The management of menopausal symptoms after cancer or risk-reduction surgery – A move towards consensus
Rosemary A Cochrane1, Ailsa E Gebbie1 and Graeme Walker2
1Chalmers Centre for Sexual and Reproductive Health, NHS Lothian, Edinburgh, UK; 2Department of Gynaecology, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
Email: rosemary.cochrane@ntlworld.com
Introduction: For women who survive reproductive cancers, menopausal symptoms following treatment can be a significant problem affecting quality of life and wellbeing. Information regarding hormonal treatment including hormone replacement therapy is a matter of debate, particularly following treatment for endometrial or ovarian cancer. Women will therefore often have received conflicting advice and may approach specialist menopause clinics in some desperation for help with management of symptoms. A woman with cancer or at high risk of cancer will have seen numerous multi-disciplinary healthcare professionals, many of whom may underestimate the impact that menopausal symptoms have on quality of life, especially in younger sexually active women.
The aim of this study was to examine referral patterns and symptom profiles of women with cancer or cancer risk, to identify areas where a more integrated approach to management might be required and to reach a local consensus across disciplines involved in the care of these women.
Methods: The Edinburgh Menopause Clinic provides the only specialist menopause service for NHS Lothian. The case records are fully computerised. A retrospective case record review of all new referrals between 2011 and 2012 for the management of cancer-related menopausal symptoms was undertaken. The results of the review were discussed at a meeting with specialists from hospital gynae-oncology, oncology and clinical genetics.
Results: Fifty-nine new patients had been referred for the management of menopausal symptoms and had had previous treatment for cancer (34), or were women with a confirmed risk factor and were considering, or had undergone, risk-reduction surgery (15). Menopausal symptoms were common and often severe in this population. The majority of women reported severe vasomotor symptoms; vaginal dryness and sexual difficulties were also common and the mean age of women with these problems was 41 years.
Management was agreed at the multidisclipinary meeting and a regional guidance document written thereafter. There has been an immediate improvement in the sharing of information between departments.
Conclusion: Management of the complex patient presenting with menopausal symptoms after treatment for cancer or for risk-reduction surgery is difficult; this multidisciplinary approach to aim for consensus between the specialties involved has so far proven fruitful and should continue to inform our management.
This presentation was awarded first prize in the Free Communications session at the British Menopause Society annual conference 2013.
Colpocleisis – An alternative operation for prolapse in elderly postmenopausal women
Mike Cust1, Carolyn Robertson1 and Maria Vogiatzi2
1Royal Derby Hospital, Derby, UK; 2Lincoln County Hospital, Lincoln, UK
Email: m.cust@nhs.net
Introduction: Increasing numbers of postmenopausal women are seeking treatment for pelvic organ prolapse symptoms. Current treatments include the use of pessaries or reconstructive surgery. Colpocleisis offers an alternative surgical option for elderly women with severe or recurrent prolapse, who are no longer sexually active, and for those who would be considered ‘high risk’ for a more complex and lengthy prolapse procedure. The Colpocleisis operation was originally described by Le Fort in 1877 but first performed by Neugebauer in 1867. Essentially it involves complete surgical closure of the vagina, leaving a small passage for draining of blood from the uterus.
Methods: A retrospective review of 30 cases of colpocleisis performed at Royal Derby Hospital between March 2007 and August 2012 was completed. Patients ranged from 67 to 89 years old and were no longer sexually active. All patients had severe (stage 3 or 4) prolapse and were symptomatic. Patients were seen in a follow-up clinic at three months post operatively to assess outcomes and patient satisfaction.
Results: At follow-up, among those who could express an opinion, 100% of patients were fully satisfied and had no prolapse symptoms. Fifty per cent of these patients had undergone previous prolapse surgery, and with the exception of one case, were performed under spinal anaesthesia. There were no cases of regret over the loss of ability to have sexual intercourse. Although follow-up was relatively short, no patients have been subsequently referred or seen with recurrent prolapse. One patient developed new urinary symptoms (recurrent urinary tract infections) and a further woman developed new bowel symptoms (constipation). There were no cases of bladder or bowel injury. One patient required a return to theatre for re-suturing of a bleeding vessel and a blood transfusion.
