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RESUME Objectif Offrir, aux fournisseurs de soins de sante, une mise a jour de la directive clinique quant a la prise en charge de la menopause chez les femmes asymptomatiques en sante, ainsi que chez les femmes qui presentent des symptomes vasomoteurs ou urogenitaux; cette mise a jour se penche egalement sur les facteurs associes a la maladie cardiovasculaire, au cancer du sein, a l'urogynecologie et a la sexualite. Issues Les interventions quant au mode de vie, les medicaments d'ordonnance et les traitements de medecine complementaire et parallele sont presentes en fonction de leur efficacite dans la prise en charge des symptomes menopausiques. Des strategies de counseling et therapeutiques en ce qui concerne les preoccupations en matiere de sexualite au cours de la perimenopause et de la postmenopause sont passees en revue. Des approches quant a l'identification et a l’evaluation des femmes exposees a un risque eleve d'osteoporose (ainsi que des options en matiere de prevention et de traitement) sont presentees dans la directive clinique sur l'osteoporose qui accompagne les presentes. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed et The Cochrane Library, en aout et en septembre 2012, au moyen d'un vocabulaire controle (p. ex. « hormone replacement therapy », « menopause », « cardiovascular diseases » et « sexual function ») et de mots cles (p. ex. « HRT », « perimenopause », « heart disease » et « sexuality »). Les resultats ont ete restreints aux directives cliniques, aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les resultats ont egalement ete restreints aux documents publies, en anglais ou en francais, a partir de 2009. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'au 5 janvier 2013. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l’evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques, aupres de societes de specialite medicale nationales et internationales, et dans des collections de directives cliniques. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits dans le rapport du Groupe d’etude canadien sur les soins de sante preventifs (Tableau 1).

The aim of this prospective, randomized, controlled trial was to evaluate the efficacy of different doses of oestrogen treatment (2 mg and 6 mg daily) after hysteroscopic adhesiolysis in patients with moderate to severe adhesion according to the American Fertility Society (AFS) classification of intrauterine adhesions. A total of 121 patients were included in the final analysis. Fifty-nine patients received 2 mg oestrogen daily (low-dose group), and 62 received 6 mg oestrogen daily (high-dose group) for three cycles after surgery. Second- and third-look outpatient hysteroscopy was performed 4 and 8 weeks after the initial surgery. There was no difference in the menstrual pattern and AFS scores before and after surgery between the two groups, and AFS scores at the second- and third-look hysteroscopy were found to be significantly lower than the scores before surgery in both groups (both P0.01). While this study did not address the fundamental question of whether oestrogen adjuvant therapy prevents the recurrence of intrauterine adhesions, the findings do not support the use of high-dose oestrogen therapy after hysteroscopic adhesiolysis.

Objective Because pessaries may offer symptomatic improvement for women with pelvic organ prolapse (POP), the study aimed to assess the opinion and knowledge of participants to a french general surgical gynecological congress, about this device. Material and methods An anonymous survey was carried out near 150 surgeons attending a congress by handing them a questionnaire. Results The average age of the 70 respondents was 50 years. 87.7 % were comfortable with fitting and monitoring pessary, 54.3 % think that a pessary can be offered as a first-line treatment in the management of POP. However, main indications of vaginal device are still old women and contraindications to surgery ; 31.4 % do not associate local estrogen therapy with a pessary for postmenopausal women. Conclusion The majority declares to be comfortable with pessaries, is ready to prescribe it as a first-line treatment and use local estrogen if necessary. Even if change of ideas seems to emerge about pessary, a change in beliefs and habits is still necessary. This progress can be achieved through doctors fully informed.

Objective To study the association between bilateral oophorectomy and the rate of accumulation of multimorbidity. Patients and Methods In this historical cohort study, the Rochester Epidemiology Project records-linkage system was used to identify all premenopausal women who underwent bilateral oophorectomy before age 50 years between January 1, 1988, and December 31, 2007, in Olmsted County, Minnesota. Each woman was randomly matched to a referent woman born in the same year (± 1 year) who had not undergone bilateral oophorectomy. We studied the rate of accumulation of 18 common chronic conditions over a median of approximately 14 years of follow-up. Results Although women who underwent bilateral oophorectomy already had a higher multimorbidity burden at the time of oophorectomy, they also experienced a significantly increased risk of subsequent multimorbidity (P=.XX). After adjustments for 18 chronic conditions present at baseline, race/ethnicity, education, body mass index, smoking, age at baseline, and calendar year at baseline, women who underwent oophorectomy before age 46 years experienced an increased risk of depression, hyperlipidemia, cardiac arrhythmias, coronary artery disease, arthritis, asthma, chronic obstructive pulmonary disease, and osteoporosis. In addition, they experienced an accelerated rate of accumulation of the 18 chronic conditions considered together (hazard ratio, 1.22; 95% CI, 1.14–1.31; P

