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RHO archives : Topics : Older Women

Annotated Bibliography

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Hormone replacement therapy

Anderson GL et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. JAMA. 2004;291(14):1701–1712.
A randomized, double-blind, placebo-controlled disease prevention trial (the Women's Health Initiative) enrolled 10,739 postmenopausal women aged 50 to 79 with prior hysterectomy. Women were randomly assigned to receive either conjugated equine estrogen (CEE) or placebo. After an average follow-up of 6.8 years, the use of CEE increased the risk of stroke (hazard ratio, 1.39; 95% confidence interval, 1.10 to 1.77), decreased the risk of hip fracture (0.61; 0.41 to 0.91), and did not affect coronary heart disease. A possible reduction in breast cancer risk (0.77; 0.59 to 1.01) requires further investigation. Overall, the burden of disease events was the same in both groups, indicating no overall benefit for CEE.

Anderson GL et al. Effects of estrogen plus progestin on gynecologic cancers and associated diagnostic procedures: The Women’s Health Initiative randomized trial. JAMA. 2003;290(13):1739–1748.
The Women’s Health Initiative is a randomized, double-blind, placebo-controlled trial of 16,608 postmenopausal women recruited from 40 US clinical centers between September 1993 and October 1998 (average follow-up, 5.6 years). Women received either combined estrogen and progestin therapy or a placebo. Neither the increase in ovarian cancer (hazard ration [HR] 1.58; 95% confidence interval [CI], 0.77–3.24) nor the decrease in endometrial cancer (HR 0.81; 95% CI, 0.48–1.36) among women using HRT were significant. There were no differences in tumor histology, stage, or grade for either cancer site. The incidence of uterine, cervical, and other gynecologic cancers was low and did not differ by HRT status. Women taking HRT were more likely than others to require endometrial biopsies (33% vs 6%; P < .001) to assess vaginal bleeding.

Antoine C et al. Influence of HRT on prognostic factors for breast cancer: a systematic review after the Women’s Health Initiative trial. Human Reproduction. 2004;19(3):741–756.
Twenty-five studies of breast cancer mortality and HRT were systematically reviewed to examine the conflict between data from the Women’s Health Initiative (WHI) and observational studies. The WHI trial found a worsening of some prognostic parameters, while most published observational studies found evidence of earlier diagnosis and better prognosis in HRT users than non-users. The WHI trial found no differences in the distributions of histology, grade, or steroid receptors, while some observational studies did. However, the observational studies suffered from a host of methodological weaknesses, including their retrospective design, small size, poor matching, and failure to consider confounding factors. The authors conclude that the prognosis for breast cancers developed while using HRT is NOT better than for other breast cancers.

Bunyavejchevin, S. and Limpaphayom, K.K. The metabolic and bone density effects of continuous combined 17-beta estradiol and noresthisterone acetate treatments in Thai postmenopausal women: a double-blind placebo-controlled trial. Journal of the Medical Association of Thailand 84:45–53 (2001).
Sixty women attending a menopause clinic in Thailand were randomized to HRT or placebo and followed for one year. HRT resulted in beneficial changes in lipid profiles and bone density. While total cholesterol and LDL levels decreased in the placebo group over time, presumably because of dietary health education at the clinic, the effects were greater in the HRT group. Bone density in the spine increased significantly by 5.1 percent among the HRT group over the course of the year, while falling by 0.9 percent among the placebo group. A similar pattern was found for bone density in the hip, but there was no significant change in the bone density of the femoral neck in either group.

Cauley JA. Effects of estrogen plus progestin on risk of fracture and bone mineral density: The Women’s Health Initiative randomized trial. JAMA. 2003;290(13):1729–1738.
The Women’s Health Initiative is a randomized, double-blind, placebo-controlled trial of 16,608 postmenopausal women recruited from 40 US clinical centers between September 1993 and October 1998 (average follow-up, 5.6 years). Women received either combined estrogen and progestin therapy or a placebo. Women in the estrogen-plus-progestin group were less likely than others to have a fracture (8.6% versus 11.1%) (hazard ratio, 0.76; 95% confidence interval, 0.69–0.83), regardless of age, body mass index, smoking status, history of falls, personal and family history of fracture, total calcium intake, past use of hormone therapy, bone mineral density, or summary fracture risk score. After three years of treatment, bone mineral density in the hip increased 3.7 percent in the estrogen-plus-progestin group compared with 0.14 percent in the placebo group (P < .001).

Chen, C.L. et al. Hormone replacement therapy in relation to breast cancer. Journal of the American Medical Association 287(6):734–741 (2002).
A nested case-control study was conducted among 705 postmenopausal women with primary invasive breast cancer and 692 age-matched controls enrolled in a U.S. health plan. Computerized pharmacy records were used to determine HRT use during a five-year period ending one year before the cancer diagnosis. The incidence of breast cancer was increased by 60 percent-85 percent in recent long-term users of HRT, regardless of formulation. HRT had a greater impact on the risk of lobular than nonlobular breast cancer.

Chlebowski RT, Wactawski-Wende J, Ritenbaugh C, et al. Estrogen plus progestin and colorectal cancer in postmenopausal women. New England Journal of Medicine. 2004;350(10):991–1004. Available at: http://content.nejm.org.
The Women’s Health Initiative (WHI) randomly assigned 16,608 postmenopausal women aged 50 to 79 to combined hormone replacement therapy or placebo. Relatively short-term use of estrogen plus progestin decreased the risk of colorectal cancer (hazard ratio, 0.56; 95% confidence interval, 0.38 to 0.81; P = 0.003). The invasive colorectal cancers in the hormone group were similar in histologic features and grade to those in the placebo group but had a greater number of positive lymph nodes (P = 0.002) and were more advanced (P = 0.004). Thus, while relatively short-term use of estrogen plus progestin was associated with a decreased risk of colorectal cancer, those cancers were diagnosed at a more advanced stage in women taking HRT.

Espeland MA et al. Conjugated equine estrogens and global cognitive function in postmenopausal women: Women's Health Initiative Memory Study. JAMA. 2004;291(24):2959–2968.
A randomized, double-blind, placebo-controlled ancillary study of the Women's Health Initiative (WHI) evaluated the effect of conjugated equine estrogens (CEE) on the incidence of dementia among 2,947 women aged 65 to 79 with prior hysterectomy. During a mean follow-up of 5.4 years, women assigned to CEE were significantly more likely to experience a 10-unit decrease in their score on the Modified Mini-Mental State Examination (3MSE) than women on placebo (relative risk, 1.47; 95% confidence interval, 1.04-2.07). The adverse effect of hormone therapy was more pronounced among women who had lower cognitive function at baseline.

Ettinger, B., et al. Reduced mortality associated with long-term postmenopausal estrogen therapy. Obstetrics & Gynecology 87(1):6–12 (1996).
This study compared the medical records of 232 women who used estrogen replacement therapy (ERT) for at least 5 years with 222 age-matched nonusers. The mean age at last follow-up was 77, the mean length of estrogen use was 17.1 years. Estrogen use was associated with a statistically significant decrease in mortality (RR = .54), largely due to reductions in cardiovascular disease. Mortality was lowest among those women who had used estrogen the longest: for 15 years or more. While cancer mortality was similar for the two groups, estrogen users had a higher risk of death from breast cancer (RR = 1.89) and a lower risk of death from lung cancer.

Fernandez E et al. Hormone replacement therapy and cancer risk: a systematic analysis from a network of case-control studies. International Journal of Cancer. 2003;105:408–412.
This analysis re-examines data from a network of case-control studies conducted in Italy between 1983 and 1999. Cases were women aged 45 to 79 who were admitted to hospitals in northern Italy and had cancers diagnosed in the preceding year. The control group included 6,976 women of the same age admitted to hospital for acute, non-neoplastic conditions. Multiple logistic regression analyses found that ever-use of hormone replacement therapy (HRT) significantly reduced the likelihood of developing cancer of the colon (odds ratio [OR] = 0.7), rectum (OR = 0.5), and liver (OR = 0.2). Ever-use of HRT increased the likelihood of developing cancer of the gallbladder (OR = 3.2), breast (OR = 1.1), endometrium (OR = 3.0), and urinary bladder (OR = 2.0).

Fillit, H.M. The role of hormone replacement therapy in the prevention of Alzheimer disease. Archives of Internal Medicine 162:1934–1942 (2002).
Increasing evidence suggests a role for estrogen in learning, memory, and degenerative processes associated with Alzheimer disease. This review found a lack of consensus among studies on the effect of HRT on Alzheimer disease. The evidence suggests that estrogen treatment may decrease the risk for or delay the onset of Alzheimer disease in postmenopausal women who do not yet show any signs of the disease. However, it probably does not have any effect on the course of the disease once it has begun.