Although the follow-up of patients was relatively short, the audit demonstrated a high success rate and a very low complication rate.
Conclusion: Colpocleisis is a simple short procedure with low morbidity and mortality rates and is an effective way of treating severe pelvic organ prolapse in elderly, medically unstable patients who are no longer sexually active.
A cross-sectional national survey assessing the clinical attitudes to the management of premature ovarian insufficiency
Monica Mittal1, Michael Savvas1, Nitish Narvekar1, Nick Panay2 and Haitham Hamoda1
1King’s College Hospital NHS Foundation Trust, London, UK; 2Queen Charlotte’s and Chelsea & Westminster Hospitals, London, UK
Email: mittalmoni@yahoo.co.uk
Introduction: Despite the first case of premature ovarian insufficiency (POI) being described in 1942, the optimal management of the condition remains largely unanswered, and there continues to be considerable variation in practices among clinicians. The aim of this study was to explore the current attitudes of members of the British Menopause Society (BMS) to the management of POI.
Methods: A cross-sectional questionnaire survey was distributed to members of the BMS to assess their views and approach to the management of women with POI.
Results: A total of 130 questionnaires were returned and analysed. The denominators vary according to the number of responses to the individual questions. The majority of responses within this survey were from Hospital Consultants (n=55/110; 50%).
A bone density scan (DEXA) was performed routinely for all new referrals by 53/124 (42.7%) clinicians, selectively by 39/124 (31.5%) and was not considered by 32/124 (25.8%). A total of 20/122 (16.4%) indicated that they would repeat the DEXA every 1–3 years and 45/122 (36.9%) every 3–5 years, while 45/122 (36.9%) would not routinely repeat it. A karyotype analysis was routinely performed by 20/123 (16.3%) clinicians, selectively by 71/123 (57.7%) and not performed by 32/123 (26.0%), while autoantibody screening was considered routinely by 41/117 (35%) clinicians, selectively by 36/117 (30.8%) and not done by 40/117 (34.2%) clinicians.
A total of 73/130 (56.2%) clinicians would prescribe hormone replacement therapy (HRT) in preference to combined ethinyl oestradiol and progesterone [COC] (27/130, 20.8%), while 30/130 (23.1%) had no particular preference. Of the former group, 41/73 (56.2%) preferred the sequential regimen compared to a continuous preparation (32/73, 43.8%); 44/108 (40.7%) routinely prescribed oral oestradiol in preference to transdermal administration (62/108, 57.4%). A total of 26/128 (20.3%) prescribed oral micronised progesterone and 31/128 (24.2%) oral progestogens, while 42/128 (32.8%) preferred the intra-uterine system. Also, 87/117 (74.4%) indicated that less than 25% of patients opted for testosterone replacement therapy, while 39/115 (33.9%) clinicians indicated that fertility was a concern in more than 50% of their patients.
Conclusion: The majority of clinicians indicated a preference for HRT instead of the COC for the management of women with POI. However, there was a significant variation in the approach to the management of these women. This information could be useful in counselling women and in guiding clinical practitioners. The results highlight the need for further research to determine the optimal regimens for the management of women with POI and the call for a national registry database to collate data and help inform clinical practice.
Socially constructed health beliefs about menopause predict utilisation of different categories of treatment for menopause-related symptoms
Helena Rubinstein
Department of Psychology, The University of Cambridge, Cambridge, UK
Email: hr272@cam.ac.uk
Introduction: It has long been known that health beliefs are important for predicting behaviour across a range of conditions but these have rarely been investigated in the context of menopause. This paper identifies the main social constructions that women have of menopause and discusses how these beliefs relate to symptom reporting and predict treatment seeking.
Methods: Totally, 295 peri- and postmenopausal women, recruited through general practitioner (GP) surgeries in Nottingham and Cambridge and via two London menopause clinics, completed the wellbeing in midlife questionnaire. From this sample, 30 women kept seven-day calendars and 24-hour diaries followed by an interview. Informed consent was obtained from all participants and ethical approval was given by NRES Committee, East of England. The Menopause Rating Scale was used as a measure of symptom severity and a measure of treatment utilisation was developed to investigate the uptake of biomedical and non-biomedical treatments. Regression analyses and structural equation modelling were used to investigate the predictive power of these beliefs.
