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Surviving Perimenopause

To give you an even better idea of just what kind of useful and practical information youll find in Perimenopause: Have It, Live It, Love It!, heres a partial list of the topics covered extensively in this ebook: Learn about the 26 signs of perimenopause both common and not so common symptoms. Find out what your symptoms are Not telling you 18 perimenopause symptoms that are linked to other serious medical conditions. Learn how you can treat your symptoms Without the use of drugs and pills. Over 50 home remedies with recipes and instructions to help you cope with various perimenopause symptoms. What you need to prepare Before your visit to your doctor, including how to make sure your doctor listens to you and takes your symptoms seriously, and reaches the right diagnosis. Get tips and techniques to re-ignite your sex life. Its not too late to bring passion back to the bedroom. Perimenopause pregnancy? Get your facts straight whether you are trying to conceive or prevent a pregnancy. Make sense of the changes that are happening to your body and the ones that are happening inside your head. Learn techniques you can apply today to get better sleep and to overcome perimenopause insomnia. Discover what you can do now to prevent osteoporosis which attacks women after they hit menopause and is easily preventable only if you start now! Identify if you are estrogen deficient or estrogen dominant and find out which remedies work for each type. Determine whats actually causing your irregular periods, Pms and heavy bleeding. Learn how to tell when youll hit menopause. Understand medical jargon so you dont come out of a doctor consultation more confused than before you went in. Understand the link between hormonal changes in your body and your mood swings and depression. Find out what to expect when you have perimenopause the common and not-so-common transformations that can really affect the way you live. Get access to information that your doctor may not be telling you. Realize that you can do something about that weight youre putting on around your waist and thighs and why old dieting methods that worked for you in the past are next to useless now. Learn about the different kinds of tests your doctor may ask you to get and actually know what theyre for.

Surviving Perimenopause Overview


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Hello Menopause Goodbye Endometriosis

For many women with endometriosis, there's an end in sight it's called menopause, the cessation of menstrual periods. Normally women stop having periods between the ages of 45 and 55 because the ovaries produce less estrogen and progesterone. At menopause, all (or almost all) primordial follicles are used up so eggs can't form. With no follicles or eggs, a woman's body doesn't produce estrogen. As a result, the tissues that normally respond to estrogen (like the endometrium and breast) no longer grow. Because hormones are responsible for the symptoms of endometriosis and because artificially induced menopause (with hormone therapy) often reduces the pain of endometriosis, we can expect menopause to end endometriosis. Although the pain of endometriosis continues into menopause for a small percentage of women, the end of menstrual periods is the end of pain for many women. This change may not happen all at once, but, after months without hormonal stimulation, the endometrial tissue no...

Treatment of menopausal symptoms with estrogen

Estrogen therapy remains the gold standard for relief of menopausal symptoms, and is a reasonable option for most postmenopausal women, with the exception of those with a history of breast cancer, CHD, a previous venous thromboembolic event or stroke, or those at high risk for these complications. Estrogen therapy should be used for shortest duration possible (eg, 6 months to 5 years). 4. Low-dose oral contraceptives. A low-estrogen oral contraceptive (20 pg of ethinyl estradiol) remains an appropriate treatment for perimenopausal women who seek relief of menopausal symptoms. Most of these women are between the ages of 40 and 50 years and are still candidates for oral contraception. For them, an oral contraceptive pill containing 20 pg of ethinyl estradiol provides symptomatic relief while providing better bleeding control than conventional estrogen-progestin therapy because the oral contraceptive contains higher doses of both estrogen and progestin. D. Urogenital changes. Menopause...

The ageing female reproductive axis II ovulatory changes with perimenopause

Perimenopause, a complex physiological transition for midlife women, begins with changes in experiences many years before cycles become irregular, oestradiol levels decrease or follicle-stimulating hormone levels increase. Erratic and average higher oestradiol levels as well as shorter luteal phase lengths and lower progesterone levels occur during perimenopause. These ovarian changes may be causally related to lower inhibin production but the dynamic prospective inter-relationships within women are not well documented. This review will first define perimenopause and then explore the limited published data on ovulatory characteristics in perimenopause. In addition, it will report preliminary prospective observational data on menstrual cycles and ovulation in initially ovulatory women followed through the perimenopause. Prospective data suggest that ovulation disturbances begin early in perimenopause and increase with irregular cycles. Combined with higher oestradiol levels...


Menopause results from ovarian burnout and, on average, occurs at age 51.6 During the transition phase, or perimenopausal period, there is lengthening or marked variation in the intermenstrual intervals. By age 45, only a few primordial cells remain, and the production of estrogen decreases. As a result, the pituitary continuously produces large quantities of FSH and LH. Ihere is no midcycle rise in estrogen to trigger a further surge of pituitary hormones for ovulation. Estrogens continue to be produced in lower, subcritical levels for a short time after menopause, until the remaining follicles become atretic, and production falls to almost zero.

Mimicking menopause

Other hormone treatments work in a way similar to negative feedback (they work on receptors), but these treatments work on the pituitary gland (the gland just below the hypothalamus), tricking the body into thinking that it's in menopause. In natural menopause, the symptoms of endometriosis also decrease for several reasons GnRH agonists or antagonists (two classes of drugs) simulate menopause except for one difference Instead of increasing FSH and LH (which leads to more eggs and more hormones ), these medications remove the stimulus to your ovaries by lowering LH and FSH. The result is, ideally, no menstrual cycles, no hormones, and the number-one goal decreased amounts of endometrial tissue and endometriosis.

Specific Nutrients Calcium

Decade, there is a steady decline in bone calcium. This is especially marked after menopause in women, when estrogen declines, and often leads to bone loss (osteopenia) to below a threshold that predisposes women in particular to fractures (osteoporosis). Osteoporosis is not just a disease of the elderly, and may occur in much younger patients, especially athletic young women, those with anorexia nervosa, those on steroids and other medications, and in anyone on prolonged bed rest, including astronauts experiencing long periods of weightlessness.

Neuroendocrine Effects of Alcohol

The development of female secondary sexual characteristics in men (e.g., gynaecomastia and tes-ticular atrophy) generally only occurs after the development of cirrhosis. In women, the hormonal changes may reduce libido, disrupt menstruation, or even induce premature menopause. Sexual dysfunction is also common in men with reduced libido and impotence. Fertility may also be reduced, with decreased sperm counts and motility.

Physical Sex Differences Gross Physical Differences

Women's and men's waist-hip ratios differ strikingly (about 0.7 vs. 0.85). Women's waist-hip ratio changes, thickening with both pregnancy and menopause thus a ratio of 0.7 in a woman sends the message I am young, and not pregnant. Across a variety of cultures, men find women's typical waist-hip ratio of 0.7 most attractive (Singh, 1993 Singh & Luis, 1995), and women do not find wide hips in men attractive. Related physical sexual differences may be exaggerated in specific environments for example, in some populations in harsh environments, women store fat on the buttocks, giving an exaggerated shape that reflects ability to thrive in harsh conditions (Low, 2000).

Endocrinology of ageing

In men, several hormonal systems show a gradual decline in activity during ageing, represented by a decrease in their bioactive hormone concentrations. The 'andropause' is characterized by a gradual decline in serum total and bioavailable testosterone, due to a decrease in testicular Leydig cell numbers and in their secretory capacity, as well as by an age-related decrease in episodic and stimulated gonadotropin secretion (Vermeulen 1991). Both cross-sectional (Vermeulen 1991) and longitudinal (Morley et al 1997) studies have shown that in healthy males mean serum total testosterone (T) levels decrease by about 30 between age 25 and 75, whereas mean serum free T levels decrease by as much as 50 over the same period. The steeper decline of free T levels is explained by an age-associated increase in sexhormone binding globulin (SHBG) binding capacity (Vermeulen & Verdonck 1972). Conflicting results have been reported concerning the question of whether luteinizing hormone (LH)...

Ageing stress and the brain

In 1988 Joseph Meites described a neuroregulatory theory of ageing, emphasizing the integrative role of the nervous system for neuroendocrine axes and circadian rhythms (Meites 1988). As the brain aged, Meites proposed, so would the hypothalamus age, leading to menopause, andropause, somatopause and dysregulated circadian rhythms. Meites tested pharmacological strategies to augment hypothalamic neurotransmitter function, which he found could reverse these 'biomarkers of ageing', a result that comports with the age-associated decline of hypothalamic monoamine neurotransmitter systems (Rodriguez-Gomez et al 1995). Though it can be modified by recent insights, the general perspective of Meites that we endocrinologists are also neuroscientists remains valid. Ageing of the brain is an important factor in overall ageing and mortality.

