Post Reproductive Health

The ageing population of the world presents major challenges for society and for health services. Mental health issues are extremely important, as mental disorders, notably dementia and depression, are common in old age. Mental ill health can profoundly affect the quality of people's old age and has a significant impact upon the use of health and social services. In this paper, we examine these problems from the point of view of older people as consumers, and discuss the role of health promotion, primary care, social services and specialist mental health services for older people. Certain groups within the population, including women, people from minority ethnic backgrounds, very old people, people with learning disabilities, and gay and lesbian older people face some particular issues, which are briefly discussed. Although this paper takes a mainly UK perspective, the mental health of older people is a huge global public health issue. Good epidemiology is central to understanding the needs of ageing populations and responding to them appropriately. Further research is needed in other areas, especially as to which service interventions are effective and efficient.

Chemicals known to disrupt the endocrine system of animal models are assessed for their potential impact on the health of menopausal and postmenopausal women. These "endocrine disrupters" consist of two groups of compounds – man-made and naturally occurring. There is some evidence to suggest that the naturally occurring phytoestrogens, derived from plant material, may have some beneficial effects on menopausal symptoms and the risk of breast cancer, cardiovascular disease and osteoporosis. Further studies are required to confirm these possibilities. Some man-made environmental pollutants appear to increase the risk of breast cancer, although again the evidence is inconclusive. Mechanistic experiments indicate that these chemicals interact with oestrogen receptors and alter metabolism in a number of different ways, some of which may be important in postmenopausal women. Further investigation of the differences in mode of action between the manmade and the natural endocrine disrupters may lead to important insights into their effects on women's health.

Toxicity of chemicals and environmental pollutants may be expressed differently in women than in men. Until recently, most research involved men. With the initiation of studies on the effects of environmental pollutants in women, there is increasing evidence of effects at specific periods in a woman's life; however, accrual of data is slow. This review focuses on the kinetics and effects of the toxic metals lead and cadmium related to menopause. Data on other metals are extremely limited. One of the few well described examples of menopausal-related effects of metals is the very painful disease called Itai-itai, which is a combination of osteoporosis, osteomalacia and renal damage caused by consumption of cadmium-polluted rice. Recent data demonstrate mild effects of cadmium on both kidney and bone with present environmental exposure levels. Women may be at greater risk than men, because of increased gastrointestinal uptake of cadmium at low iron stores, which is common in women of childbearing age. Thus, improvement of iron status, which often occurs at menopause, has a positive effect on cadmium exposure in the sense that its absorption decreases. Cadmium accumulates in the kidney with a half-life of 10-30 years. The health effects appear around menopause, concurrent with the peak in renal cadmium concentrations. About 90% of body lead is localised to bone. There is a significant release of bone lead after the menopause, in association with the acceleration of bone resorption. Thus, postmenopausal women may be at increased risk of adverse effects of lead.

There is now substantial evidence from randomised controlled trials that testosterone therapy will improve sexual satisfaction and mood in surgically menopausal women treated with concurrent oestrogen, with less data in naturally menopausal women and premenopausal women. However, long-term safety data for combined-oestrogen testosterone therapy are lacking, and the effects of testosterone-only therapy in postmenopausal women are unknown. Although there appears to be considerable potential for testosterone to improve the quality of life for selected women, inappropriate and/or excessive use of testosterone carries the risk of masculinisation and possibly more serious side effects. All women treated with testosterone need to be carefully monitored both biochemically and clinically and should have long term follow up for adverse sequelae.

Physical activity leads to a 30-50 % reduction in cardiovascular disease in women. Moderate activities such as walking, gardening or light sports appear to have beneficial effects. Additional exercise training may enhance these effects. Moderate-intensity activities constitute a key recommendation for primary prevention. Vigorous intensity activity may render additional benefits. Recent recommendations suggest an increase to at least 60 minutes of cumulative daily physical activity. Practical recommendations for the prevention of osteoporosis are less clear. There is a relative abundance of randomised controlled trials assessing bone mineral density at various sites. Meta-analyses of these studies indicate a beneficial health effect of physical activity on prevention of bone loss. However, the effects seen appear to be relatively small. Two recent end-point studies examining hip and fragility fractures show stronger evidence for the protective potential of physical activity in bone health. Exercise throughout life, particularly weight-bearing, is assumed to be beneficial for bone health. Older people at risk of falling are advised to participate in tailored exercise programmes to improve strength and balance, since physical training might contribute to fracture prophylaxis by increasing mobility and general activity of ageing people. Beyond the promotion of regular physical activity, primary disease prevention requires the adoption of healthy life habits including dietary patterns, weight control, and avoiding smoking. In the light of the failure of postmenopausal hormone use to protect against heart disease, rethinking the role of exercise in maintaining postmenopausal health is of increasing importance.

There are now a number of effective treatments for osteoporosis, which increase bone mineral density (BMD) and decrease the risk of fractures. There is no clear consensus on the optimal method for assessing response to treatment in the individual patient. The goal of osteoporosis treatment is to prevent fractures after minimal trauma, but these are relatively uncommon events and cannot be totally avoided by the use of currently available therapies. Alternative methods of assessing response to treatment include serial measurement of BMD or the biochemical markers of bone turnover, but the observed changes may be misleading if they do not exceed the least significant change. The proportion of patients who fail to respond to osteoporosis treatments is difficult to quantify. Clinical trials show continuing bone loss in up to 15% of participants on hormone replacement therapy or bisphosphonates. Non-response to treatment is probably more common in clinical practice, but may be due to poor adherence to treatment recommendations. Other potential causes of an apparent failure to respond to treatment include the use of a weak antiresorptive agent, differences in bioavailability, low dietary calcium intake, vitamin D insufficiency and underlying causes of secondary osteoporosis. The management of patients who fail to respond to treatment includes confirmation that they are adhering to treatment and have an adequate dietary calcium intake and vitamin D status and excluding causes of secondary osteoporosis. Consideration should also be given to the addition of calcium and vitamin D supplementation and the use of alternative treatments for osteoporosis.