Results: Four main social constructions are prevalent: an ageing and invisibility belief, amenable to treatment belief, postmenopausal recovery belief and an illness and change belief. Higher levels of symptom reporting are a significant predictor of greater utilisation of all categories of treatment. However, there is a significant, positive mediating effect between believing that menopause is amenable to treatment (especially the use of hormone therapy) and symptom severity such that this increases utilisation of biomedical treatments. In contrast, there is a significant positive mediating effect between believing that there is postmenopausal recovery and reporting higher symptom severity such that there is an increase in the utilisation of using non-biomedical treatments.
Conclusion: Socially constructed beliefs about menopause are significant predictors of health utilisation at menopause, over and above the level of symptom severity reported. The different types of health belief are predictive of different types of treatment uptake and it is suggested that it is relevant for clinicians to be aware of pre-existing beliefs in the context of diagnosis and prescriptive practices.
This presentation was awarded first prize in the Poster session at the British Menopause Society annual conference 2013.
Bone health in perimenopausal women can be predicted by elevated levels of FSH
Monica Samra
University College London Medical School, London, UK
Email: m.samra@ucl.ac.uk
Introduction: Loss of bone mass due to the menopause has been widely attributed to the effects of low estrogen. However, the onset of bone loss begins before any symptoms of menopause may appear, when estrogen levels are within the normal range but follicle-stimulating hormone (FSH) levels are raised. We report two cases of bone symptoms in the presence of abnormally elevated FSH and normal estrogen levels.
Methods: Both patients, aged 38 and 41, presented to the fertility clinic because of failure to conceive over the past year. They had a history of irregular periods with normal blood loss. On interview, both reported a recent onset of bone aches and pains and an increase in vasomotor symptoms, including sweating and hot flushes. Nothing was notable on examination. A female hormone blood profile was then carried out on day 3 of the menstrual cycle and serial FSH levels were taken over the following three cycles.
Results: Serum FSH was found to be elevated on all occasions (range, 20–35 u/L) for both women. Oestradiol levels were within the normal range. In order to further investigate the bone symptoms, a DEXA scan was then performed, showing suboptimal bone density consistent with osteopenia in both patients (T-score between −1 and −2.5).
Conclusions: Our results display an association between elevated FSH levels and bone density, in the presence of normal estrogen levels. We propose that the very high FSH levels have direct effects on bone resorption during the perimenopausal stage. This may allow the prediction of bone health in women approaching the menopause by measuring their serum FSH. Therefore, earlier interventions to halt the development and progression of bone loss in women with raised FSH can be implemented, which will prove extremely beneficial.
BMI>30 has no effect on microvascular perfusion in postmenopausal flushing women despite an adverse cardiovascular risk profile
J Sassarini1, W Ferrell2 and MA Lumsden1
1Centre for Population and Health Sciences, University of Glasgow, Glasgow, UK; 2Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
Email: jenifer.sassarini@glasgow.ac.uk
Introduction: Dubbed the ‘thin hypothesis’, overweight women were once thought to be afforded some protection against vasomotor symptoms, secondary to adipose conversion of androgens leading to higher levels of estrogen.1 However, findings from multiple large epidemiological studies have challenged this hypothesis. Evidence now suggests that overweight women have 1.5–2.0 times increased odds of reporting hot flushes and this risk increases with severity of obesity.2 However, the mechanism is unclear. Obesity also significantly increases the risk of cardiovascular disease (CVD), which is linked to impaired endothelial function: We have previously shown that there is an increase in perfusion responses in postmenopausal women who flush when compared to their matched contemporaries, but these were all lean women.3 We have now examined a group of women with body mass index (BMI)>30 to determine whether the increased incidence of flushing in obese postmenopausal women is due to altered endothelial function.
Methods: Subcutaneous endothelial function was assessed in 53 women with severe flushing (BMI<30, n=37; BMI>30, n=16). Cutaneous microvascular perfusion of skin blood vessels was measured using laser Doppler imaging and endothelial function was assessed by iontophoresis (administration of vasoactive agents through the skin by an electric current) of acetylcholine (ACh – endothelium dependent) and sodium nitroprusside (SNP – endothelium independent). Blood samples for risk factors were also taken.
