Post Reproductive Health

Population ageing now affects every region of the world, with all societies beginning to adopt a mature demographic profile. Falling fertility and increased longevity impact upon women's transitions as workers, carers, mothers and grandmothers, and also on the social structures within which these individual roles and responsibilities occur. Shifts from a high-mortality/high-fertility society to a low-mortality/low-fertility society and the ageing of family transitions have significant implications for both family relationships and kinship roles. Low-mortality/low-fertility results in an increase in the number of living generations, and a decrease in the number of living relatives within these generations. Women in mid-life will thus face increasing care demands as children of frail parents and mothers of adult working children with children. In addition, they will increasingly face mid and late life divorce, and the new demands of reconstituted or step families. This will occur within the framework of reduced extended kin to call upon for practical and psychological support.

Introduction of BRCA1 and BRCA2 gene mutation analysis has increased interest in prophylactic mastectomy and immediate breast reconstruction as a risk reduction measure for women at increased risk of breast cancer. Prophylactic mastectomy has been suggested to decrease the risk of breast cancer by at least 90%. Because the cosmetic result of immediate breast reconstruction may not be optimal, nipple sensation is lost, and capsule contraction may cause problems when silicon prostheses are used, the patients should be well informed of risks and other preventive methods. Surveillance or chemoprevention are suggested as alternatives to risk reduction mastectomy, but there is lack of prospective randomised trials comparing these options. Because BRCA1 and BRCA2 gene mutations also increase risk of ovarian cancer, management of these patients should be shared by the breast surgeon and gynaecologist.

Ovarian cancer presents at a late stage and is associated with a very poor chance of cure. Ability to predict women who are at genetic risk has directed our thoughts to the possibility that the timely removal of the ovaries in these women is likely to prevent cancer and save lives. Only approximately 10% of ovarian cancers arise as a result of an inherited condition; it is this group which is most likely to benefit from prophylactic oophorectomy. Women in this group may be identified following referral on the basis of personal or family histories of disease. With continued improvement in genetic screening, the literature regarding prevention of ovarian cancer appears to be moving beyond the appropriateness of prophylactic oophorectomy to a discussion of the technical aspects of the procedure. There is little doubt that this type of surgical prophylaxis will become more popular. Numerous studies have now demonstrated that prophylactic oophorectomy will not only offer a high degree of protection against ovarian cancer but also against breast cancer. It is important for the future that research continues to examine the operative technique and its implications, particularly with regard to Fallopian tube and peritoneal cancer.

Endometrial carcinoma is often listed in data sheets as an absolute contraindication to hormone replacement therapy. However, observational studies have not shown an increased rate of recurrence or mortality. Thus, it is often used after stage I or II disease. Alternatives such as progestogens, tibolone, raloxifene, venlafaxine and herbal preparations are examined. The use of progestogens is under discussion because of potential adverse effects on the breast. Generally after treatment for endometrial cancer, current preference should be for low-dose oestrogen monotherapy rather than continuous combined therapy with progestogen addition in view of the increased risk of breast cancer and cardiovascular disease found with the latter regimen. It is important to note that risk factors for endometrial cancer such as hypertension, obesity, polycystic ovary syndrome and diabetes mellitus also increase the risk of cardiovascular disease. However, women must be informed about potential risks and the use of alternatives.

Hand function declines with age, and therefore, by implication, after the menopause. The simple ageing process clearly affects both women and men, but women may experience more of a decline of hand function in older age. This is not readily explained in terms of straightforward ageing, but women are more likely to be adversely affected by diseases such as osteoarthritis and rheumatoid arthritis. Hormonal influences, particularly in osteoarthritis, may be the reason for women experiencing more severe disease. Both arthritides are multi-factorial in their aetiology, and the same is true of the declining hand function that is seen as part of the ageing process.

Objective: To assess the two-week rapid access referral system for UK general practitioners introduced in April 2000 for women suspected of having a gynaecological cancer.

Study design: An audit of details of women referred between 1st April 2000 and 31st March 2003 via the two-week rapid access system to one gynaecological consultant who performs gynaecological oncology surgery at the John Radcliffe Hospital, Oxford.

Main outcome measures: Information on waiting times, clinical indication (postmenopausal bleeding, suspicious pelvic mass, vulval lesions, or "other" symptoms including postcoital vaginal bleeding, suspicious lesions of the cervix or vagina), and subsequent diagnosis were recorded. Data on all other women in whom a diagnosis of a gynaecological malignancy was made during the same period following referral to the same consultant's routine gynaecological outpatient clinic were also collected.

Results: The target time of two weeks to see a consultant was met for 94% of women referred via the rapid access system. The response time declined slightly with increasing numbers of referrals. However, the majority of women with a gynaecological malignancy were not referred via the rapid access system.

Conclusions: To accommodate the two-week rapid access referrals and achieve UK government targets, there was a reduction in appointments for routine outpatient referrals. However, as the majority of women with gynaecological malignancy presented via traditional referral routes, there is a danger that their diagnoses are being delayed.