Post Reproductive Health

The role of diet in cancer is a major public health issue Foods associated with a low risk of cancer are those typically included in the so-called Mediterranean diet, which is also associated with low mortality rates from cardiovascular disease. Implementing such a diet would involve increasing the consumption of fruits, vegetables, cereals, whole-grain foods and fish, while reducing the intake of refined carbohydrates and red meat. In addition, olive oil should replace saturated fats. Omega-3 fatty acids found in fish inhibit the growth in vitro of colon, breast and prostate cancers. Fibre can bind bile acids, which produce carcinogenic metabolites, and fermented fibre produces volatile fatty acids that can protect against colon cancer. It has been hypothesized that the anti-cancer actions of olive oil may relate to the ability of its mono-unsaturated fatty acid, oleic acid, to regulate oncogenes.

Polycystic ovary syndrome (PCOS) is a common syndrome among young women. It is associated with fertility problems, clinical manifestations of hyperandrogenism and metabolic disturbance, particularly insulin resistance. The long-term consequences of PCOS have not been fully determined, but there is an increased risk of progression to diabetes and an increase in cardiovascular risk factors. The extent to which PCOS is present in postmenopausal women and the degree to which it increases various risk factors in addition to the known risk of the postmenopausal period are not yet known. This paper reviews the pathophysiology of PCOS and its long-term consequences and considers the evidence to date that is applicable to the postmenopausal woman.

Sexual problems such as dyspareunia and decreased sexual desire are common after the menopause. Hypoactive sexual desire disorder is the diagnostic category applied to many women with loss or lack of sexual interest or desire. The principal components of assessment for sexual dysfunction in menopausal women are: a general, gynaecological, obstetric, psychiatric, psychosexual and relationship history; use of self-report questionnaires; physical examination; and hormonal evaluation. The use of low-dose vaginal estrogen tablets, rings, creams or pessaries may help to improve local genital response but does not necessarily improve sexual interest or motivation. An improvement in sexual function has been reported with tibolone and a combination of estrogen and androgen therapy, al though it remains unclear which groups of postmenopausal women with sexual problems will benefit most from such treatments. Where there is no response to estrogens or where there is premature or surgical menopause the addition of an androgen may be necessary, particularly if the free testosterone levels are low.

Hysterectomy is one of the most common major gynaecological operations performed in the UK and the USA. Its impact on sexual function is a major cause of preoperative anxiety. Unfortunately, this anxiety is seldom articulated by patients, nor recognized and discussed by clinicians. Reports about the impact of hysterectomy on sexual function have been conflicting, partly due to the use of different and often unsatisfactory parameters to assess sexual function. The aim of this review is to assess the current evidence about the effect of hysterectomy on sexual function. Female sexual function is governed by psychological, social and physiological factors. A new model of 'the sexual response cycle', comprising physical, emotional and cognitive feedback, helps explain the sexual difficulties that arise before and after hysterectomy. Evidence is lacking for sexual dysfunction caused by the disruption of local nerve and blood supply, or by changing anatomical relationships. Removal of the ovaries at hysterectomy is associated with no change or even an improvement in sexual function, particularly in women on hormone replacement therapy. Thus, overall, hysterectomy improves sexual function, regardless of surgical method or removal of the cervix. This is probably due to the amelioration of the symptoms that have previously had a negative effect on sexual function.

This review considers the advantages that both standardization and automation of cognitive function testing can bring to clinical research. It reviews progress made in several fields of medicine with a standardized and automated cognitive function assessment system which has been in use in worldwide clinical trials for over 20 years. Data are presented showing the effects on cognitive function of both normal ageing and a variety of diseases. The utility of cognitive testing in the identification and classification of dementia is considered, and its ability to further our understanding of the cognitive sequelae of stroke is discussed. The correlation between assessments of cognitive function and patients' ability to undertake the activities of daily living is evaluated. Finally, the use of such techniques to identify beneficial effects of treatment in various conditions is described. The review concludes that standardization and automation of cognitive function testing have facilitated progress in a number of fields, and that the systematic application of such a technique in menopause research would greatly help advance our knowledge in this field.

The objective of this systematic review was to determine the effect on long-term health outcomes of lifestyle interventions designed to produce weight loss in postmenopausal women. A systematic search of the MEDLINE, EMBASE, PsychINFO and CINAHL databases retrieved four randomized controlled trials (RCTs) and one controlled clinical trial (CCT) of at least 24 weeks' duration as well as one systematic review. The majority of the studies recruited from the community, had samples with similar baseline characteristics and assessed completers only. Drop-out rates varied from 2.5% to 16%. All active-treatment arms demonstrated significant improvements in weight and body composition from baseline. Significant effects between treatment groups were shown only in intervention versus control studies. Significant weight loss was not accompanied by beneficial changes in cardiovascular risk factors in the majority of studies. None of the studies of weight loss reported disease outcomes. Weight loss in active-treatment arms varied from 1.5 kg to 9 kg over 6–12 months. The study that produced the greatest weight loss demonstrated improvements in risk factors and it may be that only this one study produced sufficient weight loss to do so. Many of the studies were probably underpowered and too short in duration to detect change in risk factors. Lifestyle interventions do produce weight loss in overweight postmenopausal women and have the potential to improve disease outcomes associated with overweight.

Over-expression of the human epidermal growth factor receptor 2 (HER2) protein, amplification of the HER2 gene or both occur in 15–25% of breast cancers and are associated with aggressive tumour behaviour. Trastuzumab (Herceptin), a humanized murine monoclonal antibody against the HER2 protein, has been shown to benefit patients with HER2-positive metastatic breast cancer when administered alone or in combination with chemotherapy. When to start therapy, the duration of treatment, adjuvant chemotherapy regimens and cardiotoxicity issues are examined.

Perimenopausal depression affects a considerable number of women and is associated with significant disability and morbidity. Major and minor depressions are the two most prevalent forms of acute depressive illness. Major depression has an estimated lifetime prevalence of 17% and affects approximately twice as many women as men. While the relationship between the onset of depressive illness and reproductive senescence is controversial, epidemiological and clinic-based studies that have distinguished between the perimenopause and the postmenopause have documented that, for some middle-aged women, the perimenopause is associated with an increased vulnerability to depression. Future studies of perimenopausal depression should identify the number of women affected, individual risk factors and the role of hormonal therapies in this condition.

Mammographic density refers to radiologically dense breast tissue, and reflects variations in the tissue composition of the breast. It is positively associated with collagen and epithelial and non-epithelial cells, and negatively associated with fat. There is extensive evidence that mammographic density is a risk factor for breast cancer, independent of other risk factors, and is associated with large relative and attributable risks for the disease. The epidemiology of mammographic density, notably the inverse association with age, is consistent with it being a marker of susceptibility to breast cancer. Cumulative exposure to mammographic density may be an important determinant of the age-specific incidence of breast cancer in the population. All risk factors for breast cancer must ultimately exert their influence by an effect on the breast, and these findings suggest that, for at least some risk factors, this influence includes an effect on the number of cells and the quantity of collagen in the breast, which is reflected in differences in mammographic density. Many of the genetic and environmental factors that influence the risk of breast cancer affect the proliferative activity and quantity of stromal and epithelial tissue in the breast, and these effects are reflected in differences in mammographic density among women of the same age. Some of these influences include endogenous and exogenous hormones, and the menopause. A better understanding of the factors that influence the response of breast tissue to these hormonal exposures may lead to an improved understanding of the aetiology of mammographic density and of breast cancer.