Results: There was no difference in perfusion responses for ACh or SNP. However, there were significant differences in cholesterol, high-density lipoprotein (HDL), triglycerides, ApoA1, ApoB, C-reactive protein (CRP) and insulin.
Conclusion: Despite differences seen in markers known to be associated with cardiovascular disease, and also linked to endothelial dysfunction, there appears to be no difference in the microvascular reactivity of skin blood vessels seen in these flushing women with a BMI>30. However, although total cholesterol, elevated low-density lipoprotein cholesterol (LDL-C) and low HDL-C are well-established risk factors for cardiovascular disease, an association with dysfunction of the subcutaneous blood vessels has not been consistently demonstrated. This supports the concept that vasodilatation of these vessels is a heat loss response rather than reflecting reactivity of deeper vessel beds which are associated with cardiovascular risk. Further work is required to determine the function of deeper vessel beds.
References
SabiaSFournierAMesrineS. Risk factors for onset of menopausal symptoms: results from a large cohort study. Maturitas2008; 60: 108–121.ThurstonRC. The skinny on body fat and vasomotor symptoms. Menopausal Med2009; 17: 1–s6.SassariniJFoxHFerrellW. Vascular function and cardiovascular risk factors in women with severe flushing. Clin Endocrinol (Oxf)2011; 74: 97–103.
Short report: Menopause symptoms suffered by women with breast cancer
Nuttan Tanna1, Grant Cumming2, Heather Currie3 and Rik Moncur4
1North West London Hospitals NHS Trust, Harrow, UK; 2NHS Grampian, Dr Gray’s Hospital, Elgin, UK; 3Dumfries and Galloway Royal Infirmary, Dumfries, UK; 4Web Developer, Internet Design Shop
Email: nuttantanna@nhs.net
Introduction: Women with breast cancer were targeted with a questionnaire, implemented via the Menopause Matters website. This short report presents findings from data collected from the first 52 respondents.
Method: Draft questionnaire piloted with two women, one with history of breast cancer, to ensure clarity and understanding of questions. Respondent consent accepted as inherent with completion of the electronically accessed questionnaire. Women with breast cancer were asked whether they suffered from menopausal symptoms, what treatments they had tried and had option to providing further comment within a separate text box.
Results: Forty-six women provided the age when their breast cancer was diagnosed (age range, 36–56). Of these, 31 (59%) went through the menopause after breast cancer treatment. More than half of the respondents reported suffering from hot flushes, night sweats, insomnia or disrupted sleep, weight gain (especially around waist), muscle and joint pains, lack of concentration and memory loss and fatigue with loss of energy. The majority had had chemotherapy (64%) and radiotherapy (77%) treatment in the past. Around 27% (14) of the women were on the anti-estrogen treatment, Tamoxifen, with 37% (19) reporting use in the past. Anastrozole, an Aromatase Inhibitor, was currently being used by five (10%) with another six (12%) women reporting past usage. Fifty per cent had consulted with their general practitioner (GP) for menopausal symptom relief. Eight (15%) were on selective serotonin reuptake inhibitors (SSRIs) with seven (13.5%) women trialling cognitive behavioural therapy/relaxation/yoga for symptom control. Forty-two per cent of the women needed treatment for vaginal dryness, with 39% reporting use of vaginal lubricants. Fifty per cent respondents indicated having problems with joint aches and pains, with 40% women using painkillers and exercise for symptom relief.
Discussion: It is noteworthy that half of these women with breast cancer had consulted with their GP for menopausal symptom relief. In the new NHS setting, GPs are going to be the primary care providers for women with breast cancer. This preliminary analysis highlights a need for individualised support for menopausal symptom control in women with breast cancer. The e-questionnaire is still live, with final analysis and report due at end of data collection period.