Understanding Your Menstrual Cycle And Its Relationship to Endometriosis

Figuring out the connection Your menstrual cycle and endometriosis Taking a closer look at the painful side of cycles Making dysfunctional periods functional Adjusting abnormal bleeding through surgery Bidding a not-so-fond farewell to endometriosis Menopause We also tell you how to know whether your pain is endometriosis or another gynecologic problem. Next we discuss medical and surgical treatments to regulate your menstrual cycle and decrease pain and irregular bleeding. Finally, we take a brief look at menopause and its effect on endometriosis

Systemic hormones that regulate skeletal growth or function growth hormone oestradiol and vitamin A

While there is no doubt that the decreased levels of oestradiol that follow normal or artificially induced menopause lead to increased bone loss, oes-tradiol's role in skeletal biology remains obscure. The recent discovery of oestradiol receptors in osteoblasts suggests it may have a direct effect on osteoblastic cells.

Bone turnover and agerelated bone loss

Age-related bone loss therefore occurs more rapidly in trabecular bone (which turns over more rapidly) and is increased by factors that promote bone turnover (transient calcium deficiency). Risk factors or disease states associated with either low peak bone mass or increased rates of loss include small body size, nulli-parity, inactivity, early natural menopause, anorexia, thyrotoxicosis, and Cushing's syndrome.

Decision analysis in the evaluation of specific products

Hormone replacement therapy 200 mg dl and smoking cessation. The authors concluded that significant potential benefits in life expectancy in coronary artery disease reduction, combined with the osteoporosis prevention in symptom relief, would point to greater emphasis on postmenopausal estrogen use in appropriate patients. Since the report by Zubialde et al22 hormone replacement therapy has undergone additional study. A growing body of literature suggests that its predicted effects have not been fully realized,23'24 and the results of a recent polymorphism study have further complicated matters.25 It bears repeating here that the reliability of a decision analysis is related directly to the quality of the data on which the analysis is based. The Zubialde analysis was based on the best data of its time, but superior data from clinical trials have since called the findings into question.

Parallels in Feminist Thought

Some parallels with disability theory can be found in feminist thought and ethics. From the point of view of gender, feminism has questioned the assumption that the male physical form embodies normality, implicitly calling into question the general validity of physical norms. It has disrupted many notions about the universality of phenomena associated with men, and questioned whether phenomena associated with women should be seen as abnormal variants of the male version. Like the social model of disability, it has challenged the medicalization of some embodied attributes in feminism's case, specifically female attributes such as menstruation and menopause. In its necessary focus on gender differences, however, mainstream feminism has largely assumed that there is a pattern of corporeal normality to which normal men and women correspond and from which normal men and women deviate. Beyond a consideration of the dual oppression of disabled women (e.g., Morris 1993) and of women as carers...

Processing how endometriosis destroys ovarian tissue

One major reason for this problem is the loss of ovarian reserve (the medical term for decreased number of eggs). You only have a finite number of eggs to last your whole reproductive life (check out the sidebar Creating a good egg in this chapter). If that number decreases for any reason, you may run out earlier than usual and have premature menopause. This decreased ovarian reserve leaves you with fewer good eggs possibly no good eggs for a pregnancy.

The genesis of chromosome abnormalities

Enters meiosis produces four spermatozoa the process is continuous, taking 64 days in all. Once past puberty, the male remains fertile into old age. In contrast, the human female is born with a complete set of oogonia - no more develop after birth. The initial stages of the first meiotic division take place early in fetal life but, after synapsis and recombination, each cell enters a period of arrest until after puberty. One egg then matures in each monthly cycle. Ovulation occurs when the oocyte is at metaphase II of meiosis and completion of the second division occurs after fertilization. Although there are several million oogonia at the outset, most are lost before birth and only a few hundred ever mature. Once the egg store is depleted, the menopause begins and the woman becomes infertile.

Familial ovarian cancer

Ovarian cancer is the fifth most common cancer in women (excluding skin) in the USA and UK. Since the prognosis of this neoplasm is largely determined by the stage of the disease at presentation, and approximately 80 of cases have spread beyond the ovary when first diagnosed, ovarian cancer accounts for a disproportionate number of deaths compared with other cancers of the female genital tract. A family history of ovarian cancer confers the highest known risk factor for developing the disease. Other risk factors include gonadal dysgenesis (Szamborski et al., 1981), early menarche and late menopause, whereas reducing the number of ovulation events either by use of an oral contraceptive or through pregnancy reduces the risk of ovarian cancer. The oral contraceptive pill appears to offer protection against the risk of developing both sporadic and familial cancer and continues to provide protection for some years after the contraceptive has been terminated (Anonymous, 1987).

Choice And Definition Of Problems To Be Studied

Using only a particular discipline's established methods may result in approaches that fail to reveal sufficient information about the problem being explored. This may be a difficulty for research surrounding medical problems particularly important to the elderly, women, men of color, and homosexual males. Pregnancy, childbirth, menstruation, menopause, lupus, sickle-cell disease, AIDS, and gerontology represent healthcare issues for which the methods of one discipline are clearly inadequate.

Modernization and Medicalization

Medical interests expanded in several directions during the 18th and 19th centuries. First, there was an increased involvement on the part of medical professionals in the management not only of individual pathology but of life-cycle events. Attending birth had been entirely the provenance of women, but from the early 18th century in Europe and North America, male midwives trained and worked at the lying-in hospitals located in major urban centers to deliver the babies of well-off women. These accoucheurs later consolidated themselves as the profession of obstetrics. By the mid-19th century other life-cycle transitions, including adolescence, menopause, aging, and death had been medicalized, followed by infancy in the first years of the 20th century. In practice, however, large segments of the population remained unaffected by these changes until the mid-20th century.

Different basis for risk prediction

Menstrual and reproductive history, such as early age at menarche, late age at menopause, nulliparity or late age at first birth, as well as family history of breast cancer and history of benign breast disease, have been shown in epidemiological studies to increase the risk of breast cancer in women relative to those without these characteristics. Risk prediction models accounting for some of these factors have been developed. The Gail model was based on data from the Breast Cancer Detection and Demonstration Project - a large mammographic screening programme conducted in the 1970s (Gail et al., 1989). Risk factors accounted for included age at menarche (> 14, 12-13, < 12 years), number of breast biopsies and woman's age (0, 1, > 2 biopsies at < 50 or > 50 years), number of first-degree relatives with breast cancer (0, 1 or > 2) and woman's age at first live birth (< 20, 20-24, 25-29, > 30 years, or nulliparous). The calculation of breast cancer risk with the Gail...

Normal Vulvovaginal Environment

In females of childbearing age, estrogen causes the development of a thick vaginal epithelium with a large number of superficial cells serving a protective function and containing large stores of glycogen. Glycogen is used by the normal flora, consisting of lactobacilli and acidogenic cornynebacteria, to form lactic and acetic acids. The resulting acidic environment favors the normal flora and discourages the growth of pathogenic bacteria. Lack of estrogen or a dominence of progesterone results in an atrophic condition, with loss of the protective superficial cells and their contained glycogen. This is turn results in loss of the acidic environment. Normal vaginal secretions may vary in consistency from a thin, watery material to one that is thick, white, and opaque. The quantity may also vary from scant to a rather copious amount. This material is odorless and produces no symptoms. The normal vaginal pH varies between 3.5 and 4.1. Alkaline secretions from the cervix before and during...