Grady, D. et al. Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/Progestion Replacement Study follow-up (HERS II). Journal of the American Medical Association 288(1):49–57 (2002). Available at: http://jama.ama-assn.org/cgi/content/short/288/1/49.
This U.S. study followed 2,321 women with coronary heart disease enrolled in a four-year, randomized, placebo-controlled trial of HRT for an additional 2.7 years. After a total of 6.8 years, hormone therapy had no impact on the risk of cardiovascular events in women with coronary heart disease. The authors conclude that HRT should not be used to reduce the risk of coronary events in women with coronary heart disease.

Grimes, D.A. and Lobo, R.A. Perspectives on the Womens Health Initiative trial of hormone replacement therapy. Obstetrics and Gynecology 100:1344–1353 (2002).
The authors describe problems with earlier trials of hormone replacement therapy (HRT) that led to the conclusion that HRT reduced the risk of heart disease. Some of these trials focused on surrogate markers, such as lipid levels, instead of clinical outcomes like illness or death. Observational trials did not take account of the fact that healthy, wealthy, and better educated women were more likely than others to choose to use HRT. Other methodological shortcomings compromised the internal and external validity of some trials. Because of its research design and excellent methods, the Womens Health Initiative has produced much better data on the effects of HRT. It found increased risks of cardiovascular disease and breast cancer among HRT users, as well decreased risks of colorectal cancer and osteoporotic fractures.

Grodstein, F. et al. Postmenopausal hormone use and secondary prevention of coronary events in the Nurses Health Study. Annals of Internal Medicine 135(1):1–8 (2001).
Data come from the Nurses Health Study, which followed 2,489 postmenopausal women with previous myocardial infarction or atherosclerosis over a 20-year period. Compared with women who never used hormone therapy, short-term current hormone users were more likely (RR = 1.25) to have major coronary artery heart disease, but long-term users were less likely (RR = 0.38) to do so. There was no clear difference between users of estrogen-only and estrogen-progestin combinations.

Hammond, C.B. Confronting aging and disease: the role of HRT. Medscape Women's Health Treatment Updates (1999). Available at: www.medscape.com/viewprogram/696. (Medscape requires free online registration.)
This continuing medical education module updates physicians and pharmacists about how estrogen acts on the body, the consequences of estrogen deficiency, and the therapeutic options for menopausal women. It exhaustively reviews current evidence on the impact of estrogen replacement on osteoporosis, Alzheimer's disease, colon cancer, macular degeneration, and cardiovascular disease. The author also discusses the need to counsel women approaching menopause about hormone replacement therapy. Good counseling should discuss the importance of lifestyle changes (for example, diet and exercise) and should explain contraindications and safety concerns related to estrogen replacement therapy, so that women can decide whether HRT is right for them.

Hays, J. et al. Effects of estrogen plus progestin on health-related quality of life. New England Journal of Medicine 348(19):1839–1854 (2003).
The Women’s Health Initiative (WHI) is the first randomized, double-blind primary prevention trial of postmenopausal hormones. This article reports on the part of the study comparing combined estrogen/progestin therapy with a placebo, which included 16,608 healthy postmenopausal women aged 50–79 who were followed for approximately five years. Quality-of-life measures were collected at baseline and at one year in all women and at three years in a subgroup of 1,511 women. Hormone therapy had no significant effect on general health, vitality, mental health, depressive symptoms, or sexual satisfaction. It was associated with a statistically significant but small and not clinically meaningful benefit in terms of sleep disturbance, physical functioning, and bodily pain after one year. At three years, there were no significant benefits in terms of any quality-of-life outcomes. Among women 50 to 54 years of age with moderate-to-severe vasomotor symptoms at baseline, estrogen and progestin improved vasomotor symptoms and resulted in a small benefit in terms of sleep disturbance but no benefit in terms of the other quality-of-life outcomes.

Heckbert, S.R. et al. Risk of recurrent coronary events in relation to use and recent initiation of postmenopausal hormone therapy. Archives of Internal Medicine 161:1709–1723 (2001).
This cohort study followed 981 postmenopausal women enrolled in a U.S. health maintenance organization who survived a first myocardial infarction. There was no difference in the risk of recurrent coronary events between current users of hormone therapy and other women over the median follow-up of 3.5 years. Closer analysis, however, found that the risk was doubled during the first 60 days after starting hormone therapy, but later fell. Women using hormone therapy for over a year were less likely than non-users to experience a recurrent coronary event.

Herrington, D.M. et al. Effects of estrogen replacement on the progression of coronary-artery atherosclerosis. New England Journal of Medicine 343(8):522–529 (2000).
This randomized, double-blind, placebo-controlled clinical trial was designed to investigate the effects of HRT on the progression of coronary atherosclerosis. It randomly assigned 309 postmenopausal women with coronary disease to receive estrogen, a combination of estrogen and medroxyprogesterone, or placebo and followed them for a mean of 3.2 years. Both hormone treatments significantly reduced low-density lipoprotein cholesterol levels (by 9.4% and 16.5%, respectively) and increased high-density lipoprotein cholesterol levels (by 18.8% and 14.2%). However, neither treatment altered the progression of coronary atherosclerosis nor did they affect the rates of clinical cardiovascular events. The authors concluded that women with established coronary disease should not use any kind of hormone replacement with the expectation that it will provide them with cardiovascular benefits.

Hogervorst, E. et al. The nature of the effect of female gonadal hormone replacement therapy on cognitive function in post-menopausal women: a meta-analysis. Neuroscience 101(3):485–512 (2000).
This meta-analysis of epidemiological and experimental studies of HRT on cognitive function in postmenopausal women found small and inconsistent effects on verbal memory, abstract reasoning, and information processing. Potential confounding factors are women’s health status when they adopt HRT and socioeconomic status. The effects of HRT may depend on the age and type of menopause and the hormone formulation used. Although epidemiological studies suggest that HRT protects against the development of Alzheimer disease, poor recall of HRT use by patients and altered physician behaviour may have confounded the effects. Controlled experimental studies have found that HRT does not prevent further cognitive decline in women who already have Alzheimer disease. Any beneficial effects seem to decline with longer treatment in women with Alzheimer disease.

Holbraaten, H. et al. Increased risk of recurrent venous thromboembolism during hormone replacement therapy. Thrombosis and Haemostasis 84:961–967 (2000).
This randomized, double-blind, placebo-controlled clinical trial included 140 Norwegian women with previous venous thrombembolism (VTE). The incidence of VTE was 10.7 percent in the hormone replacement therapy group and 2.3 percent in the placebo group. The study was prematurely ended when it became clear that women faced an increased risk of recurrence of VTE while on hormone replacement therapy.

Hulley, S. et al. Noncardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/Progestion Replacement Study follow-up (HERS II). Journal of the American Medical Association 288(1):58–66 (2002). Available at: http://jama.ama-assn.org/cgi/content/short/288/1/58.
This U.S. study followed 2,321 women with coronary heart disease who were enrolled in a four-year, randomized, placebo-controlled trial of HRT for an additional 2.7 years. Over 6.8 years, hormone therapy significantly increased the risk of venous thromboembolism (relative hazard = 2.08) and biliary tract surgery (relative hazard = 1.48).

Jain, M.G. et al. Hormone replacement therapy and endometrial cancer in Ontario, Canada. Journal of Clinical Epidemiology 53(4):385–391 (2000).
This Canadian case-control study interviewed 512 women over age 48 with endometrial cancer and 513 population controls about their use of hormones and dietary habits. The use of estrogen-only therapy for three years increased risk far more than the use of combine estrogen-progestagen formulations (OR = 1.49 and 4.12, respectively). The association was even stronger when duration of use was examined as a continuous variable. The negative effect of combined hormone therapy on endometrial cancer risk was greater among women who were thin, diabetic, or smoked.

Lacey, J.V. et al. Menopausal hormone replacement therapy and risk of ovarian cancer. Journal of the American Medical Association 288(3):334–341 (2002).
A further analysis of data from a 20-year, multi-center U.S. cohort study of breast cancer screening identified 329 women among a group of 44,000 who developed ovarian cancer during follow-up. Women who used estrogen-only replacement therapy were significantly more likely than others to develop ovarian cancer, and their risk increased with duration of use. Relative risk was 1.6 overall, 1.8 for 10–19 years of use, and 3.2 for 20 years of use or more. While women who used combined estrogen-progestin replacement therapies did not show increased risks of ovarian cancer, the authors recommend further investigation of combined therapies.

LeBlanc, E.S. et al. Hormone replacement therapy and cognition: systematic review and meta-analysis. JAMA 285(11):1489–1499 (2001).
This article reviews 29 randomized controlled trials, cohort studies, and case-control studies on the effect of HRT on cognitive decline and dementia. There was insufficient data to assess the effects of different formulations, doses, or duration of therapy. Most studies had important methodological shortcomings, including potential biases and lack of control for potential confounding factors. However, results suggest that HRT may improve verbal memory, vigilance, reasoning, and motor speed in women suffering menopausal symptoms and may decrease the risk of dementia by one-third.