Practice Nurse Survey 2013 – A survey of smear-taking nurses in regard to menopause advice
Kathy Abernethy
Menopause Clinical and Research Unit, Northwick Park Hospital, Middlesex, UK
Email: kathy.abernethy@btinternet.com
Introduction: The BMS has made recommendations that Primary Care Teams invite women on their register, around the time of their 50th birthday, to attend a health and lifestyle consultation to discuss a personal health plan for the menopause and beyond. In practice, with current NHS demands, this is difficult to achieve, but women encounter nurses on many different occasions and a well-informed nurse might identify potential risk factors for future health and give evidence-based advice about symptom management. In primary care, nurses see women at all times of life, particularly for cervical screening. Theoretically, this group of nurses could be well placed to offer menopause related advice and health promotion for the years ahead.
Method: Totally, 400 general primary care nurses who take cervical smears responded to an online invitation to participate in a brief survey about menopause advice. Eleven questions in total, including demographics.
Results: Of the 400 nurses surveyed, 293 (74%) saw women requiring menopause advice, with 42% of those feeling ‘not very confident’ or ‘not at all confident’ about advising on menopausal symptoms. With regard to vaginal atrophy, 48% felt ‘not very confident’ or ‘not at all confident’ about advising about vaginal atrophy. When asked if vaginal atrophy is observed during cervical screening and causes discomfort, would you advise vaginal estrogen, 30% reported never advised it, 52% sometimes advised it and 18% always advised it. Twenty-nine per cent would always initiate a discussion about vaginal atrophy if observed during smear taking, 30% would never initiate a discussion in these circumstances and 41% would sometimes initiate a discussion about vaginal atrophy if observed during smear taking. Forty-four per cent had received no formal education in menopause.
Discussion: This 2013 web-based survey of 400 primary care nurses indicates a lack of confidence when advising women about menopausal symptoms and vaginal atrophy. There is a need for further education if generalist practice nurses, such as those taking smears, are to be encouraged to discuss menopausal health issues.
Women’s experiences of working through the menopause ‘well, it’s not stamped on your forehead is it?
Angela Thorogood, Gail Kinman and Nadia Wager
Email: angela.thorogood@beds.ac.uk
Introduction: Many employed women over 50 years are, or will be, experiencing the menopause. Debilitating symptoms such as hot flushes sleep disturbance and irritability can have a significant impact on the working lives of women. Limited research in this area suggests that some of these symptoms are likely to impact on wellbeing and the quality of interpersonal relationships.
Methods: Drawing on interpretative phenomenology and content analysis, face-to-face, semi-structured interviews will be conducted with working women, recruited from various occupational roles and work places.
Results: On completion of the transcribed interviews, it is anticipated that a deeper understanding of menopausal experiences of working women will emerge through these phenomena, and how they construct meaning at a deeper meaning.
Conclusion: Many working women experiencing the menopause may need extra support in their working environment along with other factors.
The development and implementation of patient advice literature for patients attending the menopause clinics at St James’ University Hospital, Leeds
Julie Ayres, Lisa Bridgeman, Sarah James, Alice Leaney and Lim Su Ann
St James University Hospital, Leeds, UK
Email: julie.ayres@doctors.org.uk
Introduction: A diagnosis of premature ovarian failure (POF) may have detrimental effects on a woman’s health and psychosocial wellbeing. In order to make informed choices about future management and to avoid potential long-term health complications, it is vital that woman receive adequate information regarding their diagnosis. A recent audit identified a lack of standardised information provision for women with POF. Improving patient information availability through the development and implementation of a patient information leaflet (PIL) may help to improve quality of care and overall service satisfaction in Leeds. A service evaluation can then be undertaken into the provision of PIL in Leeds to gain an insight into the effectiveness of this method.
Methods: A review of current literature and feedback from patients enabled the design and creation of a PIL on POF. The patient information literature was reviewed by healthcare professionals, members of The Daisy Network and piloted with a small cohort of patients. A total of 18 patients and 14 healthcare professionals reviewed the information leaflet. The patient information was modified in relation to feedback received.
Results: The overall respondent feedback was positive with the majority of patients (94%) and all healthcare professionals (100%) satisfied with the content of the information. All patient respondents (100%) and a large proportion of healthcare professionals (80%) agreed that the structure, layout and flow of the leaflet were appropriate. All respondents (100%) felt that provision of this leaflet at the time of diagnosis would improve understanding, confidence and overall patient experience. Feedback suggested that more emphasis needed to be placed on the psychological effects of POF. Additional suggestions included making minor modifications to improve aesthetic appearance.