What We Do Not Know Longitudinal Cohort Studies

Currently, much is unknown about the long-term effects of contragender hormonal treatment. In light of recent studies on increased breast cancer risk in non-transgendered females due to hormone replacement therapy, it is critical that longitudinal studies are undertaken in the transgender community. Questions of increased risk of breast cancer in MTF transsexuals remain open, as do questions of breast cancer in the FTM transsexual community. Questions of the effect of estrogen on bone mass in this population are also important and go unanswered, as do questions of the effect of estrogen on oral health and the potential to affect cardiovascular problems. Only recently have studies begun to address the issues of excessive smoking in this population. Little is known about the effects of replacing estrogen with testosterone in FTM

The Paradox of Rapid Population Growth in Undernourished Populations

British data from the mid-nineteenth century on growth rates, food intake, age-specific fertility, sterility, and ages of menarche and menopause show that females who grew relatively slowly to maturity, completing height growth at ages 20 or 21 years (instead of 16-18 years, as in well-nourished contemporary populations), also differed from well-nourished females in each event of the reproductive span Menarche was later, for example, 15.0-16.0 years compared with 12.8 years adolescent sterility was longer, and the age of peak nubility was later the levels of specific fertility were lower pregnancy wastage was higher the duration of lactational ame-norrhea was longer the birth interval was longer and the age of menopause was earlier, preceded by a more rapid period of perimenopausal decline (Figure 6). Thus, the slower, submaximal growth of women to maturity is subsequently associated with a shortened and less efficient reproductive span. The differences in the rate of physical growth...

Middle Age and Old Age

Many postmenopausal women are single, either widowed or left by their husbands some time after menopause. They remain important in caring for and feeding young children. These older women usually remain hardy up until their seventies and bring in more daily calories of food than any other age-sex category. Hardworking Hadza grandmothers have received attention, especially in connection with the evolution of long life-span (Blurton Jones, Hawkes, & O'Connell, 2002 Hawkes, O'Connell, & Blurton Jones, 1997).

Husband Wife Relationship

Women often do not know exactly when they have reached menopause since they are nursing their last child and so would not be menstruating anyway. After a woman is a few years beyond menopause, her husband may leave her for a younger woman. A very low percentage of women over 60 have husbands and some of them express bitterness that their husbands have left them. However, most postmenopausal women appear to embrace wholeheartedly their role as an important provider of food and care to their grandchildren.

Disorders of Galactose Metabolism Clinical Manifestations

Ovarian atrophy appears to be an important manifestation of galactose toxicity, with clinical and biochemical evidence of ovarian dysfunction present in nearly all affected females. The basis of the toxicity has not been defined. The consequences of the gonadal dysfunction range from failure of pubertal development, through primary amenorrhea to secondary amenorrhea or premature menopause (75-76 of affected females). Although gonadal function has been described as early as infancy based on elevations of follicle stimulating hormones

Looking at Hormonal Medication Options

Why do hormones decrease the symptoms of endometriosis Because they induce a state similar to either pregnancy or menopause. (See the section Understanding Medical Treatment How Drugs Fight Endometriosis earlier in this chapter for further explanation.) Endometriosis symptoms generally disappear at those two times and may stay away for long periods of time (probably forever in menopause ).

Regulation of Metabolism

As discussed below, alterations in homocysteine metabolism also occur after menopause, in diabetes, and in hypothyroidism. These observations suggest that hormones, including estrogen, insulin, thyrox-ine, and thyroid-stimulating hormone, may directly or indirectly affect homocysteine metabolism. As for oxidative stress, the mechanisms by which these hormones affect homocysteine metabolism are poorly understood.

Pursuing antiprogestins

I Gestrinone As the most studied antiprogestin, gestrinone (Dimetriose) seems comparable to GnRH agonists in reducing pain but with fewer menopausal symptoms. Gestrinone also seems to have a less negative effect on bone density. In one study, bone density even increased slightly. The side effects are similar to androgens like danazol (see Debating danazol Danocrine earlier in this chapter). Gestrinone isn't currently available in the United States.

Perimenopausal transition

Perimenopause is defined as the two to eight years preceding menopause and the one year after the last menstrual period. It is characterized by a normal ovulatory cycle interspersed with anovulatory cycles. Menses become irregular, and heavy breakthrough bleeding can occur. Some women complain of hot flashes and vaginal dryness. C. Irregular bleeding and menopausal symptoms during this perimenopausal transition may be treated by estrogen-progestin replacement therapy. However, some women still require contraception. In this case, menopausal symptoms may be effectively treated with a low-dose oral contraceptive if the woman does not smoke and has no other contraindications to oral contraceptive therapy. D. The oral contraceptive can be continued until the onset of menopause, determined by a high serum FSH concentration after six days off the pill. Estrogen replacement therapy can be started at this point. II. Menopause occurs at a mean age of 51 years in normal women. Menopause...

Consumption of soybean and reduced incidence of disease

The structure of soybean isoflavonoids is uniquely similar to that of estrogen (17) and may account for their weak ability to act as agonists at estrogen receptors (38). Many have speculated that soybean isoflavonoids may be useful for the treatment of somatic, mood, and cognitive disturbances associated with the onset of menopause (39). Diet supplementation with soybean phytoestrogens has been reported to ameliorate hot flashes and other symptoms of menopause (40-43). Soybean isoflavonoids may also have potential in natural chemoprevention therapies against long term health problems associated with menopause, particularly for osteoporosis (44-47). After menopause, the ovaries stop producing estrogen. Because estrogen positively affects the metabolism of calcium, lack of sufficient estrogen can lead to bone loss and osteoporosis (48). Hormone replacement therapy (HRT) can reduce bone loss and the risk of osteoporosis in postmenopausal women, but unfortunately appears to also increase...

Population versus highrisk group screening

Screening before 50 years of age is controversial. Looking more closely at the effect of screening over the age of 50, the benefit seems to increase with age. In other words, screening with mammography seems effective after the menopause, but may have limited effect earlier. Moreover, the discussions on the effect of screening by mammography are statistical debates on whether or not it is beneficial to the group examined. Mammography every second year does not provide a guarantee against dying of breast cancer the individual women examined may not feel safe. When dealing with one young BRCAl-mutation-carrying woman, the issues surrounding her need for health are quite remote from the population-based cost benefit strategic thinking that underlies the screening programmes. Screening mammography may be very efficient at population level, but still inadequate for any given high-risk woman.

The Cultural Construction of Elderhood and Older Adulthood

Cultural perceptions of older adulthood or old age link changes in the person's physical being (reduction of work capacity, beginning of menopause) with social changes (such as the birth of grandchildren) to create a culturally defined sense of oldness. Like elderhood, this social boundary can have various gradations that can even extend beyond the point of death into a category of ancestors (Kopytoff, 1971). However, many societies also recognize those truly ancient adults who show sharp declines in functioning as a different category of old. For example, to the Ju 'hoansi people of Botswana old age is perceived to begin relatively early and can start in a person's mid-40s when and if changes in physical capabilities begin to diminish functional ability. Here there are three levels of old, a beginning early stage, a frail but functional stage, and a physically disabled designation. Counterbalancing the Ju 'hoansi linkage of older adults with physical decline is a powerful association...

Gender over the Life Cycle

Silverman notes that in general there was little concern over the changes associated with puberty or with menopause. Instead, the critical period in a woman's life was the period of courtship. Courtship initiated a crisis and a state of insecurity that was only partially resolved at marriage and fully resolved only at the birth of the first child. Silverman (1975b) points to a parallel between her findings in this rural area of central Italy, and those of Anne Parsons who was working in Naples at the time. Parsons (1967) also indicated that the years of courtship were the most distressing in a woman's life. The stress and anxiety related to the numerous pressures that the girl was subject to once she was engaged to be married, not least those provoked by the turmoil of the relationship itself. Young fianc es were also vulnerable to gossip. But Silverman shows that in the central Italian area where she carried out research, the intensity of the crisis varied significantly, especially...

Carcinoma Of The Breast Introduction

Breast cancer accounts for approximately 24 of all malignancies occurring in the female population in industrialised western societies and 18 of deaths in women due to malignant disease. In the UK there are approximately 117 cases per 100 000 women (34 000 new cases per annum). Thus, 1 at least 12 women will develop breast cancer during their lifetime and the incidence is rising by approximately 2 per annum. Breast cancer rarely occurs in women under the age of 25 years. Thereafter, the incidence increases steadily until at the time of the menopause, where the incidence plateaus out. After the menopause there is again a steady increase in

Gender and cardiovascular disease

The sex differential in the age of onset of CHD is also one of the reasons why estrogen is of interest as a potential preventive treatment for CHD. Lipid levels in children of both sexes are similar until puberty, when high density lipopro-tein (HDL) cholesterol levels fall by about 10mg dl in boys only, while low density lipoprotein (LDL) cholesterol levels decrease by about 5mg dl in girls.2 These changes may be attributable to rising androgen and estrogen levels in boys and girls respectively. The sex differential for HDL cholesterol persists through adult life, but is less marked in older persons. LDL cholesterol levels rise during adulthood, and in older women LDL cholesterol levels eventually catch up with those in men. Estrogen levels in women gradually decline, starting some years before the menopause, during which time LDL cholesterol levels rise and HDL cholesterol levels decrease.3 These lipid changes may underlie the lower CHD risk in premenopausal women, and the gradual...

