Post Reproductive Health

With recent emphasis toward early detection and with improved therapies, breast cancer is, increasingly, being diagnosed at a localised and curable stage More women, are therefore, entering menopause after successful treatment for breast cancer. In these former patients hormone replacement therapy (HRT) is generally avoided because of clinical concerns that oestrogen may reactivate the disease. Observational data on breast cancer survivors who have elected to use HRT do not indicate that it has a pronounced adverse effect. At the same time, data from prospective, randomised studies are not available to prove the safety of HRT in this population. Until such time, HRT should be considered with great caution in breast cancer survivors.

The endometrium is characterised by its ability to respond to steroids which exert their effects largely through their receptors. The development of antioestrogenic agents with tissue specific properties such as tamoxifen or raloxifene has shown the classical model of steroid receptor action where a hormone is responsible for switching a receptor on or off as too simplistic. It has been shown that steroid receptors require a number of coregulators for their activation and do not necessarily need the steroidal ligand to function but rather depend on peptide growth factors for their activation. The discovery of an additional oestrogen receptor subtype β and the knowledge about interactions between different members of the nuclear receptor family has finally led to a re-evaluation of steroid hormone receptor biochemistry. This review describes the growing understanding regarding the mechanisms of action of steroid receptors in the endometrium.

Skin ageing in women is due to a combination of factors including intrinsic biological ageing, extrinsic damage, particularly ultraviolet radiation and hormonal changes, importantly the menopause. The most obvious signs of ageing are atrophy, laxity, wrinkling, dryness, mottled pigmentation and sparse grey hair; most of these are attributable to chronic ultraviolet exposure rather than intrinsic ageing itself. The life expectancy of Western populations is increasing resulting in a rising demand for the treatment of the visible consequences of ageing.

The skin has a number of important physiological functions which are all affected by the structural changes that occur with skin ageing. The menopause is not associated with any specific changes in the skin, but it is thought that the decrease in oestrogen levels is partly responsible for the dryness, thinning and decreased elasticity of skin seen. Use of hormone replacement therapy has been shown to improve many of these parameters.

The main cutaneous feature of the menopause is flushing, although other conditions are also associated. Hormone replacement therapy has long been known to control many of the troublesome symptoms of the menopause, but there are a number of cutaneous side effects.

This article will look specifically at the pathophysiology of the ageing skin in women, with particular reference to the effects of the menopause and of oestrogens. Certain conditions associated with the menopause and hormone replacement therapy will also be discussed, along with the treatment of photoageing.

Many menopausal women try herbal remedies hoping to find an effective and safe form of treatment. The lay literature abounds with recommendations most of which are unsubstantiated. Systematic reviews exist for black cohosh, a promising remedy for neurovegetative menopausal symptoms. Data generated on non-menopausal patient populations also suggest that feverfew has some potential for preventing migraine, St John's Wort is an effective treatment for mild to moderate depression, valerian may alleviate insomnia and kava is an effective anxiolytic. The safety profiles of these remedies are encouraging. Before strong recommendations for the use of these or other herbal remedies can be issued, more conclusive research, in particular trials conducted on menopausal women, need to become available.

Melatonin is a hormone primarily released at night-time from the pineal gland in mammals. The increase in endogenous melatonin levels is closely associated with many physiological changes. In many cases, similar physiological changes have been found when synthetic exogenous melatonin has been administered to humans. However, the precise nature of melatonin's physiological role and its mechanism of action remain unclear. This review presents a summary of some of the current known physiological effects of melatonin, with a particular focus on the effects in humans. These effects are introduced from an evolutionary perspective. A working hypothesis as to how the diverse physiological effects of melatonin may be produced is also presented, followed by a summary of current knowledge of the toxicology of melatonin. The potential clinical applications of melatonin are also discussed.

The pelvic floor is a muscular structure, pierced by the urethra, vagina and rectum. Upright posture has played a key role in its evolution. Oestrogen and progesterone receptors are present throughout the pelvic floor. Pelvic floor dysfunction is extremely common affecting at least one third of women during their lifetime. The major aetiological factor in pelvic floor dysfunction is vaginal delivery, but conditions associated with increased intra-abdominal pressure, obesity, smoking, pelvic surgery and high impact exercise are also involved. Oestrogen lack has marked effects on the urethra and anal sphincter. Normal function can thus be replaced by dysfunctions of several kinds of which urinary and anal incontinence and pelvic organ prolapse will be discussed.

In industrialised countries worldwide women are delaying childbearing. In fertility and maternity terms, those women aged 35 years and older are considered to be of an advanced age. By this time there are usually dramatic reductions in both the fecundity rates for spontaneous conception and the success rates with assisted conception. These declines are thought to be mainly due to oocyte ageing and the established success of oocyte donation from younger individuals to older recipients supports this. Of those who conceive at an advanced maternal age there is a higher likelihood of aneuploidy (assuming conception with their own oocytes), hypertensive and other medical disorders, Caesarean birth and maternal mortality. However, most of the complications arising with advanced maternal age are caused by age-related confounding variables and older premenopausal women in good health do not require special attention. The data on perinatal mortality rates are encouraging and in the absence of congenital abnormalities are probably not much increased, if at all, in older mothers. For postmenopausal women pregnancy is now possible with oocyte donation. However, these individuals have a significantly higher likelihood of cardiovascular ageing and should be considered at increased risk of vascular complications during pregnancy.