Conclusion: This service evaluation re-affirmed that the current care of women diagnosed with POF has capacity for improvement. The provision of PILs such as this may minimise adverse emotional outcomes and facilitate clinicians in optimising the impact of finite resources. Results indicated that the PIL developed and trialled within the Leeds teaching hospitals trust improved patient understanding, awareness and confidence advocating its implementation into routine practice.
Antipsychotic-induced hyperprolactinaemia: Adapting guidelines to overcome challenges posed by this group of women
Jan Brockie1 and Rachel Brown2
1Menopause Service, Oxford University Hospital, Oxford, UK; 2Oxford Health NHS Foundation Trust, Oxford, UK
Email: janet.brockie@ouh.nhs.uk
Introduction: Routine monitoring of metabolic side effects of psychotropic medication is now well-established; however, the risk of antipsychotic-induced hyperprolactinaemia frequently remains overlooked. This is despite the known effects of amenorrhoea and hypogonadism leading to decreased bone density and osteoporosis. Comprehensive guidelines were developed, in consultation between the mental health team and the metabolic bone, endocrine and menopause services.
Original guidelines: All women with amenorrhoea for more than three to six months or other symptoms of hyperprolactinaemia, where a change of therapy is not possible and without a history of fragility fractures, were referred for DXA scan and to the Oxford Menopause Service (except those already receiving combined oral contraception). The referrals included women using progestogen-only contraception and women who were peri- or post-menopausal. Women with a history of fragility fractures were referred to Metabolic Bone Clinic.
Results: Due the complexities of this group of women, the original guidelines and referral pathway were largely unworkable because of poor attendance.
Conclusion: Recognising that it is desirable to have a baseline bone density measurement and a holistic assessment for osteoporotic risk factors, the priority is to give estrogen replacement to premenopausal women with prolonged amenorrhoea (if not contraindicated). The adapted guidelines now offer easy access to hormonal advice as required, enabling treatment to be initiated either by psychiatrists or GPs. Referrals are only now made on an individual basis, taking into account the likelihood of attendance.
The outcomes of treatment with alternatives to HRT in a specialist menopause service
Rosemary A Cochrane and Isioma Okolo
Chalmers Centre for Sexual and Reproductive Health, NHS Lothian, Edinburgh, UK
Email: rosemary.cochrane@ntlworld.com
Introduction: Menopause is associated with distressing symptoms and increased risk of osteoporosis. Hormone replacement therapy (HRT) is the mainstay of treatment. Data on prescribing practices in the UK reveal that there has been a decline in HRT prescribing. Some women are ineligible for HRT for medical reasons; others opt to use alternative treatments for personal reasons. This study explores outcomes of treatment in women attending the specialist menopause clinic within our service who were initiated on alternatives to HRT in 2012.
Methods: A case note review was performed which identified women who were initiated on alternatives to HRT. Alternatives were defined as follows:
i. Medical alternatives – selective serotonin reuptake inhibitors (SSRI), serotonin–noradrenaline reuptake inhibitors (SNRI), gabapentin, vaginal estrogen
ii. Non-medical alternatives – herbal remedies, lifestyle and diet modifications, psychosexual counselling.
Women receiving HRT, progestogen or testosterone alone were excluded.
Those ineligible for HRT due to past medical history, family history or drug interactions were in the ‘medical group’ and women who opted out of HRT were in the ‘patient choice’ group. The outcomes of alternative management were reviewed at follow-up. Outcomes noted were self-reported compliance, satisfaction with therapy and continuation or change of initial treatment option.
Results: One-quarter (75/300) of patients received alternative management. In 37 women (49%), HRT was contra-indicated; 38 women (51%) opted out of HRT. The majority of women received SSRIs and vaginal estrogen in combination or undertook lifestyle modifications; 13 women used vaginal estrogen alone, 13 used gabapentin or an SSRI and six used a combination of gabapentin and vaginal estrogen.
Of 29 women attending follow-up, 21 (72%) reported compliance with alternative treatments but only 8 (28%) were satisfied with this treatment. A third of women continued initial treatment, one-third changed to HRT at follow-up and a third of women changed to a further alternative.
