Post Reproductive Health

As in other areas of clinical activity, unintended harm to patients may occur in the course of postmenopausal health care, and measures to ensure patient safety should be actively promoted. This paper discusses the application of some basic principles of risk management to postmenopausal health care. To facilitate communication and reduce errors in diagnosis and treatment, risk management should be incorporated in the development of a dedicated menopause service.

Ovarian cancer is the leading cause of gynaecological cancer death. The mortality rate of ovarian cancer could be greatly decreased if there were a screening test which was able to detect the disease at an early stage, resulting in an increased probability of cure. The most promising prospect for the early detection of ovarian cancer comes from the rapidly advancing field of clinical proteomics. An increasing number of reports on the potential clinical application of proteomics research for early detection as well as risk assessment and management of ovarian cancer are being published. Although the research is very promising, major technical challenges are still preventing new discoveries in ovarian cancer proteomics from being translated into clinical practice.

Urinary incontinence, urgency, overactive bladder symptoms, cystitis and urinary tract infections are common conditions that collectively trouble over one-third of the female population around and beyond the time of menopause, with a detrimental effect on physical, social and mental wellbeing. Apart from pharmacological and surgical treatments, a long list of lifestyle, behavioural, physical and complementary interventions have been introduced over the years to relieve lower urinary tract symptoms. This review examines the effect on these symptoms of lifestyle factors (such as weight, smoking, dietary components, fluid intake, exercise and bowel habit), complementary therapies (such as herbal remedies, acupuncture and hypnotherapy), behavioural therapies (bladder training and timed and prompted voiding), pelvic floor muscle training and some over-the-counter preparations. The high prevalence of the above conditions in combination with the increasing publicity for and awareness of the subject has contributed to the popularity of the interventions considered in this review. Many of them, however, lack a solid evidence base with regard to their efficacy and few have been subjected to robust randomized trials. It is widely recognized that there is a need for further prospective interventional studies of all lifestyle interventions to evaluate the effects of modifying these factors on lower urinary tract symptoms.

Cardiovascular disease (CVD) is the most common cause of death in women but some of the challenges of management differ from those in men. This article addresses the gender-specific issues of cardiovascular management, with emphasis on ischaemic heart disease and modification of coronary risk factors. Women with ischaemic heart disease present later than men, and are therefore older and more likely to suffer from co-morbidities such as diabetes and hypertension. Proven CVD risk factors in women can be divided into those that are modifiable and those that are non-modifiable. The former include diabetes, dyslipidaemia, hypertension, smoking, obesity, sedentary lifestyle and poor nutrition; the latter include family history of heart disease and older age at presentation. It is this difference in age and general health that explains much of the variability in response to treatment. Pharmacotherapy, percutaneous intervention, surgical revascularization, and cardiac rehabilitation and disease prevention are discussed.

Grape flavonoids are members of a larger group of plant compounds called polyphenols. Epidemiological evidence relating to the traditional Mediterranean diet, which is high in polyphenols, derived from vegetables and red wine, suggests that dietary polyphenols are of benefit to health and reduce the incidence of cardiovascular disease. Overall, the evidence is promising for the benefit of grape flavonoids in the form of red wine, red grape juice and related preparations for cardiovascular risk factors. There are data to suggest a reduction in platelet activation, inflammation and low-density lipoprotein oxidation, and improvement of endothelial function with grape flavonoids. The evidence for grape flavonoids and renal function, cognition and cancer is less clear. However, it is important to note that much of this research has been carried out in animal and cell models; relatively little work has been done in humans and specifically on the health of menopausal women. There are no general safety concerns with ingestion of grape products. Obviously, consumption of red wine should be within recommended limits and it should be noted that grape juice has high sugar content. Grape flavonoids are also available as a supplement. In conclusion, it is likely that grape flavonoids do benefit the menopausal women. Further research is needed on the mode and dosage of application to maximize these benefits.

Falls among older people are common and their occurrence is associated with detrimental effects on physical and psychosocial functioning. However, falls are not an inevitable consequence of ageing and there is growing evidence of effective interventions to prevent them. Accurate screening methods to identify high-risk populations are important if such strategies are to be cost-efficient. Epidemiological studies have identified a diverse group of risk factors for falls of different types in a variety of settings and patient groups. These have proved useful in delineating high-risk groups and have propagated a range of risk assessment tools for falls. Without an accepted taxonomy for the reporting of trials testing these instruments, direct comparison of results has been difficult. In frail older people, 'multi factorial assessment tools' have achieved some utility in the discrimination of fallers from non-fallers, whereas performance-based 'functional mobility assessments' appear to be more suited to predicting falls in groups of more active elders. The predictive value of these measures has been hampered by the complex and dynamic interaction between attendant risk factors and their variable influence in populations of different frailty profiles. Furthermore, current indices used in the prediction of falls are built upon statistical methodologies employing logistic regression, which fail to account for the breadth and depth of these associations in populations at risk of falling. Statistical representations more consistent with the complex modelling required in the design of falls risk assessment trials, such as tree classification techniques, may provide better results in future studies that aim to generate accurate predictors of falls.

Osteoporosis affects one in three women. There has been some confusion among women and health professionals about the management of osteoporosis since the publication of the Women's Health Initiative and Million Women studies. This guidance regarding estrogen-based and non-estrogen-based treatments for osteoporosis responds to the controversies about the benefits and risks of individual agents. Treatment choice should be based on up-to-date evidence and targeted to individual women's needs.

Abnormal bleeding is a common reason for discontinuation of hormone replacement therapy. There is little consensus regarding when to investigate abnormal bleeding, what to do about persistent bleeding or when reinvestigation is indicated. Transvaginal ultrasound, endometrial biopsy and hysteroscopy are discussed. The mechanisms of this bleeding are poorly understood and do not correlate well with endometrial histology or the type or dose of hormone therapy used. Endometrial bleeding requires breakdown of endometrial vessels and their overlying epithelium. Endometrial vascular breakdown appears to be largely locally regulated. Potential mechanisms involved in endometrial bleeding include: changes in the ratio of vascular endothelial growth factor (pro-angiogenic) to thrombospondin-1 (anti-angiogenic); alterations in matrix metalloproteinases and their tissue inhibitors; changes in endometrial haemostasis due to tissue factor; and increased endometrial leucocytes.