Post Reproductive Health

In the future there will be more people aged 65 years and over ('older adults'). Although the exact mechanisms underlying normal ageing are not fully understood, ageing is generally associated with an increase in chronic diseases, such as cardiovascular disease, diabetes, cancer and osteoporosis. It is becoming clear that it is possible to prevent, slow or reverse the onset of many these by modifying lifestyle factors such as diet. Studies of older adults in a range of countries have highlighted a number of areas in which dietary quality could be improved. It is important to identify dietary patterns in addition to specific dietary components that offer protection against chronic disease. The challenge in the area of diet and healthy ageing is twofold: first, there is a need to improve the diet of older adults; and second, as most chronic diseases begin earlier in life, there is a need to encourage other age groups to adapt their diet so they can enter old age in better health.

Female fertility rates are inherently linked to a woman's age, which is in turn related to ovarian function. Reproductive potential declines gradually until 37–38 years of age, from when the rate of decline hastens. Approximately 1% of women suffer from premature ovarian ageing, and many may not have completed their families. This paper reviews the physiology and fertility consequences of ovarian ageing, premature ovarian failure, measures of ovarian reserve and methods of fertility preservation.

Interstitial cystitis (IC) is a chronic inflammatory disorder of the bladder that is notoriously difficult to manage and can result in considerable morbidity. It very likely overlaps with painful bladder syndrome, but they are different conditions. The aetiology remains obscure, and the definition and diagnostic criteria are debated. The diagnosis of IC is one of exclusion, frequently based on symptoms and cystoscopy findings. Typical symptoms include frequency, urgency, dysuria and lower abdominal, bladder, vaginal, urethral or perineal pain, in the absence of bacterial cystitis. Voiding often relieves the suprapubic discomfort, and drinking alcohol- and caffeine-containing drinks frequently exacerbates it. Many treatments have been tried, with little sustained success. Proposed systemic treatments include anti-histamines, heparin, amitriptyline and pentosan polysulfate (a synthetic analogue of glycosaminoglycan which augments the mucous protective layer of the bladder). In many patients symptoms are improved following cysto-distension but the benefits are short-lived. Instillations of dimethyl sulfoxide, hyaluronic acid or chondroitin also show promise. Where treatments have failed and symptom severity is such that the patient's quality of life is poor, a urological opinion should be sought and reconstructive surgery considered. Available options include partial cystectomy, augmentation cystoplasty, and urinary diversion with or without cystectomy.

Breast cancer is the most common female malignancy in the UK, with an overall lifetime risk of 1 in 9. Despite the high incidence, breast cancer mortality is decreasing. Approximately 40,000 women were diagnosed with breast cancer in England and Wales in 2000 but the majority will have normal or near-normal life expectancy. One of the main contributory factors to this marked improvement in survival over the last 20 years in women of all ages has been the more widespread use of systemic therapy in early-stage disease. For women with hormone-sensitive cancer, this involves adjuvant endocrine therapy that reduces estrogen synthesis (i.e. ovarian suppression in premenopausal women or aromatase inhibitors in postmenopausal women) or estrogen activity (the anti-estrogen tamoxifen, irrespective of menopausal status). Many women experience health and quality-of-life problems related to estrogen deficiency as a result, the commonest being vasomotor symptoms and vaginal dryness. This article summarizes and interprets key recent papers on the use of hormone replacement therapy (HRT) and selective serotonin reuptake inhibitors in breast cancer survivors. HRT may be safe in women with receptor-negative disease or receptor-positive cancers in the presence of tamoxifen. However, there is a dearth of useful alternatives.

Objective: To examine quality of life after a decade of continuous combined hormone replacement therapy.

Study design: The 15D, a generic health-related quality-of-life (HRQoL) instrument, was used to evaluate trends in HRQoL in women who used continuous combined hormone replacement therapy (ccHRT; Indivina^®, Orion Pharma, Finland) for up to nine years. These women had a mean age of 56 years of age at the start of therapy. Control data on HRQoL were obtained from age-matched women participating in Finnish population health surveys.

Results: Relative to controls, ccHRT was associated with significantly better HRQoL after six and nine years of treatment. Dose minimization at 8.5 years was not associated with a decline in HRQoL in the ensuing six months. One year after discontinuation of ccHRT there was evidence of a decline in HRQoL in women who discontinued ccHRT as planned, whereas HRQoL was maintained in women who had continued or resumed ccHRT during the one-year post-study follow-up. The benefits of ccHRT were apparent in multiple dimensions of the 15D, being largest and most robustly reproduced in the dimension 'discomfort and symptoms'. It is conjectured that the effectiveness of ccHRT in relieving symptoms of menopause may have contributed to the improved HRQoL scores registered in other dimensions, in addition to any direct effects of ccHRT on specific aspects of those other dimensions.

Conclusions: These data indicate that up to 10 years of low-dose ccHRT has sustained value in the enhancement of HRQoL when used by women for whom relief of symptoms of menopause and control of bleeding are primary objectives of treatment.

The British Menopause Society Council aims to help health professionals inform and advise women about the menopause. This guidance regarding estrogen-based hormone replacement therapy (HRT), including tibolone, which is classified in the British National Formulary as HRT, responds to the results and analysis of the randomized Women's Health Initiative studies and the observational Million Women Study. Treatment choice should be based on up-to-date information and targeted to individual women's needs. HRT still offers the potential for benefit to outweigh harm, providing the appropriate regimen has been instigated in terms of dose, route and combination.

Urinary incontinence is a major clinical problem and a significant cause of disability and dependency in older adults. Overall, the prevalence of urinary incontinence approaches 55% among women aged over 55 years. The past few years have seen significant advances in the pharmacotherapy of overactive bladder and stress incontinence. The review examines the evidence regarding their benefits and side-effects.

Observational studies and randomized clinical trials that have looked at the effect of hormone replacement therapy (HRT) on the risk of colorectal cancer are reviewed. Nine cohort studies in this area have included a total of over 2700 cases of colorectal cancer. Most of these studies found a relative risk (RR) of around or below unity. Of 15 case–control studies, with a total of over 7300 cases, six reported a 20–40% risk reduction among women who had ever used HRT. With reference to randomized clinical trials, in the Women's Health Initiative (WHI) study, after seven years of follow-up, 45 cases of colorectal cancer were observed in the combined HRT group versus 67 in the placebo group, corresponding to a RR of 0.63. A combined reanalysis of data from both the WHI and the Heart and Estrogen Progestin Replacement Study (HERS) included 56 cases in the com bined HRT group and 83 cases in the placebo group (pooled RR = 0.64). However, in the WHI study cancers diagnosed in the HRT group were more advanced and there were more positive lymph nodes. Furthermore, among women in the WHI who had had a hysterectomy, there was no difference at the eight-year follow-up in the incidence of colorectal cancer between those in the estrogen-only arm of the trial (n = 61) and those in the control group (n = 68).