Harnessing hormonal signaling for cardioprotection

Cardiovascular disease is the leading cause of death in women in the Western world and is predominant among the elderly. A large body of evidence suggests that hormonal signaling plays a critical role in the regulation of cardioprotective mechanisms, as premenopausal women are at significantly lower risk of heart disease compared with men, but the risk greatly increases with the onset of menopause. This association indicates that estrogen may protect the heart from cardiovascular disease. Whereas a number of analyses of the effects of hormone replacement therapy (HRT) on postmenopausal women supported the idea that estrogen is a cardioprotective factor, the findings of the more recent Women's Health Initiative (WHI) study suggested that HRT may actually increase the risk of cardiovascular events. These conflicting reports have left both patients and clinicians reluctant to continue using current HRT regimes. The WHI findings do not, however, negate the epidemiological link between menopause and increased cardiovascular risk. Hence, the identification of the specific actions of estrogen that promote cardioprotective pathways without enhancing deleterious vascular mechanisms may provide novel estrogen-based alternatives to current HRT strategies. In this Review, we outline the known actions of estrogen on the cardiovascular system, focusing on cardioprotective mechanisms that may be targeted for the development of new therapeutic approaches.     

Systemic lupus erythematosus and hormone replacement therapy

The indications for hormone replacement therapy (HRT) in postmenopausal women is the treatment of climacteric symptoms and the prevention of osteoporosis. Women with systemic lupus erythematosus (SLE) are more likely to have a premature menopause, osteoporosis and cardiovascular disease. HRT can induce SLE flares and cardiovascular or venous thromboembolic events. Therefore it should not be used in women with active disease or those with antiphospholipid (aPL) antibodies. In general, it should be used only for patients without active disease, a history of thrombosis or aPL antibodies. Non-oral administration of estrogen is recommended because of its lesser effect on coagulation. With regard to the progestogen, progesterone or pregnane derivatives are preferred. Otherwise, non-estrogen-based strategies should be used.     

A study of new referrals to a menopause clinic and their initial outcomes: how can we improve the service we provide?

This retrospective case-note study was performed to examine the ways in which an already established menopause clinic could improve service to its patients. The management of 151 patients was examined. Most were referred by their general practitioner and the most common reason for referral was to seek an alternative to hormone replacement therapy (HRT). The consultant saw 17% of the patients, and with the trainee was most likely to discharge the patient. Better information on alternatives to HRT, more consultant input and better use of telephone consultation for follow-up would enhance the service provided by the menopause clinic.     

Enhanced rate of resting energy expenditure in women using hormone-replacement therapy: preliminary results

Hormone-replacement therapy (HRT) attenuates the menopause-associated alterations in body composition. It is not known, however, whether this effect is a result of a concomitant increase in energy expenditure. The authors examined whether women submitted to a long-term HRT treatment presented greater energy expenditure than women who had never used HRT. We compared 13 postmenopausal women using HRT (>1 yr) with 13 age- (+/-2 yr) and body-mass-index-matched (BMI; +/-1.5 kg/m2) postmenopausal women not using HRT. Resting energy expenditure (REE; indirect calorimetry), body composition, and daily (DEE) and physical activity (PAEE) energy expenditure (accelerometry) were obtained. Although BMI, fat mass, fat-free mass, DEE, and PAEE were similar between groups, the HRT group displayed a significantly greater REE than the no-HRT group (Delta +222 kcal/day). In conclusion, the authors observed that a long-term treatment with HRT is associated with a greater REE in postmenopausal women. These results need to be confirmed.     

Skin ageing

Cutaneous ageing manifests itself as a progressive reduction in maximum function and reserve capacity of skin tissue. It is not a unique and uniform biological event. Skin comprises three layers: epidermis, dermis and subcutaneous tissue. Collagen atrophy is a major factor in skin ageing. There is a strong correlation between skin collagen loss and estrogen deficiency due to the menopause. Skin ageing, especially in the face, is associated with a progressive increase in extensibility and a reduction in elasticity. With increasing age, the skin also becomes more fragile and susceptible to trauma, leading to more lacerations and bruising. Furthermore, wound healing is impaired in older women. Estrogen use after the menopause increases collagen content, dermal thickness and elasticity, and it decreases the likelihood of senile dry skin. Large-scale clinical trials are necessary to help make informed recommendations regarding postmenopausal estrogen use and its role in the prevention of skin ageing.     

