Potential strategies to avoid progestogen-induced premenstrual disorders

Non-hormonal approaches to premenstrual syndrome (PMS) treatment such as selective serotonin reuptake inhibitors are by no means effective for all women and frequently we must resort to endocrine therapy. During many of the hormonal approaches, PMS-like symptoms can be introduced or re-introduced during the necessary cyclical or continuous progestogen component of the therapy. This is seen with combined oral contraception, progestogen only contraception, progestogen therapy for heavy menstrual bleeding and endometriosis, sequential hormone replacement therapy and any therapeutic strategy for premenstrual syndrome where it is necessary to provide endometrial protection, including estrogen suppression of ovulation or add-back during gonadotrophin releasing hormone suppression. The link to progestogen is very often missed by health professionals. When the pattern of symptoms mimics the cyclicity of PMS, it is termed progestogen-induced premenstrual disorder. The need to use progestogen to protect the endometrium from the proliferative actions of estrogen can pose insurmountable difficulties in managing premenstrual disorders. In the absence of any really useful evidence, nearly all practice in this area depends on clinician experience. We cannot afford to wait for adequate research evidence to be produced - it never will - and so we must rely on empirical findings, clinical experience, theoretical strategies and common sense.     

Role of bisphosphonates in the management of postmenopausal osteoporosis: an update on recent safety anxieties

Following their introduction in the 1990s, bisphosphonates have become the mainstay of treatment in the management of postmenopausal osteoporosis, and their use continues to rise. Commonly noted adverse effects in clinical practice include gastrointestinal side-effects, acute phase reactions (predominately seen with intravenous preparations) cutaneous reactions and more rarely, ocular side-effects. However, recent reports of potentially serious adverse effects of bisphosphonate therapy, including atypical subtrochanteric and femoral shaft fractures, atrial fibrillation, oesophageal carcinoma and osteonecrosis of the jaw, have prompted concerns regarding the long-term safety of this class of drugs. This review summarizes the benefits and potential adverse effects of bisphosphonates used in the treatment of postmenopausal osteoporosis. Although evidence of a definitive casual relationship between bisphosphonate therapy and serious adverse effects is lacking, concern remains particularly in relation to atypical subtrochanteric and femoral shaft fractures. This has important consequences in terms of determining optimum duration of therapy and how best to target therapy at those most at risk. Recently, attention has focused on individual fracture risk assessment in order to optimize the risk-benefit ratio of treatment for individual patients. A review of the role of hormone replacement therapy in younger women with significant risk of osteoporotic fractures may be timely in these circumstances.     

Hypogonadotrophic hypogonadism in type 2 diabetes

Recent work shows a high prevalence of low testosterone and inappropriately low luteinizing hormone (LH) and follicle stimulating hormone (FSH) concentrations in type 2 diabetes. This syndrome of hypogonadotrophic hypogonadism (HH) is associated with obesity in patients with type 2 diabetes. However, the duration of diabetes or HbA1c are not related to HH. Furthermore, recent data show that HH is not associated with type 1 diabetes. C-reactive protein concentrations have been shown to be elevated in patients with HH and are inversely related to plasma testosterone concentrations. This inverse relationship between plasma free testosterone and C- reactive protein concentrations in patients with type 2 diabetes suggests that inflammation may play an important role in the pathogenesis of this syndrome. This is of interest since inflammatory mechanisms may have a cardinal role in the pathogenesis of insulin resistance. It is also relevant that in the mouse, deletion of the insulin receptor in neurons leads to HH in addition to a state of systemic insulin resistance. It has also been shown that insulin facilitates the secretion of gonadotrophin releasing hormone (GnRH) from neuronal cell cultures. Thus, HH may be the result of insulin resistance at the level of the GnRH secreting neuron. Low testosterone concentrations are also related to an increase in total and regional adiposity. This review discusses these issues and attempts to make the syndrome relevant as a clinical entity. Clinical trials are required to determine whether testosterone replacement alleviates insulin resistance and inflammation. In addition, low testosterone levels are associated with an increase in cardiovascular events. Testosterone therapy may therefore, reduce cardiovascular risk. This important aspect requires further investigation.     

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.     

Interviewing strategies with sexually abusive youth

Adolescents who have sexually abused may pose a serious problem for both the community and the treatment provider concerning the management of risk and the application of effective intervention strategies. Fundamental to providing good clinical treatment is an assessment that results in an individualized treatment plan specifically tailored to the young person's needs. An integral but often overlooked part of this involves interviewing clients in a way that elicits accurate information and facilitates the development of a therapeutic relationship upon which effective therapy can be undertaken. This article will describe interviewing strategies and highlight the importance of the client-therapist relationship in providing effective therapeutic interventions.     