Li, C.I. et al. Relationship between long durations and different regimens of hormone therapy and risk of breast cancer. JAMA 289(24):3254–3263 (2003).
This U.S. population–based, case-control study compared 975 women age 65–79 diagnosed with invasive breast cancer with 1,007 population controls. Women using estrogen-only replacement therapy, even for 25 years or longer, did not have an increased risk of breast cancer. In contrast, users of combined hormone replacement therapy were at significantly greater risk of developing breast cancer (odds ratio = 1.7), especially invasive lobular tumors (odds ratio = 2.7), and that risk increased with the duration of use. Women faced additional risks of roughly the same magnitude, whether the progestin component was taken in a sequential or in a continuous manner

Li, C.I. et al. Hormone replacement therapy in relation to risk of lobular and ductal breast carcinoma in middle-aged women. Cancer 88(11):2570–2577 (2000).
This case control study included 537 U.S. women aged 50 to 64 who were diagnosed with primary breast cancer and 492 randomly selected women without any history of breast cancer. Analyses were performed separately for women with lobular and ductal tumors. Women who were currently using combined estrogen-progestin HRT and had done so for at least six months were at higher risk of lobular breast cancer (OR = 2.6) but not ductal breast cancer (OR = 0.7). There was no elevation in risk for women using unopposed estrogen for at least six months. Since lobular tumors represent only 5 percent to 10 percent of all cases of breast cancer, the authors conclude that relatively few women are likely to be affected.

Lobo, R. et al. Optimizing HRT: emerging lower-dose therapies. CME Circle (September 4, 2001). Available at: www.medscape.com/viewprogram/293. (Medscape requires free online registration.)
This online continuing medical education activity presents data from the Womens HOPE Study, a prospective, double-blind, placebo-controlled, multicenter trial of 2,673 healthy postmenopausal women, who were randomly assigned to one of seven study groups that received different HRT dosage regimens. At lower doses, HRT relieved vasomotor symptoms, provided endometrial protection, and maintained skeletal health with fewer adverse effects and improved bleeding profiles. The authors conclude that lower doses may increase HRT initiation and continuation rates.

Manson JE et al. Estrogen plus progestin and the risk of coronary heart disease. New England Journal of Medicine. 2003;349(6):523–534.
The Women’s Health Initiative (WHI) is a randomized, double-blind, placebo-controlled trial of 16,608 postmenopausal women aged 50 to 79 recruited from 40 US clinical centers between September 1993 and October 1998. After a mean follow-up of 5.2 years, combined hormone therapy was associated with an increased risk of coronary heart disease (including nonfatal myocardial infarction as well as death due to CHD) (hazard ratio = 1.24; nominal 95% confidence interval, 1.00 to 1.54; 95% confidence interval after adjustment for sequential monitoring, 0.97 to 1.60). Excess risk peaked at one year after beginning hormone use (hazard ratio = 1.81; 95% confidence interval, 1.09 to 3.01).

Million Women Study Collaborators. Breast cancer and hormone-replacement therapy in the Million Women Study. The Lancet. 2003;362(9382):419–427.
To investigate the effects of specific types of hormone replacement therapy (HRT) on breast cancer, 1,084,110 UK women aged 50 to 64 were recruited into the Million Women Study between 1996 and 2001. Half had used HRT. After an average of 2.6 years of follow-up, 9,364 invasive breast cancers were diagnosed; 637 women died of breast cancer after an average of 4.1 years of follow-up. Current HRT users were more likely than never users to develop breast cancer (adjusted relative risk 1.66, p<0.0001) and die from it (1.22, p=0.05), but past HRT users did not face increased risks. Risks were greater when women used combined estrogen-progestagen preparations (2.00, p<0.0001) than when they used estrogen-only HRT (1.30, p<0.0001). Results varied little between specific estrogens and progestagens, between doses, or between continuous and sequential regimens. Risks increased with duration of use: 10 years of use is estimated to result in five additional breast cancers per 1,000 users of estrogen-only HRT and 19 additional cancers per 1,000 users of combined HRT.

National Association of Nurse Practitioners in Womens Health (NPWH). Hormone replacement therapy: guidance from the National Association of Nurse Practitioners in Womens Health. Topics in Advanced Practice Nursing eJournal (July 31, 2002). Available at: www.medscape.com/viewarticle/439106_1.
This article summarizes the results of recent HRT studies, puts them into a broader perspective, and provides guidance on how HRT should and should not be used by individual women.

National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health and Giovanni Lorenzini Medical Science Foundation. International Position Paper on Womens Health and Menopause: A Comprehensive Approach. Bethesda, Maryland: NHLBI (2002). Chapter 13, "Best Clinical Practices," which summarizes the reports recommendations, is available at: www.nhlbi.nih.gov/health/prof/heart/other/wm_menop.htm.
Produced by an international team of womens health experts, this position paper reviews current scientific evidence on womens health during and following menopause. It concludes that HRT offers no benefits for coronary heart disease, memory loss, Alzheimers disease, depression, and urinary incontinence; that oral estrogen replacement therapy increases the risk of venous thromboembolism; and that HRT must be continued into old age to prevent osteoporosis. HRT remains, however, the most effective way to treat symptoms accompanying the menopausal transition. The monograph stresses the importance of tailoring any menopausal therapy to the needs and medical history of individual women, recommends lifestyle and dietary changes to prevent postmenopausal conditions, and examines alternative pharmacotherapies for each of those conditions.

Rapp, S.E. et al. Effect of estrogen plus progestin on global cognitive function in postmenopausal women, the Women’s Health Initiative Memory Study: a randomized controlled trial. JAMA 289(20):2662–2672 (2003).
This study examined cognitive function scores among 4,381 healthy postmenopausal women aged 65 or older who were enrolled in the randomized, double-blind, placebo-controlled Women’s Health Initiative trial of combined hormone therapy. Women in the hormone therapy group had smaller average increases in total scores on the Modified Mini-Mental State Examination than women in the placebo group over a 4 year follow-up period, but the difference was not clinically important. However, more women in the hormone therapy group than the placebo group had a substantial and clinically important decline in scores (6.7% versus 4.8%, P = .008).

Rodriguez, C. et al. Estrogen replacement therapy and ovarian cancer mortality in a large prospective study of U.S. women. Journal of the American Medical Association 285:1460–1465 (2001).
During 14 years of follow up, 944 ovarian cancer deaths were recorded among a cohort of 211,581 postmenopausal women recruited in 1982. Women who were using estrogen replacement therapy (ERT) at baseline were 1.5 times as likely as other women to die from ovarian cancer. The relative risk increased with duration of use, rising to 1.59 and 2.20, respectively, among baseline and former users with ten or more years of ERT. Among former users with 10 or more years of use, risk declined after women stopped using ERT; however, some excess risk persisted as long as 29 years after stopping therapy.

Ross, R.K. et al. Effect of hormone replacement therapy on breast cancer risk: estrogen versus estrogen plus progestin, Journal of the National Cancer Institute 92(4):328–332 (2000).
This population-based, case-control study matched 1,897 postmenopausal women diagnosed with breast cancer with 1,637 neighborhood residents by age and race. After adjusting for known risk factors for breast cancer, HRT was associated with a 10 percent higher risk of breast cancer for each five years of hormone therapy. The combination of progestin and estrogen was far riskier than estrogen alone: the former was associated with a 24 percent increase in breast cancer use for every five years of use compared with a 6 percent increase in risk for estrogen-only therapy. The authors conclude that the protection progestin offers against endometrial cancer is probably outweighed by this excess breast cancer risk.

Rymer, J. et al. Making decisions about hormone replacement therapy. British Medical Journal 326:322–326 (2003). Available at: http://bmj.com/cgi/reprint/326/7384/322.pdf.
After summarizing the benefits and risks of hormone replacement therapy (HRT), this clinical review provides a flowchart showing which women should be offered HRT. The authors conclude that HRT is appropriate for short-term use by perimenopauseal women with hot flashes or irregular periods; long-term use by women experiencing menopause before the age of 40; and temporary use by women with endometriosis and breast cancer who are taking gondaotrophin releasing hormone analogues. For symptomatic postmenopausal women, HRT is suitable for short-term use, but the risk-benefit ratio and mode of administration must be considered carefully before HRT is prescribed for long-term use. HRT is not recommended for women with: urogenital symptoms alone; neither estrogen deficiency symptoms nor risk factors for osteoporosis; or heart disease, breast cancer, or estrogen-provoked venous thromboembolism.

Sarrel, P.M. Effects of hormone replacement therapy on sexual psychophysiology and behavior in postmenopause. Journal of Women's Health & Gender-Based Medicine 9 (Suppl. 1):S25–S32 (2000).
Changes in sexual function during and after menopause may be due, at least in part, to estrogen deficiency. This article reviews studies of hormone replacement therapy for sexual dysfunction. Dyspareunia due to vaginal dryness is the problem most responsive to estrogen replacement therapy, but progestins can obstruct this benefit. Estrogen replacement therapy also has been reported to enhance sexual desire in many women, but not everyone responds and the relief may prove temporary. For these women, the addition of androgen has proved helpful.

