Post Reproductive Health

Cardiovascular disease remains a leading cause of morbidity and mortality in menopausal women in spite of the overall reduction in age-adjusted mortality from the disease in the last few years. It is now clear that mechanisms of cardiovascular disease in menopausal women are similar to men and rather than midlife acceleration of cardiovascular disease in women, the final impact of cardiovascular disease in later life may be a reflection of cardiovascular changes during reproductive years as a result of woman’s obstetric history. A decade after the Women’s Health Initiative trial, there is upcoming evidence to suggest that hormone replacement therapy in young recently menopausal women has a cardioprotective effect. Cardiovascular changes during normal pregnancy or pregnancy complications such as preeclampsia may affect a woman’s long-term cardiovascular health. Therefore, it is plausible that the cardioprotective benefit of hormone replacement therapy depends on occult pre-existing cardiovascular risks in women in relation to their previous obstetric history. In this review, we describe the cardiovascular changes during and after pregnancy in obstetric complications such as recurrent miscarriage, preeclampsia, intrauterine growth restriction, preterm labour and gestational diabetes; existing evidence regarding their association with cardiovascular disease later in life, and hypothesize possible mechanisms. Our aim is to improve the understanding and highlight the importance of including obstetric history in risk assessment in menopausal women and individualizing their risks before prescribing hormone replacement therapy. Future research in risk benefit assessment of hormone replacement therapy should also account for a woman’s background cardiovascular risk in the light of her obstetric history.

Premature ovarian insufficiency (POI) can have significant health implications for the affected patient population, but remains a largely under researched area. There is lack of evidence from randomised controlled trials to guide clinical practice, regarding the optimal hormone replacement therapy regimens, dose and route of administration. Furthermore, little research has addressed the effect of the various progestogens used on health parameters in women with POI. Here we describe an ongoing randomised clinical trial looking at the effects of micronized progesterone and medroxyprogesterone acetate, both used in combination with transdermal oestradiol on the cardiovascular system, lipid profile and coagulation cascade in women with POI as a step towards better understanding of the implications of hormone treatment in this cohort of women.

The case report discusses a very serious interaction between red clover and methotrexate not previously documented. It highlights the potential pitfalls of concomitant use of herbal remedies and conventionally prescribed drugs and the importance of advising our patients about OTC drugs. A 52-year-old woman attended her general practitioner for advice on menopausal flushing. She was on methotrexate weekly injections for severe psoriasis and was not keen to consider anything that would possibly affect her skin. Alternative therapies were discussed and red clover was suggested. This was bought OTC. After the third day of taking red clover capsules (430 mg), the patient developed severe vomiting and epigastric pain. She contacted the dermatology clinic that administers the methotrexate injection and was thought to have symptoms suggestive of methotrexate toxicity even though her liver function tests remained within normal levels. She had been receiving methotrexate injections for nearly two years with no adverse effects. The only new drug that had been started was red clover and this was thought to be the probable cause of the toxicity. It was withdrawn. The patient made a full recovery and received her next injection of methotrexate with no adverse effects. The interaction was reported to the MHRA with a yellow card.