Premature ovarian failure is a devastating diagnosis for reproductive-aged women. The diagnosis is relatively easy. However, it has serious health consequences, including psychological distress, infertility, osteoporosis, autoimmune disorders, ischemic heart disease, and increased risk for mortality. Management should be initiated immediately to prevent long-term consequences. Estrogen therapy is the mainstay of management. Postmenopausal estrogen therapy studies should not be used to determine the risks of treatment in these young women.

Resume Objectif Offrir, aux fournisseurs de soins de sante, une mise a jour de la directive clinique quant a la prise en charge de la menopause chez les femmes asymptomatiques en sante, ainsi que chez les femmes qui presentent des symptomes vasomoteurs ou urogenitaux; cette mise a jour se penche egalement sur les facteurs associes a la maladie cardiovasculaire, au cancer du sein, a l'urogynecologie et a la sexualite. Issues Les interventions quant au mode de vie, les medicaments d'ordonnance et les traitements de medecine complementaire et parallele sont presentes en fonction de leur efficacite dans la prise en charge des symptomes menopausiques. Des strategies de counseling et therapeutiques en ce qui concerne les preoccupations en matiere de sexualite au cours de la perimenopause et de la postmenopause sont passees en revue. Des approches quant a l'identification et a l'evaluation des femmes exposees a un risque eleve d'osteoporose (ainsi que des options en matiere de prevention et de traitement) sont presentees dans la directive clinique sur l'osteoporose qui accompagne les presentes. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed et The Cochrane Library , en aout et en septembre 2012, au moyen d'un vocabulaire controle (p. ex. « hormone replacement therapy », « menopause », « cardiovascular diseases » et « sexual function ») et de mots cles (p. ex. « HRT », « perimenopause », « heart disease » et « sexuality »). Les resultats ont ete restreints aux directives cliniques, aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les resultats ont egalement ete restreints aux documents publies, en anglais ou en francais, a partir de 2009. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'au 5 janvier 2013. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques, aupres de societes de specialite medicale nationales et internationales, et dans des collections de directives cliniques. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau).

BACKGROUND Transgender women are female individuals who were recorded men at birth based on natal sex. Supporting a person's gender identity improves their psychological health, and gender-affirming hormones reduce gender dysphoria and benefit mental health. For transgender women, estrogen administration has clinically significant benefits. Previous reviews have reported conflicting literature on the thrombotic risk of estrogen therapy in transgender women and have highlighted the need for more high-quality research. CONTENT To help address the gap in understanding thrombotic risk in transgender women receiving estrogen therapy, we performed a systematic literature review and metaanalysis. Two evaluators independently assessed quality using the Ottawa Scale for Cohort Studies. The Poisson normal model was used to estimate the study-specific incidence rates and the pooled incidence rate. Heterogeneity was measured using Higgins I2 statistic. The overall estimate of the incidence rate was 2.3 per 1000 person-years (95% CI, 0.8–6.9). The heterogeneity was significant (I2 = 74%; P = 0.0039). SUMMARY Our study estimated the incidence rate of venous thromboembolism in transgender women prescribed estrogen to be 2.3 per 1000 person-years, but because of heterogeneity this estimate cannot be reliably applied to transgender women as a group. There are insufficient data in the literature to partition by subgroup for subgroup prohibiting the analysis to control for tobacco use, age, and obesity, which is a major limitation. Additional studies of current estrogen formulations, modes of administration, and combination therapies, as well as studies in the aging transgender population, are needed to confirm thrombotic risk and clarify optimal therapy regimens.

We present the case of a male-to-female transsexual person in her 20s requesting hormone therapy in the setting of a history of a deep venous thrombosis and pulmonary embolus and carrying the prothrombin G20210A gene mutation.We interviewed the patient and reviewed her medical records. We carefully weighed the risks and benefits of hormone therapy and took into account two important ethical principles: beneficence (to act in the patient's best interest) and nonmaleficence (to avoid harm).Our patient presented to an outside facility with weight loss, generalized weakness, right lower extremity swelling, and chest pain. She was diagnosed with a pulmonary embolus and extensive deep venous thrombus by computed tomography (CT) scan and Doppler ultrasound, respectively. She was found to carry the prothrombin G20210A gene mutation. She was treated with anticoagulation therapy for 12 months, which was restarted prior to beginning therapy with transdermal estrogen.While the exact risk of recurrent deep venous thrombosis and pulmonary embolus in our patient is unknown, we recommended that hormone therapy should only be given in conjunction with anticoagulation. We speculate that this strategy would allow the patient to experience the benefits to her overall well-being with hormone therapy while reducing the risks of venous thrombosis to acceptable levels. Prospective long-term follow-up of this patient is needed to verify the benefits and risk of the intervention chosen.