Schairer, C. et al. Menopausal estrogen and estrogen-progestin replacement therapy and breast cancer risk. Journal of the American Medical Association 283(4):485–491 (2000).
This cohort study followed 46,355 postmenopausal women who participated in a breast cancer screening study. The findings compare women using estrogen-only HRT with women using a combined estrogen-progestin formulation. Compared with women who never used HRT, the risk of breast cancer was 20 percent higher for the estrogen-only group and 40 percent higher for the estrogen-progestin group. Excess risk was largely restricted to recent use of HRT and increased with duration of use: the relative risk increased by 0.01 for each year of estrogen-only HRT and by 0.08 for each year of estrogen-progestin use after adjustment for mammography screening, age at menopause, body mass index, education, and age. However, further analysis found this pattern of increasing risk with duration of HRT use was limited to leaner women. The authors conclude that physicians must consider the type of hormone used when weighing the risks and benefits of HRT.

Schneider, D.L. et al. Timing of postmenopausal estrogen for optimal bone mineral density: the Rancho Bernardo study. Journal of the American Medical Association 277:543–547 (1997).
This study divided 740 women aged 60 to 98 into groups based on their use of oral estrogen after menopause; both the duration of use and the date when they began HRT was considered. After controlling for all major risk factors for osteoporosis, bone mineral density was higher among current HRT users compared with past users or never users. However, the difference in bone density between current users who started HRT at menopause (with an average of 20 years of use) and current users who started HRT after age 60 (with 9 years of use, on average) was not significant. Women who began using HRT at menopause but then quit after an average of 10 years had only slightly higher bone density than never users. The authors conclude that estrogen therapy must be continued into late life to maintain high bone density, but that it need not be started at menopause to offer substantial benefits.

Shumaker SA et al. Conjugated equine estrogens and incidence of probable dementia and mild cognitive impairment in postmenopausal women: Women's Health Initiative Memory Study. JAMA. 2004;291(24):2947–2958.
A randomized, double-blind, placebo-controlled clinical trial (the Women's Health Initiative Memory Study) enrolled 2,947 postmenopausal women aged 65 to 79 in its estrogen-alone trial arm. Estrogen therapy alone did not reduce dementia (hazard ratio, 1.49; 95% confidence interval, 0.83-2.66) or mild cognitive impairment (HR,1.34; 95% CI, 0.95-1.89). When both end points were combined, estrogen therapy increased the risk (HR, 1.38; 95% CI, 1.01-1.89; P=.04). When data for the use of estrogen alone and estrogen plus progestin were pooled, risks for both end points were increased.

Shumaker, S.A. et al. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women: the Women’s Health Initiative Memory Study: a randomized controlled trial. JAMA 289(20):2651–2662 (2003).
This study examined probable dementia and mild cognitive impairment among 4,381 healthy postmenopausal women aged 65 or older who were enrolled in the randomized, double-blind, placebo-controlled Women’s Health Initiative trial of combined hormone therapy. Women in the hormone therapy group were twice as likely as those in the placebo group to develop dementia over a four-year period. Alzheimer disease was the most common form of dementia in both groups. Hormone therapy did not have any effect, either beneficial or harmful, on mild cognitive impairment.

Torgerson, D.J. and Bell-Syer, S.E. Hormone replacement therapy and prevention of nonvertebral fractures. Journal of the American Medical Association 285(22):2891–2897 (2001).
This meta-analysis of 22 randomized controlled trials of HRT found a statistically significant reduction in nonvertebral fractures. There was an overall reduction in risk of 27 percent, but the effect was greater among women who began using HRT before the age of 60 (33%) than in women starting therapy later in life (12%). When only hip and wrist fractures are considered, HRT reduces overall risk by 40 percent and risk among women beginning HRT before age 60 by 55 percent.

Wassertheil-Smoller, S. et al. Effect of estrogen plus progestin on stroke in postmenopausal women: the Women’s Health Initiative: a randomized trial. JAMA 289(20);2673–2684 (2003).
The Women’s Health Initiative (WHI) is the first randomized, double-blind primary prevention trial of postmenopausal hormones. This article reports on the part of the study comparing combined estrogen/progestin therapy with a placebo, which included 16,608 mostly healthy, ethnically diverse women aged 50–79, with an average follow-up of 5.6 years. Hormone therapy significantly increased the risk of ischemic stroke (hazard ratio = 1.44) but not hemorrhagic stroke. Risks for ischemic stroke were increased for all age groups, in women with and without hypertension or a prior history of cardiovascular disease, and in women with and without other risk factors for stroke.

Writing Group for the Womens Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Journal of the American Medical Association 288(3):321–333 (2002). Available at: http://jama.ama-assn.org/cgi/content/short/288/3/321.
The Womens Health Initiative (WHI) is the first randomized, double-blind primary prevention trial of postmenopausal hormones. This article reports on the part of the study comparing combined estrogen/progestin therapy with a placebo, which included 16,608 mostly healthy, ethnically diverse women. The study was ended early when health risks exceeded health benefits after an average follow-up of 5.2 years. Hormone therapy significantly increased the risks of coronary heart disease (hazard ratio = 1.29), breast cancer (1.26), stroke (1.41), and pulmonary embolism (2.13). Risks for cardiovascular disease and invasive breast cancer were increased for all ethnic, racial, and age groups and did not reflect prior risk status or disease. Hormone therapy significantly decreased the risks of colorectal cancer (0.63), endometrial cancer (0.83), and hip fracture (0.66). All-cause mortality was not affected, but the harmful outcomes outweighed the beneficial outcomes in the hormone therapy group. The authors conclude that combined HRT is not an appropriate intervention for the primary prevention of chronic diseases.

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Complementary and alternative medicine

Atkinson C et al. The effects of phytoestrogen isoflavones on bone density in women: a double-blind, randomized, placebo-controlled trial. American Journal of Clinical Nutrition. 2004;79(2):326–333.
A double-blind, randomized, placebo-controlled trial of a red clover-derived isoflavone supplement enrolled 205 women aged 49 to 65. After 12 months, loss of lumbar spine bone mineral content and bone mineral density was significantly lower (P = 0.04 and P = 0.03, respectively) in women taking the isoflavone supplement than in those taking the placebo. There was no significant effect on: hip bone mineral content or bone mineral density, markers of bone resorption, or body composition.

Borelli F, Ernst E. Cimicifuga racemosa: a systematic review of its clinical efficacy. European Journal of Clinical Pharmacology. 2002;58:235–241.
This review summarizes evidence on the efficacy of C. racemosa (black cohosh) in treating menopausal symptoms and on its mechanism of action. There have been many clinical studies of black cohosh, but only four were randomized controlled trials. While three of these reported positive results, the authors conclude that they do not provide compelling evidence of efficacy due to methodological problems. Recent animal and in vitro experiments also have cast doubt on the belief that the herb has an estrogenic effect; it appears to have a different mechanism of action.

Dog TL et al. Critical evaluation of the safety of Cimicifuga racemosa in menopause symptom relief. Menopause. 2003;10(4):299–313.
This comprehensive review examined all published literature on the preclinical and clinical safety of various forms of cimicifuga, the FDA and World Health Organization adverse-event reporting systems, monographs, compendia, internal unpublished data from a major manufacturer, foreign literature, and historical anecdotal reports. Uncontrolled reports, postmarketing surveillance, and human clinical trials of more than 2,800 patients demonstrate a low incidence of adverse events (5.4%). Of the adverse events reported, 97 percent were minor and did not result in discontinuation of therapy; the only severe events were not attributed to cimicifuga treatment. The authors conclude that cimicifuga extracts, particularly isopropanolic preparations, can be safely used by women with menopausal symptoms and by women for whom estrogen therapy is contraindicated.

Ho SC et al. Soy protein consumption and bone mass in early postmenopausal Chinese women. Osteoporosis International. 2003;14:835–42.
This population-based study conducted a cross-sectional analysis of the association between dietary soy protein intake and bone mineral density/content (BMD/BMC) in 454 healthy Chinese women during the first 12 years after menopause. Few differences were observed during the first four years of menopause. Among women in the fifth through twelfth years of menopause, there was a dose-response relationship with BMD increasing with soy protein intake (P<0.05 from tests for trend). Bone mineral density values differed by 4 to 8 percent between the first and fourth soy protein intake quartiles. The association remained after adjusting for body weight, and analyses of soy isoflavone content yielded similar results.

Huntley A, Ernst E. Soy for the treatment of perimenopausal symptoms—a systematic review. Maturitas. 2004;47:1–9.
A search of the literature identified 13 randomized controlled trials of soy preparations for the treatment of perimenopausal symptoms. Two were excluded because of potential bias due to study methods, and one was excluded because it included breast cancer patients. The results of the remaining ten studies are not conclusive: four were positive, and six were negative (although one of these showed a positive trend). Variation in the menopausal status of the women, dosage, and outcome measures probably contribute to these mixed results. Adverse event data from the studies suggest there are no serious safety concerns with short-term use of soy.

