High-dose testosterone is associated with atherosclerosis in postmenopausal women

OBJECTIVES: To study the long-term effects of androgen treatment on atherosclerosis in postmenopausal women. METHODS: In a population-based study in 513 naturally postmenopausal women aged 54-67 years, we studied the association between self-reported intramuscularly administered high-dose estrogen-testosterone therapy (estradiol- and testosterone esters) and aortic atherosclerosis. Aortic atherosclerosis was diagnosed by radiographic detection of calcified deposits in the abdominal aorta, which have been shown to reflect intima atherosclerosis. Hormone therapy users were compared with never users. RESULTS: Intramuscular hormone therapy use for 1 year or longer was reported by 25 women. In almost half of these women severe atherosclerosis of the aorta was present (n=11), while in women without hormone use severe atherosclerosis of the aorta was present in less than 20% (OR 3.1; 95% CI, 1.1-8.5, adjusted for age, years since menopause, smoking, and body mass index). The association remained after additional adjustment for diabetes, cholesterol level, systolic blood pressure, or alcohol use. No association was found for hormone use less than 1 year. CONCLUSION: Our results suggest that high-dose testosterone therapy may adversely affect atherosclerosis in postmenopausal women and indicate that androgen replacement in these women may not be harmless.     

Menopause characteristics of women with physical disabilities from poliomyelitis

OBJECTIVE: To describe menopause characteristics of women with physical disabilities from poliomyelitis. METHODS: Nine hundred and nine women with a history of poliomyelitis completed a survey on health, physical functioning, emotional well being and menopause. RESULTS: The majority of the sample was postmenopausal having had a natural menopause around the average age of 50.3 years; 34.7% of the sample had had hysterectomies. Thirty-nine percent were using some form of hormone replacement therapy (HRT). Menopause symptoms were clustered into psychological, somatic-sensory, somatic-sleep and vasomotor factors. Among never and past HRT users, there were significant differences in menopause factor severity by menopause status. Somatic/sleep symptoms were lowest in never users; past users had significantly higher vasomotor symptoms; desire for sexual activity and painful intercourse did not vary by HRT use. Compared to population estimates, post-polio women had similar rates of hysterectomies overall, but among some age cohorts they had significantly lower rates, contrary to expectations. However, they used HRT at significantly higher rates than expected. CONCLUSIONS: This study suggests that basic menopause characteristics of women with polio are generally similar to those of their non-disabled peers. There were few substantial differences in severity of menopause symptoms by HRT use, which is critical in light of the dearth of studies examining its risk-benefit ratio among women with physical disabilities. Until such studies provide some evidence of the specific risks or benefits to women with physical disability, each woman should carefully weigh the known risks and benefits with her physician.     

Recency and duration of postmenopausal hormone therapy: effects on bone mineral density and fracture risk in the National Osteoporosis Risk Assessment (NORA) study

OBJECTIVES: Results from the Women's Health Initiative showed that postmenopausal hormone replacement therapy (HRT) prevents fractures but has an overall unfavorable risk:benefit ratio, leading to the recommendation that HRT be used only for women with troublesome menopause symptoms, and for as short a time as possible. This recommendation has important implications for the timing and duration of HRT and the prevention of osteoporosis. The large number of women participating in the National Osteoporosis Risk Assessment (NORA) program provided the opportunity to evaluate bone mineral density (BMD) and 1-year fracture risk in analyses stratified by duration and recency of HRT. DESIGN: Participants were 170,852 postmenopausal women aged 50 to 104, without known osteoporosis, who were recruited from primary physicians offices across the US. BMD was measured at one of four peripheral sites, and the 1-year risk of osteoporotic fracture was assessed by questionnaire. RESULTS: At baseline, current HRT users had the highest T-scores at every age. Among current hormone users, women who had used HRT longest had the highest BMD levels. Women who had stopped HRT more than 5 years previously, regardless of duration of use, had T-scores similar to never-users. Current but not past hormone use at baseline was associated with a 25% to 29% lower risk of osteoporotic fracture (P < 0.0001) in 1 year, compared with nonusers. These findings were independent of age, ethnicity, body mass index, lifestyle, years postmenopausal, and site of BMD measurement. CONCLUSIONS: We conclude that postmenopausal BMD and fracture are closely associated with current, but not prior, HRT use. Use of HRT for 5 years or less, as proposed for treatment of symptomatic women during menopause transition, is unlikely to preserve bone or significantly reduce fracture risk in later years.     