Hypogonadal adolescent girls need estrogen therapy for the induction of puberty. For years, oral conjugated estrogens have been used for this purpose, starting at a very low dose, with gradual increments over time, to allow for the maturation of the reproductive organs, in order to mimic physiologic conditions. Several concerns, mainly due to first pass through the liver, are manifest with oral estrogen therapy. With the advent of transdermal estrogens and its improved efficacy profile as well as reduced side effects, it seems reasonable to consider it for pubertal induction. The primary objective of this study was to compare and contrast oral versus transdermal estrogen with regard to metabolism and physiology and to review current available data on transdermal estrogens with respect to exogenous pubertal induction.

The findings of the Women's Health Initiative resulted in a sharp decline in the use of estrogen therapy. Increasingly, menopausal women have been interested in soy foods as an alternative to estrogen therapy for the treatment of menopausal symptoms. This article provides an overview of the limited number of studies that assess the effectiveness of soy foods to alleviate vasomotor and urogenital symptoms. The evidence of the efficacy of soy foods in improving menopausal symptoms is limited due to the small number of trials reporting conflicting results.

Lack of estrogen affects the urinary tract mainly by diminishing vascular, muscular and epithelial trophism, resulting in negative effects on continence in postmenopausal women. Therefore, the use of estrogens in these patients may revert these alterations and lead to an expressive improvement of the urinary symptoms.Study the effect of topical estrogen therapy (conjugated equine estrogens, estriol or promestriene) in periurethral vessels detected by Dopplervelocimetric analysis using, as parameters: the number of vessels, resistance and pulsatility indexes, as well as the minimum diastolic value.Forty-one postmenopausal women with stress urinary incontinence were randomized into three groups according to different types of topical estrogen received during 3 months. Group 1 received conjugated equine estrogens, group 2 received estriol and group 3 received promestriene. Periurethral Dopplervelocimetry analysis was done before estrogen administration and during treatment in all groups.We observed an increase in the number of the periurethral vessels in group 1 and group 2, being higher in group 1 than in group 2. The pulsatility index remained unchanged in all three groups. The resistance index at the periurethral vessels reduced only at the conjugated estrogen group (group 1). In this same group we noticed an increase in the mean minimal diastolic value, meaning a better periurethral vascularization.Topical conjugated equine estrogens and estriol were effective in increasing the number of periurethral vessels in postmenopausal women with urinary stress incontinence, with the conjugated equine estrogens being the most effective intervention studied.

The increasing number of breast cancer patients who suffer from menopausal symptoms is mainly due to the extensive use of adjuvant treatments in the younger women. Both short and long-term side effects of oestrogen deficiency may severely impact on the quality of life of these women and should not be underestimated. Hormonal treatments are contraindicated in breast cancer survivors mainly due to the concern that dormant micrometastases may be stimulated to grow. Alternative non-hormonal remedies are now available to alleviate symptoms and to prevent chronic diseases associated with oestrogen deficiency. Urogenital atrophy is an important consequence of oestrogen deprivation that can be effectively treated by vaginal estrogens, although systemic absorption occurs with conventional doses. Preliminary data suggest that much lower doses of vaginal estrogens can alleviate urogenital atrophy without influencing serum estrogenic levels. Further research is warranted to confirm whether vaginal estrogens are safe in symptomatic breast cancer patients who are non-responsive to alternative treatments.

Particle induced X-ray emission (PIXE) and nuclear microprobe (NMP) have been used in an exploratory work to study elemental alterations in tissues of experimental animals submitted to osteoporosis preventive treatments. Osteopathologies have been associated with several factors, such as hormonal disturbances, metabolic aberrations, low dietary Ca and vitamin D intake, excess of iron, among other possible factors. Hormonal treatments seem to be beneficial to the incorporation of Ca in bone but breast and endometrial cancers constitute significant side effects that cannot be ignored. Wistar female rats were used to test the effect of estrogen therapy in osteoporosis progression. The variations of elemental concentrations in uterus and the Ca content of femoral bones of ovariectomised rats under estrogen therapy were investigated. PIXE, Rutherford backscattering spectrometry and secondary electron microscopy techniques were applied for the characterisation of biological materials, with respect to morphology and trace element distribution determination. The increase of Ca and Fe concentrations in uterus and the variations for Ca distribution patterns in bone of rats submitted to estrogen therapy were the major features observed.

