Post Reproductive Health

Mortality rates for colorectal cancer in many developed countries have declined in women more than in men. Possible explanations of the sex differentials in colorectal cancer mainly, but not only, refer to different exposure to exogenous hormones. This paper aims to review the available epidemiological evidence on this issue. Seven cohort studies reported information on HRT use and colorectal cancer risk, with relative risks (RRs) around or below unity, and significant inverse association was found in two of them. Of 12 case-control studies, five reported significant risk reductions among ever-users of HRT, while two investigations showed moderate, non-significant inverse associations and none showed a significant increased risk. Two recent meta-analysis showed a 20% reduction in the risk of colon cancer among current users. Overall, the studies reviewed support the existence of an inverse association between colorectal cancer and HRT. Although these epidemiological observations are consistent, surveillance bias may account for part of the association.

Over the past 20 years there has been a revolution in the management of the menopause and the use of hormone replacement therapy (HRT). As the focus on postmenopausal health changes from symptomatic relief to the protective benefits of long-term HRT both ophthalmologists and gynaecologists can expect questions to be asked by their female patients about the influence of HRT on ophthalmic disease. This paper is a review of the current best evidence of effects of HRT on the eye. As oestrogens exert significant influences on the structure and function of ocular structures, we can assume that a reduction in oestrogen levels will have a negative effect on ocular physiology and may play a role in pathological processes in the eye. There is no evidence that HRT is harmful to ocular tissues; case reports point to a beneficial effect of HRT in relation to dry-eye, cataract and macular degeneration in post menopausal women. HRT probably suppresses the formation of cataracts in postmenopausal women and may reduce the incidence of serious retinal disease.

Endometriosis is an oestrogen sensitive condition, leading to reluctance to prescribe hormone replacement therapy. Treatment of endometriosis either medically with gonadotrophin releasing hormone analogues or with surgery involving bilateral oophorectomy leads to oestrogen deficiency. While this may lead to vasomotor symptoms, the consequence which has been of most concern is a reduction in bone mass. Repeated courses of gonadotrophin releasing hormone analogues may mean that women with endometriosis enter the menopause with a below average bone density. Thus, there is a place for hormone replacement therapy both as add-back therapy in premenopausal women receiving gonadotrophin releasing hormone analogues, and in postmenopausal women with a past history of endometriosis. Addback therapy with continuous combined regimes and tibolone do not prevent disease resolution in the hypogonadal patient. The evidence regarding the use of hormone replacement therapy in patients with a history of endometriosis is poor, but suggests that we could be less conservative than we have been.

The discussion over the correct term to describe effective treatment taking continues, but may prove to be a distraction from the real issue which is that uptake and continuation of hormone replacement therapy remain low. "Compliance" continues to be widely used to describe treatment problems, despite criticisms of its implied doctor/patient relationship, but has the benefit of being familiar. Compliance is also poor with other treatments, such as antihypertensives. Numerous issues affect compliance with hormone replacement therapy: lack of information, attitude and gender of the doctor, side effects, lack of symptom control, dislike of bleeding and fear of long term consequences. Nurses and pharmacists can help doctors in providing an integrated health care team. More research is required to address the process of decision making by women as to whether they take hormone replacement therapy or not.

Cardiovascular disease is the leading cause of death in women over the age of 60. Over the last decade it has become clear that many physiological mechanisms are influenced by female sex hormones. New cardiovascular risk factors and markers are being identified. The changes in cardiovascular risk factors with menopause and hormone replacement therapy are reviewed. Types and routes of hormone replacement therapy and the effect of addition of progestogens are discussed where data are available. Lipids, coagulation, inflammation, endothelin-1 and homocysteine are examined.