Post Reproductive Health

Healthy mental ageing may be defined as the absence of the common disabling mental health problems of older people, especially cognitive decline and depression, accompanied by the perception of a positive quality of life. Older people are particularly prone to negative effects on mental health due to poor physical health. Modifiable aspects of lifestyle have been shown to be associated with healthy mental ageing. These include increased physical activity, intellectual stimulation (including education), avoidance of smoking and various aspects of diet. There is reasonably strong evidence that the treatment of hypertension will decrease the risk of cognitive impairment, and moderate alcohol intake may also have some benefits on cognition. These modifiable lifestyle factors may benefit from deliberate individual and population health promotion strategies to maximize mental health in old age, although to date intervention trials have not been performed to support the evidence obtained from observational studies.

Adjuvant hormonal therapy results in substantial improvements in disease-free and overall survival for women with operable breast cancer. Use of an aromatase inhibitor (AI) is expected to replace tamoxifen as standard care for many patients. Aromatase is the enzyme responsible for the final step in estrogen biosynthesis. This is the conversion of the androgens testosterone and androstenedione to the estrogens estrone and estradiol. AIs are potent inhibitors of estrogen production and thus one of the major concerns over their use is their effect on bone health and their potential to increase the incidence of osteoporosis and risk of fracture. The American Society of Clinical Oncology has recognized that these patients are at high risk of developing osteoporosis and has published guidelines to aid in their management. These recommend that all patients have an initial dual-energy X-ray absorptiometry (DEXA) bone scan to assess bone mineral density and are offered calcium and vitamin D supplements as well as lifestyle advice. Patients with osteoporosis should be treated with a bisphosphonate to reduce the incidence of fracture. Osteonecrosis of the jaws is a recently described adverse side-effect of bisphosphonate therapy and has been described in women with metastatic breast cancer. Oversuppression of bone turnover is probably the primary mechanism for the development of this condition. The degree of risk for osteonecrosis with bisphosphonates is uncertain and warrants careful monitoring.

The prevalence of migraine peaks during the 40s and an increased association between migraine and menstruation is often noted. Migraine generally improves after the menopause. Although menstrual irregularity, hot flushes and other climacteric symptoms may warrant management with hormone replacement therapy (HRT), there has been some concern that HRT may aggravate migraine and potentially increase the risk of ischaemic stroke. This evidence-based review concludes that migraine is not a contraindication for HRT but continuous-release transdermal estrogen, in the lowest effective dose, is recommended.

Urinary incontinence is a common but under-reported condition. Approximately 17% of women are affected by detrusor overactivity at some time in their lives. Pharmacological treatment of this condition used to be severely limited by the side-effects of the drugs and the associated poor patient compliance. Recently, however, the tolerability and effectiveness of pharmacotherapy have been improved by the introduction of new drugs and alternative methods of drug delivery. This review assesses the effectiveness and tolerability of these new treatments. Anticholinergic agents, botulinum toxin and neuromodulation are also discussed.

Objective: To assess the safety and health-related quality of life (HRQOL) of continuous combined hormone replacement therapy (ccHRT) with estradiol valerate/medroxyprogesterone acetate (E₂V/MPA) over nine years and at follow-up one year after discontinuation.

Study design: A total of 419 women were randomized to one of four treatments: once-daily 1 mg E₂V/2.5 mg MPA (1 + 2.5 group); 1 mg E₂V/5 mg MPA daily (1 + 5 group); 2 mg E₂V/2.5 mg MPA daily (2 + 2.5 group); 2 mg E₂V/5 mg MPA daily (2 + 5 group) (Indivina, Orion Pharma). For the last six months, all received the 1 + 2.5 dosage. The 2 + 2.5 dosage was discontinued at the end of year 7. A total of 198 women continued after year 7.

Results: Annualized percentage rates for cardiovascular, stroke, breast and endometrial cancer events were below national rates for Finland and those reported for the Women's Health Initiative. There were no serious events with the 1 + 2.5 dosage or after ccHRT discontinuation. Climacteric symptoms remained significantly below baseline values after dosage reduction; some symptoms recurred after discontinuation of ccHRT. HRQOL ratings improved with ccHRT, irrespective of dosage, including depressed mood, anxiety, health perception and sexual interest. Scores on a scale assessing daily functioning and enjoyment (Q-LES-Q) improved from year 7 to year 9. They deteriorated during follow-up in women not continuing ccHRT.

Conclusions: Lower dosages of HRT were as effective as higher doses in improving climacteric symptoms and HRQOL ratings and had fewer safety concerns. Following discontinuation of ccHRT, patient satisfaction was variable, with 15% electing to continue or restart HRT and 7% resuming at follow-up. This supports the need for an individualized approach to therapy recommendations.

Exercise has many benefits throughout life but in later life in particular it will protect against cardiovascular disease, obesity, diabetes and cancer, and preserve musculoskeletal health and psychological wellbeing. Women as they get older are at increasing risk of osteoporosis and the aim of exercise is to slow these skeletal changes. The early postmenopausal years in particular are associated with a rapid loss of bone mass, together with a loss of aerobic fitness and muscle strength. Therefore an evidence-based exercise regime to protect against these problems is essential, so that the exercise is of the appropriate quantity, duration and intensity for the required outcome.