Post Reproductive Health

The timing of the menopause transition has remained fairly constant throughout history. It represents a milestone in female health and, after passing through it, women experience increased musculoskeletal and cardiovascular morbidity. Muscle performance is an important determinant of functional capacity and quality of life among the elderly and is also involved in the maintenance of balance. Therefore, good muscle strength can prevent fragility fractures and lessen the burden of osteoporosis. Muscle strength begins to decline during the perimenopausal years and this phenomenon seems to be partly estrogen dependent. Randomized controlled trials have indicated that hormone replacement therapy may prevent a decline in muscle performance, although the exact mechanism of estrogen-dependent sarcopenia remains to be clarified. Exercises have been shown to improve postmenopausal muscle performance and hormone replacement therapy may also potentiate these beneficial effects. Improvement or maintenance of muscle strength alone, however, may not be considered as a primary indication for long-term hormone replacement therapy in view of current knowledge of its risks and benefits. Work history and educational background may be associated with postmenopausal muscle performance, which itself has unique associations with skeletal and cardiovascular diseases.

Older people are major consumers of drugs and because of this, as well as co-morbidity and age-related changes in pharmacokinetics and pharmacodynamics, are at risk of associated adverse drug reactions. While age does not alter drug absorption in a clinically significant way, and age-related changes in volume of drug distribution and protein binding are not of concern in chronic therapy, reduction in hepatic drug clearance is clinically important. Liver blood flow falls by about 35% between young adulthood and old age, and liver size by about 24–35% over the same period. First-pass metabolism of oral drugs avidly cleared by the liver and clearance of capacity-limited hepatically metabolized drugs fall in parallel with the fall in liver size, and clearance of drugs with a high hepatic extraction ratio falls in parallel with the fall in hepatic blood flow. In normal ageing, in general, activity of the cytochrome P450 enzymes is preserved, although a decline in frail older people has been noted, as well as in association with liver disease, cancer, trauma, sepsis, critical illness and renal failure. As the contribution of age, co-morbidity and concurrent drug therapy to altered drug clearance is impossible to predict in an individual older patient, it is wise to start any drug at a low dose and increase this slowly, monitoring carefully for beneficial and adverse effects.

Older people receive home care either by choice or because alternative means of care are not available. The reasons for home care have an economic and cultural component; most of it is provided on a voluntary basis, regardless of the culture of the older person. Good home care, however, should not be left entirely to volunteers, but should be supported by the state through legislation and social policies, especially in the area of primary care and health promotion, as should end-of-life care. By these means some of the negative effects of home care on the recipient and the carer can be reduced.

Several biological changes take place during the menopause transition. The number of oocytes declines progressively from before birth but reaches a critically low level by the time of the menopause. The regular pattern of the menstrual cycle becomes disrupted and the frequency of normal ovulatory cycles declines. Rising gonadotrophin levels, particularly of follicle stimulating hormones (FSH), and declining estrogen levels are thought to characterize the menopausal transition. It now appears that declining levels of inhibin may play an important role in maintaining estrogen levels until just before the menopause, while causing increased levels of gonadotrophins. Wide variations in hormonal profiles between and within individuals occur. The clinical responses to this endocrine instability include vasomotor symptoms, psychological symptoms, sexual dysfunction and irregular menstrual bleeding. Estradiol deficiency induces a rapid phase of increased bone turnover in the early postmenopausal period, which can contribute to osteoporosis later in life. Similarly, changes in lipid profiles, particularly high-density lipoprotein (HDL) and triglycerides, can also occur.

In England and Wales, ovarian cancer is responsible for more deaths than all other gynaecological cancers combined. Unlike cervical cancer, there is no effective population screening programme and the majority of women will present when the disease has spread beyond the ovaries. Current first-line management involves surgical debulking, followed by platinum-based chemotherapy. However, most women will relapse and the five-year survival rate is 20–30%. Novel therapies, based on an increasing understanding of the molecular biology of cancers, are being developed and evaluated in clinical trials.

Sheffield's National Health Service community menopause clinic has run a homeopathy service since 1998. The service provides an alternative treatment option for those women who cannot take hormone replacement therapy, do not want it, have found it ineffective, or have been advised to stop it. Patients receive homeopathic treatment (monthly consultations plus individualized homeopathic medicines) for up to six sessions. An audit was undertaken of all patients referred to this service between 2001 and 2003, in which patients completed the Measure Yourself Medical Outcome Profile. Patients reported significant benefit from the service. The greatest response was seen in those reporting headaches, vasomotor symptoms, emotional/psychological symptoms and tiredness/fatigue as their primary symptoms.

Hormone replacement therapy increases the risk of venous thromboembolism. The risk is already increased in those with a personal or family history of thrombosis and in those with a hereditary thrombophilia. This article gives estimates of the absolute risk of using hormone replacement therapy and practical advice on its use in these groups and on the role of thrombophilia screening.