Physical activity and hormone-replacement therapy: interactive effects on cognition?

The purpose of this study was to examine the interactive effects of hormone-replacement therapy (HRT) and physical activity (PA) on the cognitive performance of older women. Postmenopausal women (n = 101) were recruited to complete a PA questionnaire, provide demographic information, and perform the digit-symbol substitution task (DSST) and the trail-making tests (TMT). Regression analyses were conducted for participants with complete data for each cognitive test (DSST n = 62; TMT n = 69). For both tasks, results indicated that PA and education were positively related and age was negatively related to cognitive performance. The interaction of HRT with PA did not add to the predicted variance of either measure of cognitive performance. This was true even after limiting the HRT users to women using unopposed estrogen. It is concluded that the beneficial relationship between PA and these two measures of cognitive performance in postmenopausal women exists irrespective of HRT use.     

Insulin resistance and management of the menopause: a clinical hypothesis in practice

Insulin resistance (IR) is associated with a number of metabolic abnormalities including glucose intolerance, dyslipidemia and central obesity (the metabolic syndrome), which predispose to cardiovascular disease, diabetes mellitus and some cancers. The incidence of many of these conditions increases after the menopause, a time when IR also increases. Medical intervention to help alleviate menopausal symptoms, frequently vasomotor in origin, usually involves hormone replacement therapy (HRT), but some women may only experience partial symptom relief. We have hypothesized that this may be due to concurrent IR. Our approach is therefore to manage menopausal symptoms in conjunction with the treatment of any concurrent IR, achieved through a combination of hormone replacement, dietary intervention and, if necessary, an insulin sensitizer. We suggest that this approach may not only improve symptom relief but may also reduce the risk of developing more serious health complaints in the future.     

Like mother, (not) like daughter: The social construction of menopause and aging

In recent American history, the definition of menopause has shifted from a natural, developmental transition to an increasingly more medicalized perspective that emphasizes biological deficits of the aging female body. Using qualitative data from two generations of women, this essay explores how and why this redefinition has occurred and what effect it has had on women's attitudes toward health and aging. The physical experiences of menopause were remarkably similar across mother-daughter pairs; however, daughters (who represented a slice of the baby boom cohort) differed from their mothers in how they talked about menopause, how they defined and treated menopause, and how willingly they accepted or fought the changes associated with menopause. Major social institutions, including the media and pharmaceutical industry, have played a significant role in reshaping the cultural lens through which women experience issues of health, body, and aging. This essay emphasizes the baby boomers' desire to maintain control over their bodies and considers how this cohort of women, as a result, may experience late-life issues of body and health.     

National Osteoporosis Society's Position statement on hormone replacement therapy in the prevention and treatment of osteoporosis

Hormone replacement therapy (HRT) has been shown to increase bone density, reduce the risk of fracture and can successfully relieve menopausal symptoms. From a time when HRT was the major therapeutic option for the management of osteoporosis, women and their clinicians now have a range of treatments available. Following the publication of the Women's Health Initiative (WHI) and the Million Women Study highlighting potential side-effects, such as breast cancer, heart disease and stroke, many doctors and women are now reluctant to use HRT. The National Osteoporosis Society felt that the role of HRT in the management of osteoporosis needed to be clarified. Using the Charity's expert clinical and scientific advisers, and through public consultation with members and key stakeholders, a Position Statement has been published. We conclude that HRT has a role to play in the management of osteoporosis in postmenopausal women below the age of 60 years. The key recommendations of the Position Statement are presented in this paper.     