Kang HJ et al. Use of alternative and complementary medicine in menopause. International Journal of Gynecology and Obstetrics. 2002;79:195–207.
This review summarizes clinical evidence on the effect of alternative and complementary medicine (including soy products, black cohosh, dong quai, acupuncture, ginseng, and evening primrose oil) on menopausal hot flashes, lipid profiles, and bone mineral density. Most clinical data available concerns soy. Soy isoflavones slightly decrease total cholesterol and LDL levels, although the clinical significance of this change is unknown. A synthetic isoflavone derivative, ipriflavone, increases bone mineral density in healthy peri- and postmenopausal women with moderate bone mineral densities. Although earlier reports have claimed that soy improves vasomotor symptoms of menopause, recent data do not support this claim. Data on other alternative therapies for treating menopausal symptoms are insufficient. The authors conclude that well-designed large studies are needed to determine what role alternative and complementary medicine may play in managing menopause.

Kronenberg F, Fugh-Berman A. Complementary and alternative medicine for menopausal symptoms: a review of randomized, controlled trials. Annals of Internal Medicine. 2002;137 (10):805–813.
The authors identified and reviewed 29 randomized, controlled clinical trials of complementary and alternative therapies for hot flashes and other menopausal symptoms, including 12 on soy and soy extracts, 4 on black cohosh, and 2 on red clover. While soy may have a modest impact on hot flashes, studies are not conclusive. Isoflavone preparations seem to be less effective than soy foods. Black cohosh may reduce menopausal symptoms, especially hot flashes, but long-term safety data is lacking. Studies of red clover, dong quai, evening primrose oil, vitamin E, and acupuncture have found no benefit for treating hot flashes. The authors conclude that foods which contain phytoestrogens show promise for the treatment of menopausal symptoms. Clinical trials do not support the use of other herbs or CAM therapies. Long-term safety data on individual isoflavones or isoflavone concentrates are not available.

Peeters PH et al. Phytoestrogens and breast cancer risk. Review of the epidemiological evidence. Breast Cancer Research and Treatment. 2003;77(2):171–183.
Thirteen epidemiological studies (four of which were prospective) have investigated the relationship between breast cancer and individual soy consumption. Generally, the results do not show protective effects, except perhaps for consumption at adolescence or at very high doses. Four studies have assessed the relationship of breast cancer with the urinary excretion of isoflavones. The single prospective study in this group, which made urinary measurements before the occurrence of breast cancer, showed a non-significant breast cancer risk reduction for high excretion. Of the three studies that have measured enterolactone (lignan), the two case-control studies reported a preventive effect on breast cancer risk, but the prospective study did not. It is possible that none of the five prospective studies on phytoestrogens and breast cancer risk have found a protective effect because they did not focus on age at consumption, which has been an important variable in dietary case-control studies.

Tice JA et al. Phytoestrogen supplements for the treatment of hot flashes: the Isoflavone Clover Extract (ICE) study: a randomized controlled trial. JAMA. 2003;290(2):207–214.
This randomized, double-blind, placebo-controlled trial compared the efficacy and safety of two dietary supplements derived from red clover with placebo in menopausal women aged 45 to 60, who were experiencing at least 35 hot flashes per week. The 252 participants were randomly assigned to Promensil (82 mg of total isoflavones per day), Rimostil (57 mg of total isoflavones per day), or an identical placebo for twelve weeks. At the end of the 12-week protocol, reductions in mean daily hot flash count at were similar for all three groups (5.1, 5.4, and 5.0). Compared with the placebo group, women taking Promensil but not Rimostil reduced hot flashes more rapidly. Improvements in quality of life and adverse events were comparable in all three groups. The authors conclude that neither supplement had a clinically important effect on menopausal symptoms.

Vincent A, Fitzpatrick LA. Soy isoflavones: are they useful in menopause? Mayo Clinic Proceedings. 2000;75:1174–1184. Available at: www.mayo.edu/proceedings/2000/nov/7511sc1.pdf.
Studies have found that soy-based diets significantly decrease total cholesterol, LDL cholesterol, and triglyceride levels, which may protect against coronary artery disease; consuming purified isoflavones pills shows less effect. Epidemiological studies focusing on low rates of breast cancer in East Asian countries, where soy is a predominant part of the diet, have raised the possibility that soy may prevent breast cancer, but the clinical evidence for such a link remains controversial. While animal studies suggest that isoflavones could protect against bone loss, data from human studies on the effect of isoflavones on osteoporosis are limited. A few studies have found that soy has a small effect on hot flashes, and laboratory studies show no effect on cognition. The authors conclude that randomized, placebo-controlled clinical trials are needed to confirm the benefits of soy isoflavones suggested by epidemiological and laboratory studies.

Xu WH et al. Soya food intake and risk of endometrial cancer among Chinese women in Shanghai: population based case-control study. British Medical Journal. 2004;328(7451):1285–1288. Available at: http://bmj.bmjjournals.com/cgi/content/full/328/7451/1285.
To evaluate the association between eating soya foods and endometrial cancer, 832 women diagnosed with endometrial cancer from 1997 to 2001 were identified from the Shanghai Cancer Registry. These women were matched by age with 846 control women randomly selected from the Shanghai Residential Registry. Interviewers used a food frequency questionnaire to gather data on soya food intake over the past five years. Regular consumption of soya foods was inversely associated with the risk of endometrial cancer: the quartile eating the most soya foods had an adjusted odds ratio of endometrial cancer of 0.67 compared with the quartile eating the least soya foods. The inverse association seemed to be more pronounced among women with high body mass index and waist:hip ratio.

Yamamoto S et al. Soy, isoflavones, and breast cancer risk in Japan. Journal of the National Cancer Institute. 2003;95(12):906–913.
As part of a population-based prospective study on cancer and cardiovascular disease, 21,852 Japanese women aged 40 to 59 completed a questionnaire in 1990 that asked about soy consumption. Through December 1999, 179 of the women were diagnosed with breast cancer. Results show that frequent consumption of miso soup and isoflavones—but not of soy foods—is associated with a reduced risk of breast cancer, even after adjusting for potential confounders such as reproductive history, family history, smoking, and other dietary factors. Women who consumed the most isoflavones were half as likely to develop breast cancer as those who consumed the least. The association was stronger in postmenopausal women. The authors speculate that this study may have found a beneficial effect of isoflavones, unlike studies of other populations, because consumption levels are hundreds of time higher in Japan than among U.S. Caucasian women.

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Impact of HIV/AIDS on Older Women

Best, K. HIV/AIDS does not spare older people. Network 22(1) (2002). Available at: www.fhi.org/en/RH/Pubs/Network/v22_1/NWvolnenopause.htm.
Global reporting on the AIDS epidemic tends to ignore people over age 49, and older people themselves believe their risk is low. Many older people are sexually active, however, and hence at risk of HIV infection. Indeed, physical changes associated with menopause can increase a womens risk of infection. Physicians often fail to suspect HIV among older clients, assuming that their symptoms are due to diseases associated with aging and menopause, so that diagnosis and treatment are delayed. It is important for reproductive health care providers to discuss sexual behavior with older clients, teach them about HIV/AIDS, encourage safe sex practices, and, when symptoms arise, suggest that they be tested for HIV infection.

Health & Development Networks. Home-based care: women are only half the solution. Correspondent. XVth International AIDS Conference Edition. 2004;4:9. Available at: www.hdnet.org/Library3.asp?nid=4.
The scale of the AIDS pandemic is causing severe psychological, emotional, physical, and economic stress among women, who traditionally are responsible for caregiving in African societies. Relying solely on women for home-based care is entrenching gender inequalities, is probably not sustainable, and may undermine the quality of care. A program in Kenya is working to empower men to provide home-based care for HIV-positive men. This type of initiative can help young people challenge traditional gender norms and biases.

HelpAge International and the International HIV/AIDS Alliance. Forgotten Families: Older People as Carers of Orphans and Vulnerable Children. Brighton, UK: International HIV/AIDS Alliance; 2003). Available at: www.helpage.org/images/pdfs/HIVAIDS/ForgottenFamiliesReport.pdf.
After reviewing the challenges posed by HIV/AIDS for older people who assume responsibility for bringing up orphans and vulnerable children, this report urges that family and community-based support be placed at the heart of the response to the AIDS epidemic. Brief case studies illustrate effective responses. Specific recommendations include: providing income support to address the financial needs of older caregivers; creating accessible health care services to meet the health needs of families affected by HIV/AIDS, including older people and children; creating flexible education services for orphans and vulnerable children; providing older people with information and training on HIV/AIDS; developing policies and programs that address the psychosocial needs of older caregivers and children; and involving older caregivers and children in the policy and programming process.

HelpAge International. HIV/AIDS and older people. Ageways 61 (December 2002). Available at: www.helpage.org/images/pdfs/ageways/AW61.pdf.
This special issue of Ageways includes articles on: how HIV/AIDS affects older people, how to reach older people with HIV/AIDS education, how to raise awareness of the impact of HIV/AIDS on older people, and how to provide home care for people with AIDS. Other articles profile programs that support older caregivers in Thailand, train older people to serve as community educators in Sudan, and help older people care for orphaned grandchildren in South Africa.