Conclusion: This small study indicates low patient satisfaction with alternative menopausal treatment. Reasons included no improvement in symptoms and intolerable side effects, especially with SSRI and SNRI. Alternatives to HRT exist but satisfaction and compliance with alternatives is poor; this leaves few options where HRT is desired but contraindicated.
An assessment of menopausal women's attitudes to hormone replacement therapy and complementary and alternative medications
Hashviniya K Sekar1, An Vanthuyne2, Debra Holloway2 and Janice Rymer2
1School of Medicine, King's College London, London, UK; 2Guy's and St Thomas' NHS Foundation Trust, London, UK
Email: debra.holloway@gstt.nhs.uk
Introduction: Women with hormone-dependent cancers now have longer life expectancies because of more advanced treatments. This arises at the expense of severe menopausal symptoms which are difficult to manage as the increased risk of hormone replacement therapy (HRT) and complementary and alternative medications (CAMs) must be balanced against their efficacies. Our previous study highlighted that women with a history of non-hormone-dependent cancers were reluctant to take HRT due to perceived risks. Therefore, we endeavoured to investigate women’s attitudes to the different menopausal therapies.
Methods: From 11 January 2013 till April 2013, 200 questionnaires were distributed to consented patients in the gynaecology, oncology and menopause clinics, before consultation in Guy’s Hospital, with 164 returned. Each questionnaire assessed patients’ knowledge regarding the use and associated risks of HRT and CAMs. Patients also indicated whether they had a personal and/or family history of cancer. Data analysis was carried out across four groups—patients with both a personal and family history of cancer (32); patients with only a family history of cancer (47); patients with only a personal history of cancer (23) and patients with neither a personal nor family history of cancer (62).
Results: Sixty-two per centof respondents regarded cancer to be the predominant cause of death among women. For women with a personal history of cancer, 74% stated to have not been given advice relating to HRT and 100% had no advice for CAMs. In total, 54% believed that HRT increased the risk of breast cancer while 40% were unsure. An average of 73% was unsure if the use of HRT increased the risk of endometrial, cervical, ovarian and bowel cancer. Furthermore, approximately 80% were unsure if patches/tablets/gel HRT or vaginal HRT or herbal medications could be taken by women who had any of the following cancers—breast, endometrial, cervical, ovarian and bowel.
Conclusion: The results demonstrate a lack of knowledge with regard to the use of HRT and CAMs to manage the menopause. An information leaflet for patients with both a personal and family history of cancer will be created. This will enable us to address their concerns and help them make informed decisions on how they wish to manage their menopause.
Acupuncture treatment of hot flushes. A case series of 54 patients
Nicola Ridley1, Mike Pullman2 and Ravi Parekodi2
1Sexual Health and Reproductive Medicine, Wheatbridge Community Health Centre, Chesterfield, UK; 2Sheffield Teaching Hospitals, South Yorkshire, UK
Email: mike@largeblack.fslife.co.uk
Introduction: We present a case series of 54 patients suffering intolerable vasomotor symptoms treated with acupuncture. Of these, 43 patients were on anti-estrogen therapy following breast cancer surgery. Eleven were in the natural menopause. Vasomotor symptoms are such a debilitating side effect of tamoxifen therapy that approximately 10–15% of women are unable to tolerate the drug. This non-compliance increases the risk of cancer recurrence. Acupuncture is a simple, safe and effective adjunctive treatment of hot flushes and compares favourably to many alternatives.
Methods: Over a five-year period, 54 patients were referred for acupuncture to an NHS medical acupuncture clinic to control hot flushes. Acupuncture was carried out weekly for six weeks then followed up at three and six months with further sessions. Symptom severity assessment was carried out using the MYMOP (measure yourself medical outcome profile) scoring system. This is a simple VAS that allows the patient to list and score the severity of their symptoms. Activity levels and patient wellbeing were also scored. A combination of six to eight traditional acupuncture points was chosen.
Results: Thirty-nine out of 54 patients were followed up to six months. This group showed a more than 75% improvement in symptom severity. Fifteen patients were lost to six-month follow-up but at three months showed similar improvements. Acupuncture was well tolerated throughout. One patient suffered cellulitis which may have been incidental but was treated successfully with antibiotics. Wellbeing improved at three and six months also.