Declining socioeconomic differences in the use of menopausal and postmenopausal hormone therapy in Finland

Objective: Sales figures for the use of menopausal and postmenopausal hormone therapy in Finland show a rapid increase during the 1980s continued into the first half of the 1990s. Hormone therapy use became very common in Finland compared to many other Western countries. The aim of our study was to investigate the sociodemographic distribution of hormone therapy among Finnish women aged 45–64 years. Methods: The study is based on population-based surveys conducted in 1989 and 1996 (response rates 87% and 78%). Results: Between 1989 and 1996 the current use of hormone therapy increased from 22% to 27%; in 1989 it was most common in the age group 50–54 years, but in 1996 among 55–59-year-olds. In 1989 it was significantly more common among women with longer education than other women in every age group, but in 1996 this difference was significant only in those 55 years and older. In 1989 the use was more common in the capital area than elsewhere and this difference decreased but remained significant in 1996. Conclusion: Our results suggest that hormone therapy has become a routine treatment during the menopause in all educational groups and throughout the country. The lack of socioeconomic differences indicates that among women under 55 year of age the saturation point in short-term hormone use was reached in 1996. However, the persistence of socioeconomic differences among older women suggests that the use of long-term postmenopausal hormone therapy will continue to increase for some time.     

Cross-talk about the menopause: enhancing provider-patient interactions about the menopause and hormone therapy

Although many women make the menopause transition without problematic symptoms, the current tendency to prescribe hormone replacement therapy (HRT)² as a preventive measure against potential life-threatening conditions for postmenopausal women has made menopause a medical issue for all women. Informing the millions of women due to experience menopause over the next decades of the possible long-term risks and benefits of HRT presents a major challenge to primary care. Recent research suggests that women are dissatisfied with their interactions with their health-care providers regarding menopause and the options for menopause management. We identify barriers to effective communication between providers and patients about these issues, and make recommendations for both research and practice to facilitate more effective provider-patient interactions concerning menopause and its management.     

Risk perception in women: a focus on menopause

OBJECTIVE: To investigate risk perceptions in relation to menopausal experiences, comparing premenopausal women's expectations to actual experiences of menopause, including perceptions of symptoms, fears, risks of future illnesses, and side effects of symptomatic treatments. DESIGN: This was a cohort study using surveys in a random sample of Australians participating in an Australian Health Report series, supported by Pfizer. This article focuses on perceptions about menopause of 710 women. RESULTS: Peri- and postmenopausal women experienced more fatigue, sleeplessness, fluid retention, and bloating than premenopausal women expected to experience. Perimenopausal and postmenopausal women rated menopause as the "first day of the rest of [my] life" significantly more than premenopausal women. All women perceived that menopause had an impact on aging and weight gain, but more premenopausal women feared loss of sexuality (55%), loss of femininity (39%), and the inability to have more children (37%). Perceptions of illnesses differed from actual incidence, with 27% of all women perceiving breast cancer and 11% perceiving heart disease as a health risk, compared with actual female mortality figures of 3% and 41%, respectively. Perceptions of the effects of hormone therapy were inaccurate, with 53% of all women expecting a reduction in hot flushes, 44% expecting that hormone therapy increased breast cancer, and 23% expecting that hormone therapy decreased fractures. CONCLUSIONS: This study suggests a difference between perceptions of symptoms, fears, risks of future illnesses, and side effects of symptomatic treatments at menopause and actual experience. Because risk perception influences health-related behaviors, visits to healthcare providers, and treatment decisions and can be modified through education, an understanding of risk perception is clinically important. Further research is needed.     