Perspectives and conclusion

Chlebowski RT and McTiernan A (1999). Elements of informed consent for hormone replacement therapy in patients with diagnosed breast cancer. J Clin Oncol 17 130-42. Cobleigh MA, Norlock FE, Oleske DM and Starr A (1999). Hormone replacement therapy and high S phase in breast cancer. J Am Med Assoc 281 1528-30. Col NF, Hirota LK, Orr RK, Erban JK, Wong JB and Lau J (2001). Hormone replacement therapy after breast cancer a systematic review and quantitative assessment of risk. J Clin Oncol 19 2357-63. Collaborative Group on Hormonal Factors in Breast Cancer (1997). Breast cancer and hormone replacement therapy collaborative reanalysis of data from 51 epidemiological studies of 52 705 women with breast cancer and 108 411 women without breast cancer. Lancet 350 1047-59. Kavanagh AM, Mitchell H and Giles GG (2000). Hormone replacement therapy and accuracy of mammographic screening. Lancet 355 270-4. Parazzini F, Braga C, La Vecchia C, Negri E, Acerboni S and Franceschi S (1997)....

Venous thromboembolism

Persisted over the duration of the study. These findings on an adverse event from a clinical trial are very similar to those from the observational studies. In exploratory analyses, other risk factors for venous thromboembolism included older age at menopause, lower extremity fractures, cancer, being within 90 days of inpatient surgery, or non-surgical hospitalization. After non-fatal MI the risk was increased for 90 days. Use of statins or aspirin appeared to decrease risk it should be noted, however, that these were non-randomized comparisons and that the large number of comparisons performed may have led to chance findings. The WEST study investigators stated that there were no differences in venous thromboembolism between treatment groups.53 As noted above, healthy women in the WHI have been informed of an excess risk during the first few years of the study.35 Some trials with intermediate or surrogate outcomes (for example, the Postmenopausal Estrogen-Progestin Interventions and...

Treatment recommendations

Because the trials have failed to show benefit for secondary prevention, and there are no published trial data for primary prevention, in both instances decisions about hormone therapy should be based on established non-cardiovascular risks and benefits.64 The major proven benefits of estrogen are relief of the symptoms accompanying the menopause, urogenital atrophy, and prevention of osteoporosis. Known risks include endometrial cancer, venous thromboembolism, pancreatitis (in women with high blood triglycerides), and gallbladder disease. At the average age of menopause, the risk for cardiovascular and non-cardiovascular disease conditions is low, and therefore, the short-term use of estrogens to manage the menopause is not at issue.65

Shideler n3 women 10 cycles

This three-part figure summarizes prospective data on ovulation disturbances during the perimenopause. The top section shows the proportion of three women experiencing three consecutive cycles that are normal (open bar) or showed ovulation disturbances (short luteal phase SLP and or anovulatory in black). MetcalPs data in women with irregular cycles are shown on the left (n 58) and on the right prospective data for 3 4 consecutive cycles in three women (see Fig. 4). The middle portion of the diagram shows prospective data drawn as percentage of ovulatory (open bar, includes SLP for Shideler data ) and anovulatory cycles (black bar). The bottom panel shows the percentage of sera with luteal levels of progesterone (Luteal Levels Prog, open bar) or low progesterone levels (Low Prog, black bar) during the 72 61 versus 6 0 months before the final menstrual flow from Rannevik data. mo, months. All data redrawn from published work (Metcalf 1979, Shideler et al 1989, Brown 1985,...

Clinical evaluation

Ninety percent of patients with endometrial cancer have abnormal vaginal bleeding, usually presenting as menometrorrhagia in a perimenopausal woman or menstrual-like bleeding in a woman past menopause. Perimenopausal women relate a history of intermenstrual bleeding, excessive bleeding lasting longer than seven days or an interval of less than 21 days between menses. Heavy, prolonged bleeding in patients known to be at risk for anovulatory cycles should prompt histologic evaluation of the endometrium. The size, contour, mobility and position of the uterus should be noted.

Musculoskeletal System

Bone mineral content declines with age this aging process is known as 'osteopenia.' (It should be distinguished from the related pathological process in which bone architecture is altered, producing 'osteoporosis.') From the peak in the third and fourth decades, a 30 average decline in bone mineral density occurs through the ninth decade. In women, there is well-characterized acceleration of the rate of bone mineral loss immediately following the menopause. Decreasing levels of anabolic hormones may be associated with musculoskeletal atrophy and decrease in function that is observed in older women. This change in skeletal mineralization with aging is not associated with any apparent change in vitamin D nutriture as reflected in circulating levels of the vitamin.

Gonads and Reproductive System

It has been aptly stated by Harman that ''It is clear that aging results in alterations of endocrine physiology, which in turn appear to contribute to development of the senescent phenotype.'' Aging is associated with a decrease in pituitary hormone secretions. This decline explains, in part, the reduction in gonadal hormone production with aging. Primary aging of the testes and ovaries themselves accounts for the remainder of the changes. As the ovaries have a finite number of eggs, ovulation can only continue through the number of cycles that correspond to the original store of ova. Menopause ensues with the characteristic cessation of estrogenic hormone secretion. In both sexes, gonadal andro-genic hormone production declines with consequent effects on libido.

Bone Mass and Nutritional Factors

Throughout life, bone mass changes, with a maximum (peak bone mass) achieved by age 25-30 years and bone loss occurring after the fourth decade. Higher calcium intakes in childhood and early adulthood result in a 3-8 greater bone mass later in life, thereby improving the key factor in the osteoporotic process and the age-associated risk of fractures. In women, there is a perimenopausal increase in the rate of bone loss that persists after menopause following a decline in oestrogen production (Figure 3).

Female Reproductive Tract

Folliculogenesis begins in fetal life. Primordial germ cells multiply by mitosis. They begin to differentiate into primary oocytes and enter meiosis between the 11th and 20th weeks after fertilization. Primary oocytes remain arrested in prophase of the first meiotic division until meiosis resumes at the time of ovulation, which may be more than four decades later for some oocytes. Meiosis is not completed until the second polar body is extruded at the time of fertilization. Around the 20th week of fetal life, about 6 to 7 million oocytes are available to form primordial follicles, but the human female is born with about only 300,000 to 400,000 primordial follicles in each ovary. Oocytes that fail to form into primordial follicles are lost by apoptosis. The vast majority of primordial follicles remain in a resting state for many years. In a seemingly random process, some follicles enter into a growth phase and begin the long journey toward ovulation, but the vast majority of developing...

Other Lifestyle Factors

Other lifestyle choices, such as smoking, alcohol abuse, and physical activity, also impact overall bone health. Excessive alcohol intake is a risk factor for low bone mass. This finding may be a consequence of poor dietary quality in chronic alcoholics and may also be related to adverse effects of excessive alcohol intake on osteoblast function. Cigarette smoking also adversely impacts bone health. Smokers may be leaner, and female smokers may experience an earlier menopause and have lower postmenopausal estrogen levels. Smoking may also have adverse effects on bone cells either directly or indirectly through an increase in oxidative stress.

PMS and Dietary Factors

The abnormally high prolactin secretion of PMS via the ability of certain of its phytochemicals to mimic the action of dopamine by binding to dopamine receptors in the pituitary. Other herbs traditionally used in phytotherapy for PMS contain phyto-oestrogens. These molecules may have oestrogen-like action, either due to the steroidal nature of their active constituents (false unicorn root, Chamaelirium luteum A. Gray) or to the spatial similarity of active groups in their constituents, which allow them to bind to oestrogen receptors. Among the latter group are isoflavonoids and lignans, which appear to have 'adaptogenic' properties They are weakly oestrogenic at low circulating oestrogen concentrations and antioestrogenic at high oestrogen concentrations. Isoflavonoids are present in soya bean and its products and in medicinal herbs such as black cohosh (Cimicifuga racemosa Nutt.) these show a beneficial effect in reducing symptoms of PMS and the menopause. Lignans are present in high...