International HIV/AIDS Alliance and HelpAge International. Supporting Older Carers. Building Blocks: Africa-Wide Briefing Notes. Brighton, UK: International HIV/AIDS Alliance; 2004. Available in English, French, and Portuguese at: www.aidsalliance.org.
This briefing note reflects discussions held at an international workshop in Kenya on the situation of older carers and vulnerable children. It explains why more attention should be paid to the needs of older carers and outlines the factors that affect their well-being. The brief presents program guidelines for addressing the needs of older people caring for children as well as ways to take action at the community level to support older people. It calls for: raising awareness of the needs of older people and the role they play; ensuring that policies, laws, and programs cater to the needs of older people; providing economic and psychosocial support; encouraging social inclusion; protecting older carers and vulnerable children from abuse; increasing children’s access to education and training; improving the physical well-being, health, and nutrition of older carers; and working with older people to reduce risky cultural practices and promote HIV/AIDS prevention.

Knodel, J. et al. AIDS and older persons: an international perspective. PSC Research Report No. 02-495. Ann Arbor, Michigan: Population Studies Center (January 2002). Available at: http://psc.isr.umich.edu/pubs/papers/rr02-495.pdf.
While people over age 50 account for 10 to 16 percent of AIDS cases in developed countries, they account for 5 to 7 percent of cases in developing regions of the world. The consequences of the AIDS epidemic for older people in developing countries are more often indirect, as their adult children are infected with HIV and require care. This reverses the normal inter-generational flow of resources, which generally channels family support and care to the elderly. There are seven potential pathways through which the AIDS epidemic can adversely impact the well-being of parents of adult children with AIDS: caregiving, co-residence, financial support, funeral expenses, fostering grandchildren, loss of child, and negative community reactions. To illustrate the problems, data is presented for Thailand, where 13 percent of Thais over age 50 as of 1995 are likely to lose at least one adult child to AIDS. In Thailand a parent provides some care for almost two-thirds of adults who die of AIDS and serve as main caregivers for half. Mothers are four to five times more likely than fathers to become the main caregiver. Elderly caregivers frequently experience fatigue, insomnia, anxiety, strained muscles, headaches, and stomachaches. While the financial impacts are substantial, caregivers in Thailand are not stigmatized as often happens in Africa. In Africa, higher incidence levels, less well developed public health services, and the lack of state support for the sick means that burdens on family caregivers are even greater.

Lindsey E et al. Home-based care in Botswana: experiences of older women and young girls. Health Care for Women International. 2003;24:486–501.
Researchers conducted 70 interviews in three districts of Botswana, half with people caring for family members living with HIV/AIDS or another chronic illness, and half with health care workers and other key informants. Over half of the caregivers were older women, who reported being physically and emotionally overwhelmed by the number and magnitude of the tasks they had to perform. The young girls who often played a supportive role to the primary caregiver also suffered from the situation: they often missed school, were physically or sexually abused, and felt depressed. Major concerns were poverty, social isolation, stigma, psychological distress, and a lack of basic caregiving education. The authors recommend educating patients, families, and health workers on HIV/AIDS care, prevention, and counseling; addressing the stigma associated with HIV/AIDS; supporting girls to remain in school; conducting joint education sessions with traditional doctors, spiritual healers, and health workers; and teaching income generation.

Saengtienchai, C. and Knodel, J. Parents providing care to adult sons and daughters with HIV/AIDS in Thailand. UNAIDS Best Practice Collection. Geneva: UNAIDS (November 2001). Available at: http://aidseld.psc.isr.umich.edu/sons_daughters.pdf.
Almost no attention has been paid to the parents of people with AIDS, yet they serve a critical role as caregivers to their adult sons and daughters. The most extensive research on this phenomenon comes from Thailand. This case study provides a qualitative analysis of the circumstances and consequences of parental caregiving to adult children with AIDS in Thailand based on open-ended interviews. The substantial emotional, physical, and financial demands of caregiving are especially overwhelming for older persons. In order to cope with the situation, Thai parents often solicit help from other family members and try to view their role as a parental responsibility, without blaming their children for becoming infected or viewing them as a burden. Real or perceived stigma, however, may prevent some parental caregivers from soliciting support outside the family. Programs need to harness parents in efforts to improve care, while also providing them with the support they need to provide more effective palliative care.

UNAIDS and World Health Organization (WHO). HIV/AIDS and older people. Press kit for Second World Assembly on Ageing, Madrid, Spain, 8–12 April 2002. New York: United Nations Department of Public Information (March 2002). Available at: www.un.org/ageing/prkit/hivaids.htm.
Little is known about the epidemiology of HIV/AIDS in developing countries, but about 10 percent of AIDS cases in the United States and Western Europe occur among people over age 50. Age accelerates the progress of HIV to AIDS, blunts responses to antiretroviral therapy, and increases the risk of severe complications. It also may increase womens vulnerability to infection. Diagnosis is often delayed as early HIV symptoms are mistaken for signs of aging. Because of age stereotypes, health care workers and prevention programs do not target older people and are less likely to provide them with prevention information. Older people, especially in Africa, also are affected by the need to care for adult children with AIDS and orphaned grandchildren, but this problem has received little attention in policy and program discussions. Older people must be offered the education, psychological support, and resources they need in order to care for the sick and the orphans.

Williams, A and Tumwekwase, G. Multiple impacts of the HIV/AIDS epidemic on the aged in rural Uganda. Journal of Cross-Cultural Gerontology 16(3):221–236 (2001). (Summary available online at www.id21.org/health/h5jw3g7.html.
Of 30 men and women aged 60 to 90 in a rural Ugandan village, 13 had experienced an AIDS illness or death in the house. Monthly interviews revealed various impacts of the HIV/AIDS epidemic, including: their own vulnerability to infection as sexually active adults; the need to provide for the emotional, physical, and economic needs of their HIV-infected children (including burial); the need to feed, clothe, and educate orphaned grandchildren; and loss of economic support that their deceased children would have provided. Caring for the sick and for orphans also reduced the time they had available for agriculture. Households headed by women were more likely to be affected by the AIDS epidemic than households headed by men.

Wilson, A.O. and Adamchak, D.J. The grandmothers disease—the impact of AIDS on Africas older women. Age and Ageing 30:8–10 (2001). Available at: http://ageing.oupjournals.org/cgi/reprint/30/1/8.pdf.
This commentary describes how changing population profiles caused by AIDS are eroding the informal family support system that older Africans traditionally have relied upon. Older people also face heightened risks of HIV infection due to their diminished health and nutritional status, vulnerability to sexual abuse, activities as traditional healers and midwives, and widowhood. The authors urge governments, donors, and NGOs to provider older African women with the formal and informal support they need to deal with the social, economic, and health burdens of AIDS.

World Health Organization (WHO). Impact of AIDS on older people in Africa: Zimbabwe case study. Geneva: WHO (2002). Available at: www.who.int/hpr/ageing/zimaidsreport.pdf.
This pilot project is the first step in developing a reliable methodology to examine the impact of HIV/AIDS on older caregivers. A mix of qualitative and quantitative research methods was designed and tested in six provinces of Zimbabwe. Older caregivers are under serious financial, physical, and emotional stress due to their caregiving responsibilities. Barriers to care include: financial constraints, lack of food and other basic necessities, burn-out, stigma, violence, fear of contracting the disease, and frustrations in performing daily chores. The report suggests strategies and makes recommendations for strengthening the capacity of older persons to perform caregiving duties. Three key areas for policy and program action are identified: enhancing the capacity of older people to give care via outreach services from the health care system; improving access to and utilization of existing social support services; and ensuring economic independence and income support for older caregivers.

WHO. Community home-based care: action research in Kenya. Geneva: WHO (2001). Available at: http://whqlibdoc.who.int/hq/2001/WHO_NMH_CCL_01.01.pdf.
Focus group discussions and individual interviews were conducted in Kenya with 53 family caregivers and 27 key informants from the health care system and the community. Caregivers of all ages complained of exhaustion, stigma and isolation, and poverty. Lack of a functioning health care infrastructure compromised the provision of community home-based care, undermining referrals, supplies, communication, and transportation. Study results were applied to a conceptual framework of community home-based care, culminating in a series of intervention strategies to help sustain services in Kenya.

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Osteoporosis

Altkorn, D. and Vokes, T. Treatment of postmenopausal osteoporosis. Journal of the American Medical Association 285(11):1415–1418 (2001).
This update reviews evidence on the effectiveness of various treatments for osteoporosis in postmenopausal women, including hormone replacement therapy, selective estrogen receptor modulators, bisophonates, combined HRT and alendronate, and calcitonin. There are no large trials that directly compare the different treatments, but the authors recommend individualizing treatment, depending on womens menopausal status, the severity of their osteoporosis, their vulnerability to other health problems, and their tolerance of therapy.