Resume Introduction. - De fatalite biologique par le passe, la menopause est devenue, en l'espace d'une decennie, un enjeu majeur en sante publique. Les tenants et les aboutissants de cette evolution meritent une analyse critique exhaustive, car la situation est beaucoup plus complexe qu'il n'y parait en premiere analyse. Actualites et points forts. - 1) L'information epidemiologique disponible repose a 95% sur des etudes d'observation ou de cohorte, de type cas-temoins, qui ne permettent - faut-il le rappeler -, aucune certitude. 2) La carence estrogenique chronique joue probablement un role pathogenique dans la survenue de certains symptomes ou etats pathologiques qui s'associent a la menopause. 3) Mais derriere ce qui constitue bel et bien un paradigme a part entiere, il y a toute une construction psychosociale qui assimile un etat physiologique a un risque majeur, a l'instar des maladies chroniques les plus graves. 4) La menopause ne peut etre traitee comme une maladie a part entiere et l'hormonotherapie de substitution constitue indeniablement une intervention therapeutique complexe, qu'il convient d'utiliser avec discernement, en tenant compte de son rapport benefice/risque. 5) Si elle est desormais consideree comme le gold standard dans le traitement preventif de l'osteoporose post-menopause, il n'en est pas de meme dans le domaine cardiovaculaire, loin s'en faut. 6) Si elle peut avoir des effets symptomatiques positifs benefiques, elle est egalement a l'origine d'effets indesirables qu'une medicalisation extreme de la femme ne peut pretendre eviter, d'autant que certains de ceux-ci sont encore mal apprehendes, notamment dans le cadre des traitements a long ou tres long terme. Perspectives et projets - Il faut a l'evidence une evaluationh plus rigoureuse des effets de l'hormonotherapie post-menopause dans le cadre d'essais controles a long terme: les indications de ce traitement doivent etre en effet definies sur des bases objectives et non sur des donnees contestables ou de simples impressions cliniques.

Women now spend 30% of their lives after the menopause in a state of profound sex-steroid deprivation. The realization of the profound changes that occur as a result of this ovarian failure, and the relatively simple treatments that are available for the condition, make it imperative that more effort should be dedicated to the study of the postmenopausal years with specialist clinics being more widely available to women. The treatment of choice for the management of menopausal symptoms and sequelae is oestrogen therapy, which should, in most cases, successfully correct this deficiency state. This hypoestrogenaemic state leads to multisystem disorders. Other treatments available only serve, at best, to manage a particular symptom without the multisystemic effect of oestrogens. In some cases serious side-effects occur that could be worse than any possible from properly managed hormone replacement.

There is growing and consistent evidence that estrogen use in postmenopausal women is associated with a substantial reduction in the occurrence of cardiovascular disease. However, remarkably little is known about the biological mechanisms by which estrogen therapy may influence risk. Even less information is available on the cardiovascular effects of combined estrogen-progestin use. PEPI was not designed to test whether estrogen and estrogen-progestin therapy is efficacious in the prevention of cardiovascular disease, as a much larger trial with clinical disease outcomes is needed to answer that question. However, PEPI will provide critical evidence regarding the potential effectiveness of the various estrogen and estrogen-progestin regimens in altering risk factors for cardiovascular disease in women. Detailed information on factors such as adherence, side effects, and general patient acceptability will also be ascertained.