Who Might Benefit From Ovarian Tissue And Egg Freezing

All women are born with a limited supply of eggs. These eggs continue to dwindle in supply as we grow older. One recent study indicated that 98 percent of women are fertile through their early 20s. However, by their mid-30s, the percentage of those who are still fertile drops to about 70 percent. This biological clock phenomenon continues to tick until a woman reaches menopause and all of her eggs are depleted. Given that, the preservation of eggs and ovarian tissue by means of freezing can be of great benefit for many women who Are facing the loss of their ovarian function because of approaching menopause, disease, or planned complete hysterectomy

Endocrine abnormalities and bone loss in women

This phase begins at menopause, can be prevented by oestrogen replacement, and almost certainly results from the cessation of ovarian function. Oestrogen acts through high affinity oestrogen receptors in osteoblasts and osteoclasts to restrain bone turnover, and when this restraint is lost at menopause, overall bone turnover increases and resorption increases more than formation. In addition, the increased activity of osteoclasts and their prolonged lifespan lead to trabecular plate perforation and to loss of structural elements, thus weakening bone out of proportion to the loss of bone density. The high rate of bone resorption increases skeletal calcium outflow, which leads to a partial suppression of parathyroid hormone (PTH) secretion and compensatory increases in urinary calcium excretion (Riggs et al 1998). The reason for the cessation of the rapid phase of contrast, serum PTH levels increase progressively in the late slow phase of bone loss and are decreased by oestrogen...

Endocrine abnormalities and bone loss in ageing men

Except after orchiectomy, men do not have an equivalent of the rapid phase of bone loss that women experience following menopause. After accounting for the absence of this phase, the patterns of late bone loss and of the increases in serum PTH and bone resorption markers in ageing men are virtually superimposable upon those occurring in women (Riggs et al 1998). In the past, it has been difficult to attribute male bone loss to sex steroid deficiency because men do not have an equivalent of menopause, and because serum total testosterone levels

Hysterectomy Cures Endometriosis

However, hysterectomy with removal of both ovaries will permanently get rid of endometriosis symptoms in most women, because removing the ovaries removes most of the hormonal stimulation that activates endometrial implants, wherever they're found. Unfortunately, the surgical menopause that results has a multitude of additional symptoms to cope with (refer to Chapter 11 for more info).

Cardiovascular Disease

In ischemic heart disease, there is a very marked gender difference Women die 10-15 yr, later than men and the death rate in women increases exponentially after the age of 50. In case of artificial menopause, the risk for atherosclerosis is two to three times higher than a menopausal age of 50 yr. The mortality figures for coronary heart disease vary from 50 to 200 per 100,000 inhabitants (male more than female) and for cerebrovascular disease, 100 per 100,000 inhabitants (female more than male). Elevation of homocysteine (> 80th percentile of controls) appeared to be at least as strong a risk factor for vascular disease in women as in men, even before menopause. For post-methionine-load homocysteine, there is a 40 stronger association with vascular disease in women than in men. In both sexes, low vitamin B6 conferred a twofold to threefold increased risk of vascular disease, independent of homocysteine. Folate levels lower than the 20th percentile were associated with a 50...

Gender and Religion

Beliefs about purity and pollution explained Cherokee attitudes toward menstruation, childbirth, and menopause. They believed that the periodic contact with blood was powerful and dangerous. During menstruation blood was outside its appropriate place in the body and women had to take precautions such as retiring to menstruation huts, not participating in ceremonial activities, avoiding contact with the sick, or performing normal tasks. Cherokees believed that the power of blood would neutralize all the treatments of medicine people. Husbands also had regulations to observe, such as dancing behind others in ceremonial occasions and not having intercourse (Perdue, 1998).

National Osteoporosis Foundation

Measurement of BMD is recommended for all women 65 years and older regardless of risk factors. BMD should also be measured in all women under the age of 65 years who have one or more risk factors for osteoporosis (in addition to menopause). The hip is the recommended site of measurement.

Clinical Conditions in Reproductive Age Females

LEIOMYOMAS Leiomyomas (fibroids) are benign tumors of muscle cell origin and are the most frequently occurring pelvic tumor. They are found in one of four white women and in one of two black women.10 Commonly, there is more than one fibroid present. The etiology of leiomyomas is unclear, and theories include the proliferation from a single muscle cell from a small embryonic rest or a defined region of tissue with a higher level of estrogen receptors. They decrease in size during menopause, and enlargement is seen early in pregnancy and, in some cases, OCP use. Up to 30 percent of patients with leiomyomas experience pelvic pain and abnormal bleeding. Acute pain is rare, but severe pain may be experienced with torsion or degeneration. Degeneration is a result of rapid growth and loss of blood supply. This is almost exclusively seen in early pregnancy. The diagnosis of leiomyoma is made on physical examination. A mass or commonly multiple masses are palpable. In patients with acute...

Physical Examination

Older patients with a history of pelvic pain and bleeding should undergo a full gynecologic examination. Degenerative changes to the lumbar spine and hips may make the traditional lithotomy position difficult. Alternatively, the patient may be examined supine with knees flexed and legs dropped to the side, or lying on her side with the lower arm behind her back and thighs flexed (the Sims position). A small speculum (e.g., a 1- to 1.5-cm Pederson) should be used if the vulva and vagina appear atrophic. Physicians must remember that the vaginal walls may become adherent in individuals who are not sexually active, and a gentle digital examination may be required to ensure that a speculum examination is possible. Vaginal examination is generally well tolerated in women who are on estrogen replacement. Documentation of the size, shape, and mobility of the uterus is especially important when making a diagnosis in this population. Ihe normal ovary should not be palpable 5 years after...

TABLE 987 Etiology of Postmenopausal Bleeding

Hormone replacement therapy is commonly used to relieve symptoms associated with menopause and to reduce the risk of cardiovascular disease. Most therapeutic regimens deliver sequential progestins to induce withdrawal bleeding and protect the endometrium from atypia. Other therapies use continuous administration of estrogen and progesterone to achieve an atrophic endometrium and amenorrhea.12 In patients treated with sequential hormonal therapy, heavy or prolonged bleeding at the end of the cycle or breakthrough bleeding in two or more cycles should be investigated. Of patients on continuous therapy, 40 percent will have abnormal bleeding in the initial 4 to 6 months. There is no acceptable criteria for abnormal bleeding on these therapies, and investigations are warranted if bleeding continues beyond 6 months or recurs after amenorrhea is established. Although bleeding is frequently caused by an unstable or atrophic endometrium, other causes must be considered. Important conditions...

Channel Functions And State Functions

It is unlikely that there will be a one-to-one relationship between any of these modulatory pathways and specific cognitive or comportmental domains. In general, however, the activation of these modulatory pathways provides a mechanism for augmenting the neural responses to novel and moti-vationally relevant events, facilitating their storage in memory, enhancing their access to on-line processing resources, sharpening the attentional focusing they elicit, and increasing their impact on consciousness. These projections are in a position to alter the tone, coloring, and interpretation of experience rather than its content. In addition to cholinergic and monoami-nergic receptors, many areas of the cerebral cortex, especially components of the limbic system, also contain receptors for estrogen, testosterone, and other steroids. Alterations in the circulating level of these hormones, as in puberty or menopause, could influence behavioral states in a manner analogous to the effect of the...

Biomedical Realities Constructing Diseases

Sociolinguistic and narrative studies of Biomedicine take discourse as a central topic in terms of education (Good, 1994) and therapeutics (Labov & Fanshel, 1977 Mattingly, 1999). Biomedical communication patterns, physician silence, and aspects of a discourse of practitioner error have been investigated, as well as the discourse on medical competence (Bosk, 1979 DelVecchio Good, 1995 Paget, 1982), and the logic and semantic load of patients' discourse (Good, 1994 Kleinman, 1988b Mattingly, 1999 Young, 1995). Physician discourse also serves to construct the patient not only as body part, but also in terms of social identity (e.g., implicative age, race, gender or gender categories). Such constructions have strong consequences for treatment (Gaines, 1992c, 1992d Good, 1994 Gordon & Paci, 1997 Lindenbaum & Lock, 1993) for example, physicians often create probabilistic scenarios about patients that guide diagnosis and treatment (e.g., this 50-year-old white female patient with...