Atkinson, S.A. and Ward, W.E. Clinical nutrition: 2. The role of nutrition in the prevention and treatment of adult osteoporosis. Canadian Medical Association Journal 165(11):1511–1514 (2001). Available at: www.cmaj.ca/cgi/content/full/165/11/1511.
This article reviews how much calcium and vitamin D people in different age groups should be getting to maximize bone mass. Excess protein, sodium, and caffeine consumption also are important because they may have a negative effect on the absorption of calcium. Good evidence is still lacking on whether phytoestrogens in the diet can protect against bone loss among postmenopausal women.

Chien, M.Y. et al. Physical activity, physical fitness, and osteopenia in postmenopausal Taiwanese women. Journal of the Formosa Medical Association 99(1):11–17 (2000).
This cross-sectional study compared two groups of postmenopausal Taiwanese women aged 42 to 65 years; one group had normal bone mineral density values while the other group had below-normal values. A questionnaire was used to assess the women's physical activity and calcium intake, while tests of flexibility, muscular strength, endurance, body composition, and cardiopulmonary fitness were used to assess their physical fitness. After adjusting for age, body weight, height, and years since menopause, findings showed that physical activity levels (both energy expenditure and hours spent on difficult activities) and cardiopulmonary fitness (measured in terms of maximum oxygen consumption) were significantly lower in the group with subnormal bone density. Other measure of physical fitness did not differ significantly between the two groups.

Cummings, S.R. and Melton, L.J. Epidemiology and outcomes of osteoporotic fractures. Lancet 359(9319):1761–1767 (2002). Available at: http://pdf.thelancet.com/pdfdownload?uid=llan.359.9319.editorial_and_review.21125.1&x=x.pdf.
Osteoporotic fractures are an important cause of disability and medical costs worldwide. Hip fractures, the most serious outcome of osteoporosis, are becoming more frequent as the worlds population ages and because incidence rates are rising in most areas of the world. Age-adjusted incidence rates vary widely between and within countries. Worldwide the risk of hip fracture varies more in women than in men. As a result, rates in men and women are similar in low risk populations (for example, in Asia and Africa), while rates in women are far higher than men in high risk populations (for example, the United States and Europe). There is less geographic variation in the incidence of vertebral fractures.

Cure-Cure, C. et al. Bone-mass peak in multiparity and reduced risk of bone-fractures in menopause. International Journal of Gynecology & Obstetrics 76:285–291 (2002).
This study examines a series of 1,855 postmenopausal women referred to a clinic in Colombia for a routine evaluation of bone mineral density. Almost a quarter (23%) of the women had a history of fractures. Bone mineral density was higher in women who had delivered at least one child, compared with multiparous women. Total mineral and calcium body contents were higher in women who had at least two children. Compared with multiparous women, nulliparous women had significantly higher risk of fractures, osteopenia, and osteoporosis. The authors conclude that pregnancies protect against osteoporosis.

Delmas, P. Treatment of postmenopausal osteoporosis. Lancet 359(9322):2018–2026 (2002). Available at: http://pdf.thelancet.com/pdfdownload?uid=llan.359.9322.editorial_and_review.21342.1&x=x.pdf.
A variety of treatments are available to reduce the frequency of vertebral and hip fractures among people diagnosed with osteoporosis. Calcium (usually given together with vitamin D) slows the rate of bone loss but is not sufficient to treat individuals with osteoporosis. Hormone replacement therapy stops bone loss in postmenopausal women but is associated with other health risks. Other drugs, including selective estrogen receptor modulators (SERMS), bisophonates, and calcitonin, also have been shown to reduce bone loss in postmenopausal women. Good nutrition, including adequate calcium intake, and exercise beginning early in life lead to high peak bone mass, thus reducing the risk of osteoporosis later in life. Exercise later in life may prevent fractures in two ways: first, by directly increasing bone mass and, second, by increasing mobility and muscle function which, in turn, reduces the risk of falls.

Delmas, P.D. and Fraser, M. Strong bones in later life: luxury or necessity? Bulletin of the World Health Organization 77(5):416–422 (1999).
Osteoporosis and its major complications, hip and spine fractures, affect one in three postmenopausal women and will become an increasingly important problem in developing countries as the proportion of the population over age 65 increases. Worldwide, the number of hip fractures could rise from 1.7 million in 1990 to 6.3 million by 2050. The incidence of osteoporosis varies geographically, so that, for example, women suffer fractures 10 to 20 years earlier in India than in the west. The authors conclude that education is a priority because, in many parts of the world, medical professionals and the public view fractures as a natural part of aging rather than as symptoms of a preventable and treatable disease. While guidelines exist for diagnosing and treating osteoporosis and for calcium and vitamin D intake, many health agencies are reluctant to pay for these interventions. There also is little accurate data on the incidence, prevalence, and risk factors for osteoporosis and the cost-effectiveness of different interventions in developing countries.

Feskanich, D. et al. Walking and leisure-time activity and risks of hip fracture in post-menopausal women. Journal of the American Medical Association 288(18):2300–2306 (2002).
This prospective study followed 61,200 healthy postmenopausal women enrolled in the Nurses Health Study for 12 years. Exercise significantly reduced the risk of hip fracture, after controlling for age, body mass, use of postmenopausal hormones, smoking, and diet. Among women not taking postmenopausal hormones, the risk of hip fracture decrease linearly as activity levels rose; the same was not true for women taking hormones. Walking for at least four hours a week lowered the risk of hip fracture by 41 percent for women who did no other exercise. More time spent standing also lowered fracture risks.

Geusens, P. et al. Performance of risk indices for identifying low bone density in postmenopausal women. Mayo Clinic Proceedings 77(7):629–637 (2002). Available at: www.mayo.edu/proceedings/2002/jul/7707a2.pdf.
By screening women for bone mineral density (BMD), health programs can diagnose and treat osteoporosis and reduce the public health burden of fractures. Mass screening is expensive, however. This study examined the ability of simple risk assessment tools to increase the efficiency of BMD testing by identifying those women most likely to have osteoporosis. All four risk assessment tools tested were able to predict low bone mass. The Osteoporosis Self-Assessment Tool (OST) is easiest to calculate, since it is based only on age and weight. This approach may be especially useful where resources and access to BMD measurements is limited. Use of a risk assessment tool also has the potential to raise awareness of the problem of osteoporosis among doctors and women.

Hui Y. Osteoporosis: should there be a screening programme in Hong Kong? Hong Kong Medical Journal. 2002;8:270–277. Available at: www.hkmj.org.hk/hkmj/abstracts/v8n4/270.htm.
Because the health burden caused by osteoporosis is growing in Hong Kong, this article examines the need for and feasibility of a screening program. Osteoporosis satisfies three WHO criteria for screening of diseases: it is a significant health problem, its natural history is fairly well understood, and early detection is possible. However, the effectiveness of treatments in preventing fractures, the duration of therapy, and the selection of patients for treatment remains unresolved—especially with respect to Asian populations. It also is not yet possible to measure the cost-effectiveness of a screening program. The author concludes that large-scale screening for osteoporosis is not a valid option for Hong Kong.

Huo D et al. Influence of reproductive factors on hip fracture risk in Chinese women. Osteoporosis International. 2003;14:694–700.
This case-control study investigated the relationship between reproductive factors and the risk of hip fractures in postmenopausal Chinese women over age 50 living in Beijing. Researchers identified 121 women from hospital records who sustained a hip fracture after minor trauma. Each case was matched with two controls, based on age and neighborhood. After adjusting for potential confounding factors, breastfeeding was statistically associated with risk of hip fracture. Compared with women who breastfed each child for six months or less, women who breastfed each child for an average of 7–12 months, 13–23 months, and 24+ months had odds ratios of 1.14 (95% CI: 0.48, 2.72), 0.28 (95% CI: 0.10, 0.82), and 0.34 (95% CI: 0.13, 0.92), respectively. Among parous women, there was a 13 percent reduction in hip fracture risk for every six-month increase in breastfeeding per child.

Iqbal, M.M. Osteoporosis: epidemiology, diagnosis, and treatment. Southern Medical Journal 93(1):2–18 (2000). Available at: www.medscape.com/viewarticle/410461. (Medscape requires free online registration.)
This article reviews the different types of osteoporosis, risk factors, and the use of bone densitometry and biochemical markets of bone turnover to diagnose the condition. Most of the article is devoted to a detailed assessment of the ways to prevent and treat osteoporosis, including exercise, dietary and lifestyle changes, calcium and vitamin D supplementation, hormone replacement therapy, biphosophonates, calcitonin, SERMs, sodium fluoride, testosterone therapy, human parathyroid hormone, and growth hormone. The author concludes that the primary goal should be prevention—that is, ensuring adequate dietary calcium intake, good nutrition, exercise, and hormone sufficiency so that young women achieve optimum peak bone mass by early adulthood.

Koh LKH. An Asian perspective to the problem of osteoporosis. Annals of the Academy of Medicine of Singapore. 2002;31(1):26–29.
This literature review highlights similarities and differences in research on osteoporosis among Asians and Caucasians. While low, hip fracture rates in Asia are rising, and epidemiological trends are similar to Caucasian populations. Risk factors for osteoporosis and fractures are similar in the two populations, but dietary factors seem to play a larger role in Asia, where calcium intake is generally lower. A uniquely Asian self-assessment tool based on clinical factors has been developed to assist in case-finding of osteoporosis. Calcium supplements and exercise appear to benefit Asians, and Asians and Caucasians respond similarly to hormone replacement, alendronate, and parathyroid hormone.