Determinants of self rated menopause status

This study, based on a population survey, examines the self ratings of progress through the menopausal transition of women in natural menopause, women using hormone therapy and women who have undergone hysterectomy. The latter two groups are usually excluded from discussions of menopausal transition, since the accepted menstrually defined criteria do not apply to them. Hysterectomised women do not differ in their self rating profile from non-hysterectomised women, after hormone therapy status is taken into account. This is surprising, since they may have been expected to see themselves as in the main postmenopausal. Use of hormone therapy is tantamount to self perception as at least perimenopausal. Among women in natural menopause there is 29% disagreement between self ratings and menstrually defined categories. On the basis of these observations it is hypothesised that experience of symptoms associated with menopause is important in determining self ratings. The good fit of logistic regression predictions of self ratings from hysterectomy status, hormone therapy status and experience of hot flushes is consistent with this hypothesis. This research indicates that it is important to take women's subjective evaluations into account in assessing progress through the menopausal transition.     

The North American Menopause Society 1998 Menopause Survey. Part I: Postmenopausal women's perceptions about menopause and midlife.

OBJECTIVE: To collect information relevant to the mission of The North American Menopause Society (NAMS)--i.e., increasing understanding of menopause--by assessing perceptions held by postmenopausal women in the United States aged 50 to 65 years regarding their menopause transition and early postmenopausal years. DESIGN: During the period from June to July 1998, The Gallup Organization conducted 752 telephone interviews with a randomly selected sample of postmenopausal women aged 50 to 65 years from across the United States, based on questions developed by NAMS. In Part I of this survey, women were asked about their personal experiences with menopause, their health-related lifestyle changes since premenopause, their frequency of discussing menopause, and their rating of preparedness for menopause. Part II of this survey, including use of hormone replacement therapy as well as use of healthcare services, will be reported in a future communication from NAMS. RESULTS: The majority (51%) of the postmenopausal women surveyed reported being happiest and most fulfilled between the ages of 50 to 65 years, compared with when they were in their 20s (10%), 30s (17%), or 40s (16%). Many areas of their lives had improved since menopause, including family/home life, sense of personal fulfillment, ability to focus on hobbies or other interests, relationship with spouse/partner, and friendships. A majority (51%) said their sexual relationships had remained unchanged. Approximately three-quarters of women surveyed reported making some type of health-related lifestyle change, such as stopping smoking, at menopause/midlife. Women who had undergone hysterectomy expressed more improvement than women with an intact uterus, especially in the areas of sexual relationships, spouse/partner relationships, personal fulfillment, and physical health; data are not available regarding the health state of these women before surgery or whether they experienced surgical menopause, but this improvement did not appear to be the result of hormone replacement therapy. Women tended to look to women from their own generation for menopause-related information and believed that they have prepared the younger generation for menopause better than they were prepared by their mothers' generation. Those surveyed advised younger women to engage in healthful activities and become knowledgeable so that they could make informed health decisions. CONCLUSIONS: Although the postmenopausal women surveyed had differing views of menopause as well as their perceptions of postmenopause compared with premenopause, the majority viewed menopause and midlife as the beginning of many positive changes in their lives and health. Hysterectomy was a factor associated with improved sexual relationships, spouse/partner relationships, sense of personal fulfillment, and physical health.     

Hormone replacement therapy and symptom reporting in menopausal women: a population-based study of 35-65-year-old women in mid-Sweden.

OBJECTIVE: To measure the prevalence rate of hormone replacement therapy (HRT) in the general population and to see whether HRT users report less symptoms, better general health and less use of other palliative than non-users and previous users. METHODS: The study was performed in 1995 as a cross-sectional postal questionnaire study in seven counties in mid-Sweden. The questionnaire was sent to a random sample of 4200 35-64-year-old women of whom 2991 responded. The age distribution of responders and non-responders was similar 49.6+/-8.5 and 49.8+/-8.7 years, respectively. The main outcome measures were vasomotor and general symptoms in relation to menstrual status and HRT. RESULTS: Fifteen percent were on HRT and 2.3% had stopped treatment during the past year. Thirteen percent used other palliatives. Twenty-five percent of premenopausal women experienced any vasomotor symptoms, as compared with 51% of menopausal and 40% of postmenopausal women. Those on HRT reported higher frequencies than non-users of all symptoms except for sweating during the daytime. In addition, menopausal women experienced more of other symptoms, usually not associated with the menopause, than premenopausal and postmenopausal women. HRT users reported a significantly worse perceived health and they took other palliatives drugs to a larger extent than HRT non-users. CONCLUSION: HRT seemed to be effective in relieving some vasomotor symptoms but did not affect the prevalence of other symptoms or perceived health, in spite of the fact that women on HRT supplemented their therapy with palliative drugs to a larger extent than other women.     