Mental health around and after the menopause

The menopause is a time in a woman's life when it is recognized that biological and social changes can impact upon mental wellbeing. Several studies have investigated the relationship between menopause and psychological symptoms, especially depression, with mixed results. In part, this is due to a considerable overlap between depressive symptoms and those due to declining estrogen levels, causing challenges in assessment. However it appears that vulnerable women are at a higher risk of succumbing to depression during menopausal transition. Antidepressants remain the mainstay of treating depressive symptoms, with little conclusive evidence for hormone replacement therapy. Memory problems during menopause are a common complaint, but there is no demonstrated link to subsequent dementia. This paper also reviews considerations of diagnosis and treatment of postmenopausal depression.     

Menopause and schizophrenia

We have come a long way from our understanding of the menopause as it was described in the 11th century by Trotula of Salerno, a female gynaecologist who said 'there are older women who give forth blood matter especially as menopause approaches them'. Yet very little is known about the impact menopause has on the mental health of women especially severe and enduring illnesses like schizophrenia. A lot of research has shown that estrogen acts as a protective factor due to its antidopaminergic properties, thus providing an explanation for the increase in risk of a new psychotic disorder during the menopause. This has further led to the hypothesis of hormone replacement therapy providing benefits in the management of these disorders in menopausal women. This review article highlights the importance of a clear understanding of this phase of life in patients suffering from or who present with a risk of developing schizophrenia.     

Qualitative inquiry into women's menopause experiences in southeastern Iran

Menopause is defined as amenorrhea for one year. Signs and symptoms are categorized as physical and psychological changes, including depression, hot flushes and ageing. Woman's responses to menopause are governed by lifestyle factors. The purpose of this study was to determine how Iranian women experience menopause and hormone therapy. A qualitative inquiry was conducted through semistructured, in-depth interviews to explore study questions in 11 menopausal women. Participants had positive and negative menopause experiences. Negative menopause experiences are due to severity of symptoms. Menopause can be facilitated by increasing women's knowledge about this phase and ways to cope with it.     

At Midlife, Intentionally Childfree Women and Their Experiences of Regret

Based on the author’s exploratory qualitative study of the experiences at midlife of 15 intentionally childfree married or partnered women, this paper focuses on one finding and related themes. A constructivist grounded theory methodology guided data collection in many areas of midlife, including regret, menopause, and relationships. The data suggested that for most in the study, menopause, perimenopause, and reaching midlife did not awaken feelings of regret over their decision to live childfree. The author discusses implications for clinical work with childfree women at midlife.     

Prevention of osteoporosis: one step forward, two steps back

For many years, hormone replacement therapy (HRT) was the mainstay for osteoporosis prevention in postmenopausal women until a large randomized clinical trial raised serious safety concerns. This resulted in a big drop in HRT use and its demotion by regulatory authorities to second-line treatment. Many clinicians now feel that HRT is not safe to use, and recommend various alternatives for the treatment of osteoporosis. But how effective are these alternative therapies, are they any safer than HRT, and how do their costs compare? This review questions the validity of the safety concerns about HRT, and highlights the safety concerns about alternative therapies. It concludes that HRT is as safe as the other treatment options, and its efficacy and low cost demand that it be restored as a first-line treatment for the prevention of postmenopausal osteoporosis. Other therapies are available for use in osteoporosis, and the bisphosphonates are particularly effective for the treatment of the established disease. However, they must be used selectively and with caution, and are best restricted to those patients who are elderly or have severe disease. New treatments are emerging, but again caution must be taken until any long-term adverse effects have been identified.     

The Evolution of Understanding Menopause in Clinical Treatment

This paper integrates the meanings created about menopause through a biopsychosocial perpective. Once understood only as a biological illness creating affective disorders, new paradigms provide understanding based on the psychological and social constructions of the process. History emphasizes a view of women experiencing increasing deficiency and loss, while modern interpretations view women as gaining new freedoms. Case material is presented to direct attention to the meanings of menopause as it emerges in the treatment process.     