Conclusion: Acupuncture successfully controlled the severity of hot flushes in the majority of patients in this case series. The evidence for acupuncture treatment of menopausal symptoms has increased over the past decade. Acupuncture has become a serious option in hot flush management and is comparable to most medical options but better tolerated. Acupuncture deserves much more attention in management of menopausal symptoms.
Effect of LycoRed on biochemical markers for cardiovascular protection and osteoporosis protection at menopause: A parallel group placebo controlled double blind superiority RCT
Meeta Singh
Tanvir Hospital, Hyderabad, India
Email: drmeeta919@gmail.com
Introduction: LycoRed® contains bioactive lycopene in its natural bio-environment of associated phytonutrients as found naturally in the tomato. Lycopene has attracted considerable interest in recent years as an important phytochemical with a beneficial role in human health due to its potential as an anti-oxidant and anti-inflammatory therapeutic agent. Several recent studies have suggested that dietary lycopene is able to reduce the risk of cardiovascular diseases and osteoporosis.
Objectives: To analyse the effect of LycoRed (lycopene) supplementation on biochemical markers for cardiovascular-protection and osteo-protection at menopause.
Material and methods: This multicentric study screened 198 women, recruited 176 postmenopausal women at 19 centres across 12 cities in India for baseline data. Fifty women did not enrol and 40 were excluded. The study started with 108 women. These women were randomly assigned to LycoRed or placebo supplementation. Eight women did not complete the study. Ethical Committee clearance for the study was taken and informed consent was obtained from each subject prior to enrolment. Demographical details and menopausal symptoms were recorded using a questionnaire. Fasting blood samples were obtained from each subject to analyse blood lycopene levels, lipid markers, CAD marker, i.e. high-sensitivity C-reactive protein (hs-CRP) and bone markers [aminoterminal propeptide of type 1 procollagen (P1NP) and Beta C-terminal telopeptide (β-CTx-1)] at pre and post-supplementation.
Results: Out of the 100 women enrolled, only 57 women in LycoRed group and 43 women in placebo group completed the RCT. LycoRed supplementation significantly increased the blood lycopene levels in menopausal women and significantly lower levels of blood lycopene were found in placebo group. LycoRed supplementation significantly decreased the levels of hs-CRP and P1NP in menopausal women. Moreover, decreased level of β-CTX was also observed in LycoRed group. A significant increase in diastolic blood pressure was found in placebo group after four to six months supplementation. With regard to menopausal symptoms, LycoRed supplementation significantly improved hot flushes (64%), sleep disorder (63%), depression (70%), irritability (62%), anxiety (60%), sexual problem (67%), physical/mental exhaustion (74%), bladder problem (47%), vaginal dryness (56%) and joint and muscular discomfort (48%).
Conclusion: Based on these results, it may be concluded that LycoRed supplementation to menopausal women is cardio-protective and osteo-protective. For early prevention of coronary artery disease and osteoporosis, these women may benefit from supplementation with lycopene early in life either through diet or through supplements.
Evaluation of a community menopause service using patient stories
Amanda Smith and NA Ridley
Derbyshire Community Health Services, UK
Email: amanda.smith@dchs.nhs.uk
Introduction: A community menopause service asked clients for feedback on the service provided.
Methods: Patient stories were used to get more in depth qualitative feedback. This was to complement a more quantitative survey performed two years ago. Over a three-month period in 2012, patients were given information about patient stories and asked to provide anonymous feedback under a few suggested headings. The survey was approved by the trusts audit and PPI departments.
Results: Five stories were received of 25 requests given out. These provided evidence of the high level of satisfaction of these clients with the service received from receptionists, HCAs and doctors. They also detailed how their visit had improved their life, e.g. enabling them to contribute at home and work more effectively and feel better in the process. The menopause service was asked to advertise the service more to local GPs and healthcare staff.
Conclusion: The survey has provided evidence of the positive impact on patients lives It has also highlighted the difficulty patients have had finding the service and the need to advertise more. This has been actioned. (If space on the poster we can discuss the pros and cons of patient stories.)