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.     

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.     

Interviewing Strategies with Sexually Abusive Youth

SUMMARY

Adolescents who have sexually abused may pose a serious problem for both the community and the treatment provider concerning the management of risk and the application of effective intervention strategies. Fundamental to providing good clinical treatment is an assessment that results in an individualized treatment plan specifically tailored to the young person's needs. An integral but often overlooked part of this involves interviewing clients in a way that elicits accurate information and facilitates the development of a therapeutic relationship upon which effective therapy can be undertaken. This article will describe interviewing strategies and highlight the importance of the client-therapist relationship in providing effective therapeutic interventions.     

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.     

Clinical application of anxiety management and relaxation training: A multi-referral workshop

Anxiety may be so significant a block to problem-solving and the treatment process that clinicians, regardless of their treatment orientation, often find it useful to have tranquilizing medications prescribed for their clients as a concomitant to therapy. This paper reports on the practical application of group relaxation training as an anxiety management tool for clients at mental health centers. Besides teaching relaxation, this training, for which there are no contraindications listed in thePhysicians Desk Reference, teaches body awareness and self-regulation, specificity and clarifying thoughts, and is a useful model for the rational, problem-solving process.     

Epilepsy in older women

Women suffering from epilepsy require special attention throughout their life. In this review, management of epilepsy during the periods of perimenopause, menopause and late maturity is discussed. The effect of epilepsy on age at menopause, changes in seizure frequency during perimenopause and menopause, and the risks of hormone replacement therapy are also presented. Altered antiepileptic drug pharmacokinetics with increasing age and the management of this vulnerable population is also discussed.     

Estrogen treatment affects brain functioning after menopause

Sex hormones have powerful neuromodulatory effects on functional brain organization and cognitive functioning. This paper reviews findings from studies investigating the influence of sex hormones in postmenopausal women with and without hormone therapy (HT). Functional brain organization was investigated using different behavioural tasks in postmenopausal women using either estrogen therapy or combined estrogen plus gestagen therapy and age- and IQ-matched postmenopausal women not taking HT. The results revealed HT-related modulations in specific aspects of functional brain organization including functional cerebral asymmetries and interhemispheric interaction. In contrast to younger women during the menstrual cycle, however, it seems that HT, and especially estrogen therapy, after menopause affects intrahemispheric processing rather than interhemispheric interaction. This might be explained by a faster and more pronounced age-related decline in intrahemispheric relative to interhemispheric functioning, which might be associated with higher sensitivity to HT. Taken together, the findings suggest that the female brain retains its plasticity even after reproductive age and remains susceptible to the effects of sex hormones throughout the lifetime, which might help to discover new clinical approaches in the hormonal treatment of neurological and psychiatric disorders.     

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.     

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 EFFECTIVENESS OF FAMILY INTERVENTIONS IN THE TREATMENT OF PHYSICAL ILLNESS

Although a large body of research demonstrates that the family has a powerful influence on physical health, the evidence for the effectiveness of family interventions in physical illness is less conclusive. Family therapy and other family interventions appear to be most effective in chronic childhood illnesses such as asthma and diabetes. Family interventions have also been shown to be effective in the management of some cardiovascular and neurologic disorders and for the treatment of obesity. Family therapy appears to be more effective than individual therapy for some groups of patients with anorexia nervosa. This research supports the increasingly important role of medical family therapy in the new health care system. Recommendations for future research are discussed.     

THe Use of Hormone Therapy in the Male-to-Female Transgender Population: Issues for Consideration in Thailand

ABSTRACT

Objectives: Prejudice against transgender people is evident around the world with discrimination in many aspects of life, including access to health care. Even in Thailand, where male-to-female (MTF) transgender people are particularly visible and society is reputedly accepting, barriers to attaining appropriate health care still exist. The vast majority of MTF transgender people in Thailand are reported to be taking hormone therapy; however, most do not seek medical advice regarding these regimens, with the initiation and tailoring of medication often being guided by sympathetic peers instead. The objectives of this review are to consider hormone therapy in the context of the Thai population and provide recommendations regarding ways to improve practice and reduce health risks. Methods: The data analysis in this article represents a comprehensive literature review regarding hormone therapy for MTF transgender people including the guidelines for initiation, prescribing, and monitoring of hormone therapy, risks for serious adverse events and reported hormone use by the MTF transgender population in Thailand. Results: There is a notable lack of published research regarding hormone therapy in the transgender population. Guidelines, whilst relying considerably on expert opinion, do provide clear recommendations on the initiation, maintenance and monitoring of hormone therapy. Comparison of endocrine guidelines with reported practice in Thailand reveals significant opportunities for improvement in MTF transgender hormone therapy. Conclusions: The incautious use of hormone therapy may represent a considerable health risk behavior undoubtedly contributing to the morbidity and mortality in MTF transgender people. Although there is currently considerable focus on sexually transmitted infections in the MTF transgender population, a more comprehensive approach to health care is required, including education for transgender people and the health professionals who attend to them regarding appropriate hormone therapy.     