Risk as Self Governance

Medicalization of female middle age, and in particular the end of menstruation, commenced early in the 19th century but it was not until the 1930s, after the discovery of the endocrine system, that menopause came to be represented in North America and Europe as a disease-like state characterized by a deficiency of estrogen. In order to sustain this argument, the bodies of young pre-menopausal women must be set up as the standard by which all female bodies will be measured. Post-menopausal, post-reproductive life can then be understood as deviant. This expert knowledge is buttressed through comparisons made with human populations where Today older women are warned repeatedly about heart disease, osteoporosis, memory loss, and Alzheimer's disease, and numerous other conditions for which they are said to be at increased risk due to their estrogen-deficient condition. Misleading interpretations of often poorly executed epidemiological research create confusion about estimates of risk for...

Other Causes of Hyperhomocysteinemia

Homocysteine levels tend to rise in women after the menopause. Hormone replacement therapy reduces homocysteine back to premenopausal levels. Moreover, homocysteine decreases in male to female transsexuals, and increases in female to male transsexuals, primarily related to the estrogen and androgen regimens that such individuals respectively follow. Taken together, these observations strongly suggest an influence of sex hormones on homocysteine metabolism, though the mechanisms are not well understood.

New Trends in the Study of Biomedicine

Midwifery (see Davis-Floyd, Cosminsky, & Pigg, 2001) and menopause (e.g., Lock, 1993) all of which have been intensely biomedicalized. Many of its latest works focus on Biomedicine's new reproductive technologies (NRTs), which have expanded exponentially in recent years, from the birth of the world's first test-tube baby in 1978 to current attempts at human cloning.

Clinical consequences of the decline in activity of the hormonal systems

Andropause In most women, the period of decline in oestrogens during menopause is accompanied by vasomotor reactions, depressed mood, and changes in skin and body composition (increase in body fat and decrease in muscle mass). In the subsequent years, the loss of oestrogen is followed by a high incidence of cardiovascular disease, loss of bone mass and cognitive impairment (Lindsay et al 1996). Only recently has it become evident that oestrogens may not only play an important role in regulating bone turnover in women, but also in men. Smith et al (1994) described a male with a homozygous mutation in the oestradiol receptor gene who, even in the presence of normal T levels, had unfused epiphysis and marked osteopenia, along with elevated indexes of bone turnover. A few studies now have demonstrated significant relations between serum (bioavailable) oestradiol levels and bone mineral density in elderly men (Khosla et al 1998).

Nutrients in the soil in the absence of permanently cultivated fields hotcold health systems See humoral medicine human

Non-biomedical realms (e.g., pregnancy, birth, menopause, exercising). medical pluralism. In contrast to indigenous societies, which tend to exhibit a more-or-less coherent medical system, state or complex societies have an array of medical systems a phenomenon generally referred to by medical anthropologists, as well as medical sociologists and medical geographers, as medical pluralism. medium. Part-time religious practitioner who is asked to heal and divine while in a trance.

Fat Distribution and Disease Risk

Since fat distribution is correlated with age as well other risk factors for disease, such as smoking, alcohol consumption, physical activity, and menopause in women, it is important to control for the effects of these variables in order to obtain an estimate of the independent effect of central obesity on morbidity. The impact of some of these correlates of fat distribution may be subtle and unlikely to seriously distort relationships between fat patterning and disease. However, age, the ultimate risk factor for disease and death, is sufficiently highly correlated with fat distribution to result in substantial distortion. Similarly, cigarette smoking is related adequately strongly to fat patterning and to various diseases and outcomes to make analyses that do not adjust for smoking difficult to interpret.

Changes in Calcium Metabolism during the Life Span

Menopause begins a period of bone loss that extends until the end of life. It is the major contributor to higher rates of osteoporotic fractures in older women. The decrease in serum estrogen concentrations at menopause is associated with accelerated bone loss, especially from the spine, for the next 5 years, during which approximately 15 of skeletal calcium is lost. The calcium loss by women in early menopause cannot be prevented unless estrogen therapy is provided. Calcium supplements alone are not very helpful in preventing postmeno-pausal bone loss. Upon estrogen treatment, bone resorption is reduced and the intestinal calcium absorption and renal reabsorption of calcium are both increased. Similarly, amenorrheic women have reduced intestinal calcium absorption, high urinary calcium excretion, and lower rates of bone formation (compared to eumenorrheic women). In both men and women, there is a substantial decline in intestinal absorption of calcium in later life.

Life Span and the Aging Process

The aging process causes many changes, both visible and invisible. In humans, these changes take several forms. In the first two decades of life, from birth to adulthood, aging involves physical growth and maturation and intellectual development. These changes are fairly noticeable and relatively swift compared to the rest of the life span. After reaching physical maturity, humans begin to show subtle signs of physical aging that grow more pronounced over time. Long-term exposure to sunlight and the outdoors may begin to toughen the skin and produce wrinkles on the face and body. The senses change Sight, hearing, taste, and smell become less acute. Gradual changes in the eye cause many older adults to need glasses to read. Hair begins to thin and turn gray. Individuals with less active lifestyles often begin to gain weight, particularly around the waist and hips. Beginning in their 40s (or, rarely, in their late 30s), many women experience menopause, which marks the end of...

Removing your ovaries

Some women don't want to risk losing all their natural hormones. One ovary can provide plenty of natural hormones to prevent menopausal symptoms with the potential problems of osteoporosis and other menopausal problems. The only major difference with an oophorectomy is the removal of the ovarian hormones and the short- and long-term effects of no estrogen. If both ovaries are gone, essentially all the estrogen and progesterone producers are gone too. This absence of estrogen can cause menopausal symptoms within a few days of the surgery and may last for a variable amount of time, from months to years. Symptoms usually abate eventually. If they don't, your doctor may prescribe hormone replacement, depending on your overall health history, such as history of heart disease or cancer. If surgery removes only one ovary, the other ovary may shut down for some time. As a result, a woman may have the same menopausal symptoms for the short term. In almost all cases, the remaining ovary begins...

Colorectal Cancer Background and aetiology

In 1972, Burkitt described the relationship between diet and incidence of bowel cancer he hypothesised that a diet rich in fibre was associated with regular bulky stools and reduced bowel carcinogenesis, perhaps by reducing exposure of colonic mucosa to dietary carcinogens. It does seem likely that the combination of high fibre and low fat may be protective against bowel cancer. Protection against colorectal carcino-genesis is also derived from dietary supplements of calcium and folate and evidence from the Nurses Health Study (North America) suggested that oestrogen in the form of hormone replacement therapy (HRT) lowers the incidence of colorectal neoplasia. There has been interest in the potential influence of non-steroidal anti-inflammatory drugs in colorectal carcinogenesis. Cyclooxygenase (COX)-2 inhibition appears to have potent effects on the colonic mucosa, increasing apoptosis and reducing cellular proliferation. It is also likely that these drugs function through...

Investigating The Aging Brain

One relatively recent set of findings illustrates this problem particularly well. Several studies have shown that the female sex hormone estrogen may affect neurons so that higher hormonal levels improve learning and memory. Moreover, some research suggests that estrogen may protect against Alzheimer's disease. Therefore, when women go through menopause, they could show a decline in cognitive function due to reduced estrogen levels, and thus, there will be a sex-based aging difference. For those women at risk for Alzheimer's disease, there may be a further insult on neuronal function. Estrogen replacement therapy, more common now than in previous years, may ameliorate these effects. Whether or not these specific findings hold up as research continues, this illustration shows the complex interactions involving aging changes, sex, cognitive alterations, and disease risk factors that can confound experimental studies of aging and that can affect our ability to define what healthy aging...

Whats in a Name

In addition to its myeloablative effects, HDC is extremely toxic to other tissues with dividing cells, such as the gastrointestinal tract, the skin, and the hair follicles. Acute toxicities include cramping and dysfunction in the gastrointestinal tract, mouth sores, nausea, diarrhea, rashes, and fatigue. Total hair loss is very common but varies with the type of chemotherapy used. Severe organ toxicity is less common but can be fatal. The lungs are particularly sensitive to some drugs (e.g., vincristine in the Solid Tumor Autologous Marrow Program I regimen), and life-threatening interstitial pneumonitis can occur, resulting in fluid accumulation and reduced blood oxygen. Other severe adverse effects may include liver damage and inflammation of the bladder. Cardiac events occur more often with HDC. For these reasons, patients who underwent HDC ABMT were usually hospitalized for several weeks and sometimes for months if complications occurred. During hospitalization, patients were at...