Hormone replacement therapy: a study of women's knowledge and attitudes.

Hormone replacement therapy can successfully treat menopausal symptoms. A postal questionnaire was used to investigate the knowledge of and attitudes to hormone replacement therapy of an age-stratified, computer-generated, representative sample of 1500 women living in the Grampian region of Scotland. A response rate of 78% was achieved. Comparisons were made between women of differing age, educational background and their current or past experience of hormone replacement therapy. The questionnaire also assessed their knowledge of osteoporosis, including the possible beneficial role of hormone replacement therapy. The results showed that women had a poor knowledge of the potential risks and benefits of oestrogen, lack of knowledge being greatest in the less educated and older women. The majority of women agreed with the view that because the menopause is brought on by diminished hormone levels, it should be viewed as a medical condition and treated as such, and also that a woman who experiences distressing menopausal symptoms should take hormone replacement therapy. Despite this, relatively few postmenopausal women were currently taking hormone replacement therapy (9%) or had taken the treatment in the past (7%), although many had experienced menopausal symptoms for over six months. The most common reason for postmenopausal women never having taken hormone replacement therapy was that they had never considered the treatment (70%) and had not discussed it with a doctor (79%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Early postmenopausal hormone therapy improves postural balance

OBJECTIVE: Postmenopausal hormone therapy (HT) results in more substantial reductions in the risk of hip fracture when initiated sooner rather than later after menopause. We studied the effects of postmenopausal HT on the postural balance of postmenopausal women, with further assessment according to the time since they achieved menopause. DESIGN: One hundred women with a mean age of 52.5 years (91 evaluable) were randomly and blindly assigned to either a sequential estradiol-norethisterone acetate regimen or placebo for 3 months, after which all participants received open HT for a further 3 months. Postural balance was assessed as sway velocity using a force platform. RESULTS: After 3 months of HT, sway velocity had improved (decreased) from baseline by 7.0% (P = 0.007 vs baseline and P = 0.038 vs placebo). Continued HT for 6 months further improved sway velocity by 12% from baseline (P < 0.0001) to reach values similar to those historically found in younger women or in postmenopausal women after long-term HT. Closer proximity to menopause and more pronounced increases in serum estradiol values were associated with stronger improvements in sway velocity (P = 0.018 for interaction). HT also improved dizziness (P = 0.016 vs baseline and 0.022 vs placebo). (Nonparametric statistics are used throughout, except for analyses of interaction and dizziness.) CONCLUSIONS: Initiation of HT soon after menopause rapidly improved postural balance to levels normally seen in young women. We suggest that improved postural balance can contribute to the protection against fractures associated with HT and explain the more substantial reduction in hip fracture risk after HT initiated sooner, compared with later, after menopause. Further study is required to confirm these results.     

Does osteopenia warrant treatment?

The progressive loss of bone mass that leads to osteoporosis in postmenopausal women is known to result in substantial morbidity and mortality. Underdiagnosed and undertreated, osteoporosis jeopardizes the health of an estimated 8 million American women 50 years of age or older who are at high risk for hip, vertebral, and other fractures. Because osteopenia is generally a subclinical condition that results in a lower fracture rate than osteoporosis, its potential impact is more difficult to recognize, although it is nearly three times more prevalent than osteoporosis. The question arises as to whether osteopenia should be diagnosed and treated before it transitions into osteoporosis. Because the number of postmenopausal women is projected to increase substantially in the near future and the number of postmenopausal women who will or who have discontinued their use of hormone therapy has increased sharply, the consequences of failing to identify and treat women at increased fracture risk are considerable. Moreover, the rate of bone loss in the first year after discontinuation of hormone therapy is especially rapid and similar to the rate that occurs early after menopause. Accordingly, fracture risk is substantially increased at this time in relation to the magnitude of bone loss. The goal of nonpharmacologic and pharmacologic therapy is to prevent the first fracture in any woman at risk for fracture. Initiation of antiresorptive therapy known to provide rapid efficacy can be particularly important in achieving the treatment goal in appropriate osteopenic women.     

