for women taking hormone replacement therapy with those not on treatment. Out of a list size of 15,000, there were 1309 women aged 50 to 64. Of these 265/286 (92.7%) of women taking hormone replacement therapy, and 877/1023 (85.7%) not taking treatment, attended for mammograms. Overall 286/1309 (21.8%), and in the 50-54 subgroup 193/524 (36.8%), were taking hormone replacement therapy. This study supports the idea that there is a selection bias with women taking hormone replacement therapy significantly more likely to attend for screening mammograms.

Aging is associated with endothelial dysfunction in healthy men years before the age-related decline in women

OBJECTIVES

This study assessed whether aging is associated with progressive endothelial dysfunction, whether the pattern of any age-related decline in vascular health is different in men and women and whether any gender difference is consistent with known changes in hormonal status.

BACKGROUND

Coronary and cerebrovascular disease are much less common in young and middle-aged women compared with men, although the gender difference in death from atherosclerosis is less marked after the menopause. Endothelial dysfunction is an early event in atherogenesis and is important in dynamic plaque stenosis in later life. The effect of aging on endothelial function in men and women, however, is not well known.

METHODS

We used high resolution ultrasound to study endothelium-dependent and endothelium-independent vascular responses. Brachial artery physiology was investigated in 238 subjects (103 men, 135 women; mean [+/- SD] age 38 +/- 17 years, range 15 to 72) with no known risk factors for atherosclerosis. The responses to reactive hyperemia (flow-mediated dilation, which is endothelium dependent) and to glyceryl trinitrate (an endothelium-independent dilator) were assessed for all the subjects and then for men and women separately.

RESULTS

On multivariate analysis for the whole group, reduced flow-mediated dilation was related to older age (r = -0.34, p < 0.0001). In men, flow-mediated dilation was preserved in subjects aged < or = 40 years but declined thereafter at 0.21%/year. In women, flow-mediated dilation was stable until the early 50s, after which it declined at 0.49%/year (p = 0.002 compared with men). In contrast, there was no significant change in the glyceryl trinitrate response with aging in either gender.

CONCLUSIONS

Aging is associated with progressive endothelial dysfunction in normal humans, and this appears to occur earlier in men than in women. In women, however, a steep decline commences at around the time of the menopause. This is consistent with a protective effect of estrogens on the arterial wall.

Cardioprotective effect of hormone replacement therapy in postmenopausal women: is the evidence biased?

OBJECTIVE

To quantify the effect of selection of relatively healthy women in studies reporting reduced relative risk for cardiovascular disease in postmenopausal women taking hormone replacement therapy.

DESIGN

Review of the follow up studies reported in three recent meta-analyses to determine the effect of oestrogen therapy on both total cancer and cardiovascular disease. The same standard statistical methods as in the original analyses were used.

MAIN OUTCOME MEASURES

Relative risks of total cancer and cardiovascular disease.

RESULTS

In most of the follow up studies the relative risk for total cancer was below 1. The studies that showed the largest reduction in cardiovascular disease also showed the largest reduction in cancer, indicating a healthy cohort effect. Although heterogeneity within the studies prevented pooling, the best estimate for the protective effect on total cancer was a relative risk of 0.83 among women taking oestrogen (95% confidence interval 0.71 to 0.96), while in the same studies the relative risk for cardiovascular disease was 0.57 (0.50 to 0.64).

CONCLUSIONS

Unintended selection of relatively healthy women for oestrogen therapy may have influenced the reported beneficial effect of oestrogen therapy on cardiovascular disease. It is unclear how much of the cardioprotection is due to this selection. Universal preventive hormonal replacement therapy for postmenopausal women is unwarranted at present.

A study on the use of medication for climacteric complaints in western Europe--II

Samples of about 300 women aged 40-69 were interviewed in Denmark and the Netherlands about consultations with a physician for climacteric complaints, awareness regarding the menopause and hormone replacement therapy (HRT), and use of medication. Twenty percent of Danish and 13% of Dutch respondents had consulted a physician. Fifty percent of Danish and 16% of Dutch respondents were informed about the menopause, and 46% of Danish and 10% of Dutch respondents were informed about HRT, the mass media being the most important information source. In Denmark and the Netherlands HRT use rates were 12% and 4%, respectively, those for non-hormonal treatment being 6% and 2%, and for tranquillizers 11% and 7%. Pooling of the data with those from a similar study conducted in Italy, the United Kingdom, West Germany and France [6] revealed that consultation for climacteric complaints was a universal phenomenon in all six countries which correlated mainly with perimenopausal status. Awareness of the menopause and HRT, and actual use of HRT were predominantly associated with the individual countries. These findings suggest that HRT prescription and use for climacteric complaints depend greatly on country-specific reservations about HRT among both physicians and women. Surprisingly, these appeared more prevalent in the countries where GPs played a predominant role in climacteric counselling.

Postmenopausal hot flushes and their management

Hot flushes are frequently incapacitating to the patient and the severe vasomotor disturbances may seriously impair normal daily life. This review attempts to provide an understanding of the pathophysiology of the hot flush as a basis for rationale therapy for each individual patient. The physiological mechanisms controlling body temperature are discussed briefly, and the changes in the system which precipitate the menopausal hot flush are detailed. The neuroendocrine events leading to the onset of the flushing syndrome are then considered. Finally, the therapeutic strategies which may be used in the management of the affected patient are discussed.

Incidence of hip fractures in Malmö, Sweden (1950-1991)

In a 24-year sub-sample taken from a 42-year period of study (1950-1991), hip fracture incidence was analysed from a defined catchment area within one hospital. During this time, 8,256 hip fractures occurred in a generated risk population of 1,915,571 person-years. Crude incidence increased three-fold in women and five-fold in men. In men, the age-specific increase was twice as large as the age drift. In women, the two components were of equal size. The more marked increase in men caused the female:male ratio to decrease from 4.2 in 1950 to 2.4 in 1991. In men, all age classes experienced a significant yearly increase (1.6% in the 50-59 age group, 3.9% over the age of 80). In women, only the 70-79 and 80+ age groups showed a significant increase (1.4%, 2.3%). In the age-standardised curve, a levelling off occurred during the mid-80s. In women, this was attributable to changes in climate during wintertime. In men, no significant association was found with temperature. The age-standardised curve followed an approximate linear trend with an increase of 6.4/100,000/year in women and 4.9/100,000/year in men. The cumulative rate for the age group 50-79 years doubled in men but increased only by one-third in women. The impact of increasing incidence in men compared with women is discussed using an osteoporosis model consisting of base risk, senile risk, and post-menopausal risk.