Background In patients hospitalized over a 4 year period for pulmonary embolism (PE), and subsequently found to have familial-acquired thrombophilia, we assessed relationships of thrombophilia with testosterone (TT) and estrogen therapy (ET) anteceding PE. Methods From 2011 through 2014, 347 patients were hospitalized in Cincinnati Mercy Hospitals with PE. Retrospective chart review was used to document TT or ET anteceding PE in patients subsequently found to have familial or acquired thrombophilia. Results Preceding hospitalization for PE, of the 154 men and 193 women, 8 men (5% of men) used TT, 24 women (12% of women) used ET (16 birth control pills, 6 hormone replacement therapy, 2 progesterone). Median age in the 8 men was 56 and for the 24 women 38. After excluding 45 women with cancer preceding PE, 24 of 148 (16%) women with PE had used ET, and after excluding 33 men with cancer, 8/121 men (7%) used TT. Of these 8 men, 6 used TT gels, 50 mg/day, and 2 had intra muscular TT 50 mg/week. Of the 8 men, 5 (63%) smoked, 2 had a history of thrombotic events, and 2 had type 2 diabetes. The median number of months from the initiation of TT to development of PE was 7 months. Coagulation evaluations were done in 6 of the 8 men. All 6 had ≥1 thrombophilia; 1 heterozygous for the G20210A prothrombin gene (PTG) mutation, 1 with high factor VIII, 3 with high homocysteine (1 of whom had MTHFR C677T homozygosity), 2 with low protein C, 2 with low protein S, and 2 with low free protein S. Two of 8 men had Klinefelter9s syndrome. Of the 24 women, 2 were diabetic, 1 had a history of thrombosis, and 7 (29%) smoked. The median time between initiation of ET and the PE was 18 months. In 18 out of the 24 women, coagulation evaluations were performed. 15 had ≥1 thrombophilia; 4 were factor V Leiden heterozygotes, 1 PTG heterozygote, 2 high Factor VIII, 1 high Factor XI, 2 with the lupus anticoagulant, 3 low protein S, 2 low Free S, 3 low antithrombin III, 3 high anticardiolipin antibodies. Conclusion After excluding antecedent cancer, 24/148 women (16%) had ET before PE, and TT was taken by 8/121 (7%) men. PE is an important complication of TT in men and ET in women, in part reflecting an interaction between familial and acquired thrombophilia and exogenous hormone use.

Unstable angina and non-ST-elevation myocardial infarction (MI) accounted for 1,433,000 hospitalizations in the U.S. in 1996 [(1)][1]. Nearly 60% of those with unstable angina were >65 years and 46% were women. Women comprise a larger proportion of the unstable angina population than of the MI

Coronary heart disease (CHD) is the leading cause of death in both older men and women. Elevated cholesterol and especially elevated low-density lipoprotein/high-density lipoprotein (LDL/HDL) ratios may be significant risk factors, although less so than among middle-aged persons. No formal study has yet demonstrated the efficacy of lipid lowering in the prevention of CHD in persons over 65 or in women at any age. The maximal age for treatment of an elevated LDL/HDL ratio is probably age 70 or less. In older women, the most effective and cost-effective pharmacologic means to prevent atherosclerosis and heart attacks is most likely estrogen therapy.

Bacteriuria is much more common among elderly than among younger populations, and is most often asymptomatic. Asymptomatic bacteriuria in the elderly is a benign condition in the vast majority of cases and does not require therapy. When symptomatic lower UTI occurs, short-course (3-day) therapy with any of several agents is indicated, and is usually effective. Women with frequently recurrent symptomatic UTI may benefit from estrogen therapy. Fourteen days of therapy is indicated in patients with upper UTI. The typical signs and symptoms of pyelonephritis may be altered or absent in elderly patients.

A cross-sectional study of the relationship of calcium intake and estrogen therapy (ET) to cortical bone mineral content/bone width (BMC/BW) was conducted in 129 postmenopausal "free-living" women in California. Diet was assessed by frequency questionnaire, ET by interview, and BMC by single-photon absorptiometry. Women with adequate ET (defined as ≥0.625 mg conjugated equine estrogen/d for >20 d/mo beginning within 3 y after menopause and continuing >3 y) were compared to those who had not received ET. Calcium intakes early in life (15 to 30 y of age) were predictive of BMC/BW only in women with adequate ET. Calcium intakes later in life were not predictive regardless of ET. In women who had both adequate ET and early calcium intakes >500 mg/d, BMC/BW could be expected to fall below the "fracture threshold" (0.58 g/cm 2 ) about 17 y later than in all other subjects. Adequate early calcium intakes may contribute to bone formation and, since ET reduces bone loss, the 2 strategies combined may be more effective in maintaining BMC than either one alone.

Estrogen remains the single most effective agent in the treatment of menopausal symptoms and prevention of bone loss. This article focuses on the use of estrogen therapy during menopause and the pharmacotherapy of osteoporosis. Risks and benefits of hormonal therapy and regimen selection for menopausal women are discussed. The second section of the article focuses on current treatment strategies for osteoporosis.

Physicians have become more conservative regarding prophylactic oophorectomy after publication of the Women's Health Initiative trial. They are less likely to prescribe estrogen therapy for women who have a high risk of coronary heart disease and more likely to use nonoral routes for estrogen therapy.