WHI risks: Any relevance to menopause management?

Two randomised controlled trials of hormone therapy (HT) were conducted within the US Women's Health Initiative. Both were chronic disease prevention trials, undertaken to determine whether HT reduced cardiovascular risk and increased breast cancer risk. Because the majority of subjects in both trials were asymptomatic and many years postmenopausal, and because substantial numbers had received HT prior to recruitment to the trials, care must be taken in drawing conclusions that the observed risks are applicable to women for whom HT is conventionally prescribed. Each of the reported risks must be examined critically to determine its likely applicability to symptomatic women treated for two to three years to relieve symptoms, but sometimes for substantially longer periods. Further, the risks reported in each of the two trials must be considered separately. Concerning cardiovascular disease, many subjects in the trials were at increased baseline risk because of their age, body mass index, smoking status, blood pressure and years since menopause, in contrast to the usual situation for symptomatic perimenopausal women. Therefore the reported overall cardiovascular risks in WHI, in both treatment arms, should be regarded as irrelevant to menopause management. In contrast, breast cancer risk is relevant, providing that proper note is taken of the fact that there was no increased risk after five years of combined hormone therapy in non-prior HT users and there was a tendency to a decreased risk in oestrogen only treated individuals. Other risks are analysed similarly.     

The prevalence of symptoms possibly related to the climacteric in pre- and postmenopausal women in Linköping,Sweden

BACKGROUND: Some extragenital symptoms have been suggested to be associated with the menopause and thus to be affected by estrogen status. In such case extragenital symptoms may be more frequent in postmenopausal women without hormone replacement therapy (HRT) than in premenopausal women or women using HRT. OBJECTIVE: To assess if the prevalence of a number of extragenital symptoms is higher in postmenopausal women without than with HRT, or in premenopausal women of the same age. MATERIAL AND METHODS: All women aged 53 and 54 years in the community of Link?ping (n=1760) were sent a validated questionnaire about use of HRT, time since last menstruation and about different extragenital symptoms. RESULTS: 1298 (73.8%) women answered the questionnaire and answers from 1180 (67%) women were possible to analyze. Postmenopausal women woke up significantly more often during night than premenopausal, and those without HRT often due to hot flushes and sweating. Women with HRT reported more muscular pain than the others. We found no other significant difference in prevalence of extragenital symptoms between the three groups of women. CONCLUSIONS: Sleeping disorders, arthralgia, xerophthalmia, xerostomia and dry skin are not more prevalent in 53 and 54 years old postmenopausal women without HRT than in women with HRT or in premenopausal women of the same age. It may still be that some of these symptoms are related to estrogen deficiency, but do not develop until some years after menopause. It may also be that women with the most severe symptoms decided to use HRT and thereby decreased symptoms to the same level as in non-users.     

Urogenital symptoms of postmenopausal women in Turkey

OBJECTIVE: The objective of this study was to collect data on the prevalence and risk factors of urogenital symptoms in postmenopausal women in Turkey. DESIGN: The study was performed with the participation of 510 postmenopausal women who presented to previously defined clinics for reasons other than urogenital complaints. Women completed a questionnaire including questions about their demographic properties and their urogenital symptoms. Data were analyzed by SPSS 10.0. The chi-square test was the statistical test of choice. RESULTS: The mean age of participants was 58.64 +/- 8.14 years. The mean age of menopause was 47.21 +/- 4.36 years. Urinary frequency was found to be the most common postmenopausal urogenital symptom (16.5%), followed by stress incontinence (10.4%), dyspareunia (10%), and vaginal dryness (9.6%). Risk factors investigated were found not to affect the prevalence of the vaginal symptoms in postmenopausal women. Dysuria was found to be more common in women with diabetes mellitus (P = 0.022) and in women who had given birth to more children (P = 0.018). Stress incontinence was more common in those 60 years of age or older (P = 0.03), in those who had been in the postmenopausal period for more than 20 years (P = 0.01), and in those who had more than three pregnancies (P = 0.047) or who had given birth to more than three children (P = 0.011). Diabetes mellitus (P = 0.001) and use of hormone therapy (P = 0.001) significantly increased the prevalence of urinary frequency. CONCLUSIONS: Urogenital symptoms observed in our population were found to be fewer than reported previously. Symptoms that appear in the postmenopausal period may be related to several factors such as age, number of births, time elapsed since menopause, presence of diabetes mellitus, and use of hormone therapy, but this topic requires further study.     