Each month, under the influence of your reproductive hormones, one of your ovaries selects between 10 and 20 eggs to become possible candidates for release. The number of eggs decreases with age until menopause, when ovulation stops completely. The chosen eggs begin to mature within their own sacs, called follicles. In


Menopause, occupies only half of average adult life expectancy. Despite the enduring fertility potential, fathers older than 50 years are responsible for only *1 of births in developed countries. Communal procreative patterns are determined by the similarity of couple's age and the overwhelming age-restriction of female fertility. Nevertheless, fertility concerns of men cannot be disregarded at any set age particularly with increasing remarriage to younger women.

Androgen effects

Following the adage that when one's only tool is a hammer, remarkably soon all problems turn into nails, it is an understandable that androgen administration is proposed for older men. Such proposals long pre-date the first availability of testosterone (Hamilton 1937) with many bouts of rejuvenation quackery associated with the names of Brown-Sequard, Steinach and Voronoff into the early 20th century. Standard clinical endocrine practice includes replacement therapy for unequivocal hormonal deficiencies of the pancreas (insulin), thyroid (thyroxine), adrenal (glucocorticoid, mineralocorticoid) and gonads (oestrogen, androgen). Conversely, hormone replacement is not provided for other classical hormones such as prolactin, glucagon, somatostatin, calcitonin, calcitonin-gene related peptide and adrenalin, and other hormones (thyroid-stimulating hormone, LH, FSH, parathyroid hormone) are not replaced but substituted by simpler non-peptide end products. Generally, the criteria for a...

Reproductive factors

It is now 100 years since George Beatson, a Glasgow surgeon, first reported that removal of the ovaries of a young female could reverse the progress of recurrent breast cancer, and there is now unlimited evidence that deprivation of oestrogens in both pre- and post-menopausal women can alter the progress of the disease. In young women, oestrogens are secreted by the thecal cells of the ovary, but following the menopause, oestrogens are synthesized from precursors of adrenocortical origin in liver and fat through the action of aromatase enzymes. Active ovarian function is a necessary prerequisite for the development of breast cancer. Women who have an artificial menopause before the age of 35 years have one-third the incidence of breast cancer compared to women whose ovaries remain intact until their natural menopause. The younger the age at menarche and the older that at menopause the greater is the risk of breast cancer, this being related to the number of ovarian cycles during the...

Gender Bias

Age of disease onset is invariably later in female FSHD gene carriers, who are also more likely to exhibit a less severe form of the disease. 13 It has been suggested that female hormonal status somehow confers a mild protective effect. Consistent with this view, disease progression is markedly accelerated in female patients following menopause, which is often associated with a general decline in muscle strength.

Candida Vaginitis

The organism can be isolated from up to 20 percent of asymptomatic, healthy women of childbearing age, some of whom are celibate. Therefore, this infection is not considered a sexually transmitted disease (STD), although it can be transmitted that way. Factors that favor increased rates of asymptomatic vaginal colonization include pregnancy, oral contraceptives, uncontrolled diabetes mellitus, and frequent visits to STD clinics (perhaps as a result of antimicrobial therapy). It is rare in premenarchial girls4 and has a decreased incidence after menopause unless replacement estrogen is being used, emphasizing the hormonal dependence of VVC. Immunity to Candida infections is primarily cell mediated.

Breast Cancer

The etiology of breast cancer is multifactorial. Family history is an important determinant if a mother or a sister develops breast cancer during the premenopausal years or when the disease occurs bilaterally. Genetic mutations have been identified. However, only 5 to 10 percent of all breast cancers are due to such mutations. 2 Specific risks for carrying the BRCA1 and BRCA2 mutations, and the subsequent risks for development of disease have been reviewed by others. 2 Such specifics are best left to genetic counselors or breast specialists, and genetic testing should not be ordered in the emergency department. Less well-defined, and more universally applicable risk factors for breast cancer include nulliparity, late first pregnancy or late menopause, increased fat intake, exogenous estrogen, and ethanol use.


Stress urinary incontinence occurs when urine is involuntarily lost as a result of increased intraabdominal pressure, i.e., when the intraurethral pressure is less than the intraabdominal pressure. It is caused by multiparity, vaginal delivery, pregnancy, menopause, chronic cough (i.e., chronic obstructive pulmonary disease), or other forms of pelvic relaxation. Symptoms include leaking of urine during cough, straining, laughing, sneezing, running, or other causes of increased intraabdominal pressure. Diagnosis involves ruling out infection, neurologic disease, medications, or other systemic illness as possible causes of stress urinary incontinence. A thorough history and physical examination are required, including full vaginal examination with inspection of all the vaginal walls. Further workup by the consulting gynecologist includes stress testing and, if necessary, urodynamic testing. Treatment options are both nonoperative and operative. Nonoperative options include Kegel...

Uterine Cancer

Multiple risk factors have been associated with endometrioid adenocarcinoma of the uterus such as early menses, late menopause, nulliparity, obesity, diabetes, hypertension, and unopposed estrogen use. The use of progestins has drastically reduced the risk of endometrial cancer by 50 percent. Tamoxifen, an antiestrogen that competes with estrogen at its receptor site, has been shown to increase the risk of adenocarcinoma of the uterus.


Because of the difficulty in differentiating benign from malignant disease and the potential malignant behavior of benign lesions, many surgeons support an aggressive surgical approach for all Hurthle cell neoplasms.5,10 In addition, the majority of patients with Hurthle cell carcinoma do not respond to iodine-131 ablation therapy, rendering thyroidectomy the only effective treatment for malignant disease. Others, however, support a more conservative approach, recommending total thyroidec-tomy only for histologically documented malignant disease.1 Proponents of the conservative approach cite the potential surgical complications that can arise from overtreating benign disease with total thyroidectomy in addition to the lifelong requirement for thyroid hormone replacement therapy.

Resistance Training

The incidence of coronary heart disease increases with age and after the menopause (BHFS, 2004). This coincides with an age-related decline in muscular strength and fat-free mass after the age of 50 (ACSM, 2001). RE has been shown to prevent decline in muscle strength and has shown favourable improvements in lean muscle mass (Pollock, et al., 1998).These benefits support the inclusion of RE within a comprehensive cardiac rehabilitation programme.


Risk factors for breast cancer should be determined, including menarche before age 12 years, first live birth at age > 30 years, and menopause at age > 55 years the number of previous breast biopsies, the presence of atypical ductal hyperplasia on biopsy, obesity, nulliparity, increased age, the amount of alcohol consumed, and the number and ages of first-degree family members with breast cancer with two such relatives with breast cancer at any early age should be determined.

Abnormal Lactation

Galactorrhea is an inappropriate nonlactational milky white nipple discharge. Spontaneous galactorrhea usually indicates hyperprolactinemia, especially when there is concomitant amenorrhea. However, in approximately 30 percent of cases, prolactin levels are normal. Physiologic hormonal alterations that occur at menarche and early menopause can sometimes cause galactorrhea. Hormonal preparations can stimulate the breast tissue directly, elevating prolactin levels and stimulates milk production.


Fibroadenomas are the commonest benign tumours to arise in the breast and are most often seen in women under the age of 35 years. They comprise approximately 10 of symptomatic breast lumps. In older women, particularly after the menopause, they are quite uncommon. In the latter age group they can undergo involution and become calcified. Large, rapidly growing fibroadenomas may occur in girls and young women.

Hormonal factors

Data has accumulated from different epidemiological studies that a prolonged exposure to oestrogens may increase the risk of subsequently developing breast cancer. Therefore, the following have been shown to increase the relative risks of developing breast cancer early menarche, delayed menopause, late age of birth of first child and nulliparity.