Primary prevention of coronary heart disease in women

The British Menopause Society Council is committed to provide up-to-date authoritative reviews to aid health professionals to inform and advise women about key issues in postreproductive health. Coronary heart disease (CHD) is a leading cause of death in women. Observational studies have consistently shown estrogen to help prevent CHD in postmenopausal women. The large randomized controlled Women's Health Initiative (WHI) trial did not confirm these observational findings. However, further analyses of the WHI study as well as the observational Nurses' Health Study have now found that the timing of onset of hormone replacement therapy (HRT) use is important and that estrogen may have a protective role in CHD in women aged 50-59 years. This consensus statement will examine the evidence regarding HRT and non-estrogen therapies (lipid lowering agents, aspirin, antihypertensives, antidiabetic medications, selective estrogen receptor modulators [SERMs]) as well as diet, lifestyle and smoking cessation in the primary prevention of CHD in women.     

Gender,interaction and intonational variation: The discourse functions of High Rising Terminals in London

In this paper, I examine the different conversational and interactional functions that High Rising Terminals (HRT) fulfil among young, White, middle‐class speakers of London English. Data are drawn from sixteen small‐group interviews with forty‐two individuals (28 women and 14 men) aged 18–25. From this corpus, 7351 declarative Intonation Phrases were extracted, and auditorily coded for the presence/absence of HRT as well as for a variety of social, interactional and pragmatic factors. I combine quantitative and qualitative methods to demonstrate that while all of the speakers investigated use HRT to accomplish relational work in conversation, the specific interactional strategies that the feature is recruited to perform differ markedly across genders. I consider the ramifications of this finding for our understanding of ‘politeness’ as a gendered practice, and illustrate the importance of examining a variable like HRT in its discourse‐functional context.     

Dysfunctional sexual beliefs as vulnerability factors to sexual dysfunction

The differences on sexual beliefs presented by men and women with sexual dysfunction and their sexually functional counterparts were investigated. A total of 488 participants (160 females and 232 males without sexual problems and 47 females and 49 males with a DSM-IV diagnosis of sexual dysfunction) answered the Sexual Dysfunctional Beliefs Questionnaire. Findings showed that, although effects have only reached statistical significance for the female group, both dysfunctional men and women endorsed more sexual dysfunctional beliefs than functional. Women presented significantly more age related beliefs (after menopause women loose their sexual desire, as women age, the pleasure they get from sex decreases) and body image beliefs (women who are not physically attractive cannot be sexually satisfied). Additionally, sexually dysfunctional males presented higher scores (not statistically significant) on 'macho' belief (a real man has sexual intercourse very often) and the beliefs about women satisfaction (the quality of the erection is what most satisfies women). Overall, findings support the idea that sexual beliefs may play a role as vulnerability factors for sexual dysfunction.     

Quality of life in obese postmenopausal women

The aim of this review was to identify the ways in which obesity affects the health-related quality of life (HRQoL) of postmenopausal women. This was considered important because a growing body of literature has identified obesity as a significant predictor for a poor psychological wellbeing and negative HRQoL, particularly in women, and because during the transition through the menopause women tend to accumulate more body weight. After searching eight electronic databases, only nine papers appeared meaningful. Although a meta-analysis was not possible, we found that a body mass index (BMI) > 30 kg/m2 was associated with a poor HRQoL in postmenopausal women; particularly in the areas associated with physical functioning, energy and vitality, and health perceptions. Thus, clinical management of obese postmenopausal women should focus on weight reduction and exercise in an attempt to improve wellbeing in these areas. However, the paucity of research, the different instruments chosen to measure HRQoL and the methodological limitations of the studies identified, prevented firm conclusions being made about whether the relationship between BMI and HRQoL is linear in postmenopausal women. Further research is needed to explore this relationship; particularly in comparison with underweight postmenopausal women and obese premenopausal women, where a few papers have identified these women as having a worse HRQoL than their obese postmenopausal counterparts. Other measures of central adiposity, including waist circumference and waist-hip ratio are recommended as useful supplemental measures to BMI in future studies.