Attitudes towards the menopause and hormone therapy over the turn of the century

Objective

To assess attitudes and beliefs about the menopausal transition in a population of peri- and postmenopausal women, and if these attitudes differed before and after publication of studies on risks and benefits with hormone therapy (HT).

Materials and methods

In 1999 and 2003 all women aged 53 and 54 years in the community of Linköping, Sweden, were sent a questionnaire about use of HT, menopausal status and attitudes regarding menopause and HT.

Results

Most women regarded menopause as a natural process characterized by both hormonal deficiency and aging and these views did not differ between 1999 and 2003. A majority of women thought that significant climacteric symptoms were a good reason to use HT, but not that women without symptoms should use HT. The fraction of women who supported HT use was, however, significantly lower in 2003 than in 1999. Most women agreed that menopause leads to increased freedom and that it is a relief not to have to think about contraception and pregnancies.

Conclusions

Most Swedish women had a mainly biological view on menopause but nevertheless they thought that only women with climacteric symptoms should use HT. Women's attitudes towards HT have changed after recent reports on risks from long-term use of HT whereas the attitudes towards the menopausal transition were stable. Other factors than attitudes towards menopause affect women's actual use of HT. Probably women's and health care provider's apprehension of the risk-benefit balance of HT use is one such factor.     

Postmenopausal hormone therapy: new questions and the case for new clinical trials

Observational studies suggest that postmenopausal hormone therapy (HT) prevents coronary heart disease, whereas randomized clinical trials have not confirmed a cardioprotective effect. Although observational studies may have overestimated the coronary benefit conferred by postmenopausal hormone use, there are other plausible explanations for the apparent discrepancy between previous results and the less favorable findings from clinical trials such as the large Women's Health Initiative. There is now a critical mass of data to support the hypothesis that age or time since menopause may importantly influence the benefit-risk ratio associated with HT, especially with respect to cardiovascular outcomes, and that the method of administration, dose, and formulation of exogenous hormones may also be relevant. Although the weight of the evidence indicates that older women and those with subclinical or overt coronary heart disease should not take HT, estrogen remains the most effective treatment currently available for vasomotor symptoms, and its effects on the development of coronary disease in newly postmenopausal women remain unclear. Moreover, effects of HT on quality of life and cognitive function in recently postmenopausal women merit further study. These unresolved clinical issues provide the rationale for the design of the Kronos Early Estrogen Prevention Study, a 5-year randomized trial that will evaluate the effectiveness of low-dose oral estrogen and transdermal estradiol in preventing progression of atherosclerosis in recently postmenopausal women.     

Hormone therapy and sleep quality in women around menopause

OBJECTIVE: To obtain data on sleep quality in women attending menopause clinics in Italy. DESIGN: A cross-sectional study was conducted on the sleep quality of postmenopausal women attending a network of first-level outpatient menopause clinics in Italy for general counseling about menopause or treatment of its symptoms. Eligible for the study were women observed consecutively during the study period with natural or spontaneous menopause.All participating centers enrolled women into the study who had never used hormone therapy (HT) (group 1, 819 women), current users of transdermal estrogens with or without progestins (group 2, 819 women), and current users of oral estrogens with or without progestins (group 3, 790 women). The women were asked about their quality of sleep using the Basic Nordic Sleep Questionnaire, their quality of life using the Short Form-12 questionnaire, and the intensity of hot flushes using a visual analogue scale. RESULTS: Women in groups 2 and 3 tended to report difficulties in sleeping less often than those in group 1. For example, never users of HT more frequently reported sleeping poorly and needed more time to sleep or had problems falling asleep; these differences were significant (P < 0.05). Otherwise, no difference emerged from the Basic Nordic Sleep Questionnaire between women in groups 2 and 3. CONCLUSIONS: This study gives support to the suggestion that HT improves the quality of sleep. The effect was similar in women taking oral or transdermal therapy with or without progestins.