Compounded or confused? Bioidentical hormones and menopausal health

The aim of this article is to focus on compounded bioidentical hormone (BH) formulations for menopausal symptoms and to discuss the impact of these on women's choice of treatment. The practice of compounding BHs for individualized treatment of women with menopausal symptoms has developed in the USA. In spite of claims of superiority, there is no evidence to suggest that these formulations are any more efficacious or safe than conventional hormone replacement therapy (HRT). In fact, there are some concerns about dosing inconsistencies and usefulness of saliva testing that is carried out as part of this type of treatment. While there should be no serious safety issues for women, there is a mismatch between the reality of compounded BH formulations and women's perception of them.     

l-Arginine and tetrahydrobiopterin,but not sodium nitrite partially restored erectile dysfunction in aged rats

This paper gives an overview of our own studies and the literature on the biosynthesis and metabolism of estrogens in elderly men, the estrogen action in the male, and the clinical usefulness of estrogen therapy, including the phytoestrogens. Finally, the paper includes a short review of our knowledge of xenoestrogens and men's sexual health. A strong estrogen-deficient status is seen in male patients with mutations of the estrogen receptors or in cases of deviations of the aromatase gene. On the other hand, there are no clear age-dependent changes in estrogen secretion. But, in men with disorders of glucose metabolism and also of increased body mass index, the serum estrogen concentrations are significantly elevated. There are also strong positive correlations between serum estrogen levels and bone density, including prevalence of fractures and mood in men. New fields of interest are natural fatty esters of endogenous estrogens, e.g. lipoprotein-associated estrogens, and the role and clinical significance of tissue-specific, local estrogen biosynthesis (e.g. different promoters of the aromatase gene). Exogenous estrogen treatment is focused today on patients with normal testosterone and low levels of circulating estrogens documented on several occasions and with clinical symptoms of hormone deficiency; male-to-female transsexuals; and selected patients with prostate cancer. Some clinical studies show the benefits of estrogen treatment on some cardiovascular parameters and for treating selected signs of mental stress. An indirect estrogen replacement can occur if dehydroepiandrosterone is given orally to men. The clinical usefulness of dissociated estrogens, including non-feminizing estrogens and selective estrogen receptor modulators, is still an open question. The beneficial action of phytoestrogens in lowering the clinical symptoms of benign prostatic hyperplasia is well documented. Finally, the question about the definitive influence of so-called endocrine disruptors (xenoestrogens) on sexual functions in men is also discussed.     

Nursing interventions for parasuicidal behaviors in female offenders

Parasuicide refers to the nonfatal, intentional, self-injurious behaviors frequently exhibited by individuals with features of a borderline personality disorder. In correctional systems, the rate of parasuicidal behavior among incarcerated female offenders can be high and intertwined with complex behavioral and social issues. Nursing interventions in the management and treatment of parasuicidal behaviors incorporating the principles of dialectical behavior therapy have been developed and implemented at the authors' institution. This treatment approach provides practical, effective nursing interventions including pretreatment orientation, strategies for use with threats to self-harm and during self-harming episodes, and follow-up treatment.     

Growth hormone,somatomedins and men's health

According to current basic science as well as the clinical literature, human growth hormone has become an important topic in the field of anti-aging medicine. It is well known that the administration of human growth hormone compensates for the dwarfism syndrome in growth hormone-deficient children and growth hormone is also established as a substitution therapy for adults with pituitary deficiency. The effects mediated by growth hormone comprise an increase in muscle mass, a decrease in body fat, improved physical condition, oxygen consumption and overall quality of life, an improvement of the ratio of high-density lipoprotein to low-density lipoprotein, as well as an increase in bone density. Due to the insulin antagonistic effect of growth hormone as well as its insulin-like growth factor-1-mediated mitogenic effect, there is reason to doubt the safety of administering growth hormone outside the framework of approved indications. In an ongoing study, we are evaluating whether growth hormone and somatomedins might be of importance in the regulation of male sexual performance, including penile erection.