Primary prevention

The Nurses' Health Study is representative of the observational studies, and the women in this study comprise one of the largest and best studied cohorts in the USA.21 The 1976 baseline examination included 121 700 nurses aged 30-55 years of whom 21 726 were postmenopausal. With the passage of time a progressively larger proportion entered the menopause and these women contributed data to a series of papers on the associations between menopause, hormone therapy, and cardiovascular disease. Data on


Hormone therapy has the advantage of less severe side effects than chemotherapy. Hormone therapy would be indicated in patients who were unfit for chemotherapy and also in those with disease present in multiple sites and with bone metastases. Responses to hormonal therapy have been reported in up to 60 of patients whose tumours have a high level of OR. Response rates are unlikely in OR negative tumours or in patients with hepatic metastases. If patients have been taking tamoxifen as adjuvant therapy before the development of metastatic disease then only 20-30 will respond to second-line hormonal manipulation, for example using medroxyprogesterone or aromatase inhibitors. It is also important to remember that even if patients demonstrate no response to first-line hormonal therapy, 20 will respond to second-line hormonal treatment. A further 10-15 may show a response to third-line hormonal treatment. In pre-menopausal women ovarian ablation (e.g. oophorectomy or radiation-induced...


5-2 years of follow up rather than the planned 8-5 years. The reasons for stopping were that an increased risk for breast cancer started emerging at 4 years, which by 5 years had crossed the prespecified monitoring boundary. In addition, there was evidence of overall harm. At the time of stopping, the hazard ratios (HR) for the major adverse effects were breast cancer 1-26 (95 CI 1-00-1-59), CHD 1-29 (95 CI 1-02-1-63), stroke 1-41 (95 CI 1-07-1-85), and pulmonary embolism 2-13 (95 CI 1-39-3-25). There were benefits for colorectal cancer, HR 0-63 (95 CI 0-43-0-93), and for hip fracture, HR 0-66 (95 CI 0-45-0-98), while endometrial cancer and all-cause mortality were not affected. The investigators conclude that the risk-benefit profile found in this trial is not consistent with the requirements for a viable prevention treatment, and in particular that this regimen should not be initiated or continued for the primary prevention of CHD. In addition, the substantial risks for...

Research in progress

Prospective data from the Vancouver Ovulation and Bone Change Cohort (Prior et al 1996, 1990a) are still being collected as these women become perimenopausal or menopausal. Some of those women continue to keep quantitative basal temperature and Daily Perimenopause Diary (Prior 1999) records, and will potentially provide important comparisons of ovulation and experiences in premenopausal and perimenopausal cycles in relation to subsequent menopause and bone density. As an illustration, one year of ovulatory characteristics (analysed by the QBT least squares method Prior et al 1990b) are shown from the initial study and 10 years later in one woman (Fig. 5). This woman's initial cycles averaged 29.3 1.6 days in length and became two days shorter (27.0 1.5 days, P 0.0004). The changes in luteal phase length were even more dramatic with reduction from a mean of 11.2 2.0 to 5.4 2.7 days over the 10 years (P< 0.0001). Note that she had no normally ovulatory cycles in 1994 1995 even though...


One needs to weigh up the balance of waiting, and thereby possibly risking the development of cancer, versus performing an early oophorectomy and leaving the patient prematurely hypo-oestrogenic. One would then need to address the issue of hormone replacement therapy (HRT). There is some evidence to suggest that the prolonged use of HRT is associated with an increased risk of breast cancer. In an extended follow-up of the participants in the Nurses' Health Study, Colditz found that the risk of breast cancer was significantly increased among women who were currently using oestrogen alone (relative risk (RR), 1.32 95 CI, 1.14-1.54) or oestrogen plus progestins (RR, 1.41 95 CI, 1.15-1.74) when compared with postmenopausal women who had never used hormones. Women currently taking hormones, who had used such therapy for 5-9 years, had an adjusted relative risk of breast cancer of 1.46 (95 CI, 1.22-1.74). Those currently using hormones, who had done so for a total of 10 or more years, had a...

Egg Donation

Of course, you'd prefer to use your own eggs, but that's not always possible. It could be that you've already tried to use your eggs during IVF procedures but had poor results. Or perhaps you no longer have any viable eggs because of menopause, chemotherapy, radiation, or another medical condition. In some cases, you may carry a genetic defect that you don't want to pass along to your offspring. In any of these situations, receiving eggs from another woman may be the answer to your fertility concerns.

Genetic testing

Genetic testing for the presence of mutations in BRCA1 or BRCA2 is still relatively new, and individuals undergoing genetic testing carry a substantial stress burden. If the results of the test are positive they cannot, of course, indicate when the disease will develop, or indeed whether it will, as the genes do not have full penetrance. Also, sporadic breast cancer risk factors are still present for these women (e.g. age of menarche, menopause, pregnancy and age).

Small Intestine

Figure 3 Rate of bone loss 1, bone mass change in women with a high initial amount of bone and an average loss after menopause 2, bone mass change in women with a low initial amount of bone and an average loss after menopause 3 and 4, bone mass change in women with high losses after menopause 5 and 6, bone mass change in women with an early menopause or after surgical removal of ovaries. First fractures occur approximately 10years after menopause. Figure 3 Rate of bone loss 1, bone mass change in women with a high initial amount of bone and an average loss after menopause 2, bone mass change in women with a low initial amount of bone and an average loss after menopause 3 and 4, bone mass change in women with high losses after menopause 5 and 6, bone mass change in women with an early menopause or after surgical removal of ovaries. First fractures occur approximately 10years after menopause.


Osteoporosis is a disease characterized by low bone mass and increased bone fragility and susceptibility to fracture. Adequate calcium, vitamin D, and other nutrients are critical to achieving optimal peak bone mass and modify the rate of bone loss with aging. After menopause, women experience rapid bone loss due to declining estrogen levels. Hormone replacement therapy, in conjunction with calcium, has been shown to be effective in reducing bone loss. Although less common in men, prolonged use of medications such as glucocorticoids as well as other factors may lead to osteoporosis in men.


On average, women have a higher body fat percentage the differences, however, decrease at older ages (72) , a smaller plasma volume, and a lower organ blood flow than men, with obvious implications for disparities in drug distribution. Moreover, the major protein groups responsible for binding in human plasma are influenced by sex hormone levels, so that plasma drug binding can clearly be influenced by gender. Note, however, that albumin is not greatly affected by gender (73). There were multiple reports of gender-related differences in aj-acid glycoprotein (AAG) concentrations (74-79), gender-dependent stereospecific binding (80,81), and estrogen-mediated decreases in AAG production (82). Nevertheless, gender differences in unbound fractions of disopyramide are lacking despite differing AAG levels (75). Further investigations did not demonstrate gender-related differences in free fractions of highly bound drugs in patients or in subjects receiving hormone replacement therapy or oral...


In women, oestrogen deficiency due to the menopause is the major cause of both the early rapid and late slow phases of age-related bone loss. In ageing men, oestrogen deficiency also appears to be the dominant cause and is due to age-related increases in serum SHBG and to impaired gonadal production of sex steroids. The role played by decreases in bioavailable testosterone in bone loss in

Atrophic Vaginitis

During menarche, pregnancy, and lactation and after menopause, the vaginal epithelium lacks the stimulation of estrogen. The maturation of the vaginal and urethra mucosa depends on the presence of estrogen and can be altered by the absence of estrogen or the presence of antiestrogenic factors, such as hormones, drugs, or diseases. Menopause results in a vaginal mucosa that is attenuated, pale, and almost transparent as a result of decreased vascularity. The vagina loses its normal rugae. The squamous epithelium atrophies, the glycogen content of the cells decreases, and the vaginal pH ranges from 5.5 to 7.0. The mucosa is only three or four cells thick and is less resistant to minor trauma and infection. Marked atrophic changes can cause atrophic vaginitis. It is important to distinguish between symptomatic atrophic vaginitis, which is rare, and an atrophic vagina that is a result of physiologic changes of menopause. When symptomatic vaginitis occurs, the vaginal epithelium is thin,...

Estrogen Signaling

Ovarian hormones have dichotomous effects when applied to the biology of the breast. On one hand, prolonged exposure through early menarche, belated menopause, or postmeno-pausal hormone replacement therapy increases the risk of breast cancer. On the other hand, an early full term pregnancy can significantly reduce breast cancer risk to humans (51), and in rodents pregnancy levels of estrogen and progesterone will impart a significant protection against carcinogen induced breast cancer (52,53). The context and duration of the signaling is likely to be the important determinant in the effects of estrogen. There is no doubt, though, that estrogen remains one of the critical hormones that regulate both normal and malignant development of the mammary gland.