Kung AWC et al. Comparison of a simple clinical risk index and quantitative bone ultrasound for identifying women at increased risk of osteoporosis. Osteoporosis International. 2003;14:716–721.
Osteoporosis is a growing problem in Asia, but access to bone mineral density measurements is limited. This makes it difficult to target preventive measures to the women most at risk. This study compared a simple clinical risk assessment tool (the Osteoporosis Self-assessment Tool for Asians or OSTA) with quantitative bone ultrasound measures in 722 postmenopausal women from Hong Kong. The sensitivity and specificity of OSTA was 88 percent and 54 percent respectively, compared with 81 percent and 65 percent for ultrasound. Both methods correlated significantly with bone mineral density at the femoral neck (0.62 and 0.36, respectively, P both <0.001). The authors conclude that a simple clinical risk assessment tool is a cheap and effective method to identify patients at increased risk of osteoporosis, and its use could facilitate appropriate and cost-effective use of bone densitometry in developing countries.

Lau, E.M.C. Osteoporosis: a worldwide problem and the implications in Asia. Annals of the Academy of Medicine of Singapore 31(1):67–68 (2002). Available at: http://annals.edu.sg/pdfJan02/LauEMC.pdf.
In the 1960s, hip fracture rates in Asia were a fraction of those in North America and northern Europe. However, the incidence of osteoporosis and hip fracture has risen considerably over the last twenty years with socioeconomic development, so that the incidence of hip fracture in Hong Kong and Singapore is nearly as high as in the West. Given these changes, osteoporosis will be an increasingly important health challenge for Asia in decades to come. The author recommends implementing preventive strategies for osteoporosis in Asia. It is unclear, however, whether Asian governments will be able to find the funds to pay for screening with bone mineral densitometry or for lifelong drug therapy of those affected.

North American Menopause Society (NAMS). Management of postmenopausal osteoporosis: position statement of the North American Menopause Society. Menopause 9(2):84–101 (2002). Available at: www.menopause.org/aboutmeno/consensus.htm.
This evidence-based position statement was developed by an expert panel. The goal of osteoporosis therapy is to prevent fractures by slowing bone loss, maintaining bone strength, and minimizing falls. Risk factors are age, genetics, lifestyle, and menopausal status. Management of osteoporosis should focus first on lifestyle and diet, including adequate calcium and vitamin D intake, exercise, smoking cessation, avoidance of excessive alcohol intake, and the prevention of falls. For women at high risk of fracture, because of low bone mineral density or prior fractures, pharmacologic therapy may also be considered. Options include estrogens (for prevention only), bisophonates and SERMS (for prevention and treatment), and calcitonin (for treatment only).

North American Menopause Society (NAMS). The role of calcium in peri- and postmenopausal women: consensus opinion of The North American Menopause Society. Menopause 8(2):84–95 (2001). Available at: www.menopause.org/aboutmeno/consensus.htm.
This evidence-based consensus opinion was developed by a panel of experts. Adequate calcium intake, together with vitamin D, can prevent bone loss and reduce fracture risk and also has benefits for some nonskeletal disorders. Most peri- and postmenopausal women need at least 1,200 mg of calcium each day, along with 400–600 IU of vitamin D to ensure adequate absorption.

Picard, D. et al. Longitudinal study of bone density and its determinants in women in peri- or early menopause. Calcified Tissue International 67:356–360 (2000).
This follow-up study examined 141 French Canadian women assessed 10 years earlier, before they had reached menopause. Bone loss over the 10-year period was strongly associated with time without estrogen and, to a lesser extent, present weight and vitamin D intake. Current bone density was strongly associated with premenopausal bone density; length of time without estrogen played a small role. These results suggest the importance of building a good bone mass before menopause, of having adequate vitamin D intake, and of beginning estrogen replacement therapy as soon as possible after menopause.

Sherman, S. Preventing and treating osteoporosis. Annals of the New York Academy of Sciences 949:188–197 (2001).
Bone mineral density in later life is determined by the peak bone mass attained in early adulthood and the rate of bone loss later in life. Supplementation with calcium and vitamin D significantly reduces the risk of fracture, is inexpensive, and is well-tolerated. While estrogen has long been a mainstay in postmenopausal osteoporosis therapy, its side effects and risk limit acceptability and adherence. Among the SERMs, raloxifene may have protective effects against cardiovascular disease and breast cancer as well as osteoporosis. The bisophonates alendronate and risendronate also are highly effective in reducing the risk of fracture in postmenopausal women with osteoporosis.

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Healthy aging

Burghardt, M. Exercise at menopause: a critical difference. Medscape Women's Health 4(1) (1999). Available at: http://www.medscape.com/viewarticle/408896. (Medscape requires free online registration.)
This review article discusses the benefits of regular exercise for menopausal women, including increases in metabolism, improved mood, and reduced risk of osteoporosis and heart disease. The author urges doctors to prescribe weight-bearing exercise, resistance training, and high-intensity fitness regimens along with estrogen replacement therapy for menopausal women.

Dangour, A.D. and Ismail, S.J. Aging and nutrition in developing countries. Tropical Medicine and International Health 8(4):287–289 (2003).
This editorial points out that, as populations in developing countries continue to age, good nutrition for the elderly will become an increasingly important issue, since dietary deficiencies contribute to a host of health problems, including bone fractures, mental deterioration, and loss of immune function. Older people are nutritionally vulnerable for a variety of functional, physiological, psychological, and social reasons, and undernutrition, including micronutrients, is especially pervasive among the elderly in developing country settings. However, little research on nutritional status of older people has been conducted in developing country settings, even though they are likely to reach old age after a lifetime of poor health and suboptimal nutrition. The governments of South Africa, Mexico, and Chile have launched programs to improve the diet of older people by distributing food or money to buy food.

Sulak, P. The perimenopause: a critical time in a woman's life. International Journal of Fertility 41(2):85–89 (1996).
This review article defines perimenopause and discusses its symptoms and sequelae, including menstrual changes, vasomotor symptoms, urogenital atrophy, psychosexual dysfunction, infertility, declining bone mass, and increasing risk of heart disease. The author concludes that hormonal treatment during the menopausal transition must be individualized so that it replaces only those hormones which are lacking. Once menopause is over, women must be counseled on the risks and benefits of long-term estrogen replacement. It is also important to encourage women to adopt preventive health care measures, such as exercise and a healthy diet, and to screen them for common risk factors, such as cholesterol levels.

World Health Organization (WHO) and Tufts University School of Nutrition and Policy. Keeping Fit for Life: Meeting the Nutritional Needs of Older Persons. Geneva: WHO (2002). Available at: www.who.int/nut/publications.htm#older.
After reviewing the evidence for the impact of nutrition and exercise on health, especially on the prevention of noncommunicable chronic diseases related to aging, this publication sets out dietary guidelines for health aging and promoting physical activity among older persons. Diet (including energy, protein, and fat intake, micronutrients, and phytochemicals) and exercise are important in the prevention of coronary heart disease and stroke, cancer, osteoporosis and bone fracture, diabetes, and cataracts. They may also play an essential role in maintaining older people’s immune response and cognitive function. The dietary recommendations follow a food-based approach rather than relying on vitamin, mineral, and other supplements. The goal is to develop culturally sensitive, country- and cuisine-specific guidelines that promote health traditional dishes and modern foods. The guidelines for physical activity recognize the importance of both aerobic and strength-training exercise to prevent and treat age-associated disease.

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Designing health services for older women

Bavadam, L. HRT and older women in India. Hainews 108:1–2,11–12 (August 1999).
Few women in India use HRT because of the expense, the belief that menopause is a natural stage that does not require treatment, and lack of awareness. A study of 500 women found that 40 percent were willing to take short-term HRT therapy while 32 percent agreed to long-term therapy. There is a growing tendency to medicalize menopause in India as women's traditional support systems erode, their life spans increase, and the urban middle class grows. Some health care professionals worry that gynecologists are promoting HRT as a miracle medicine and are prescribing it without appropriate screening or follow-up. Older women are marginalized in India's medical system because women's health has been closely linked with family planning. There are no programs catering for the reproductive health needs of aging women, even though women now live from one-quarter to one-third of their lives after menopause.

Elias C, Sherris J. Reproductive and sexual health of older women in developing countries. British Medical Journal. 2003;327:64–65.
This editorial calls on the global health community to focus attention on the reproductive health needs of aging women in developing countries. Reproductive health programs are well positioned to care for women as they approach menopause and beyond. However, providers need training to screen for and treat gynecological disorders, counsel women about menopause and a healthy lifestyle, and manage chronic diseases. Outreach activities and public awareness campaigns also are essential to attract older women to clinics.

HelpAge International. Home care and volunteers. Ageways 58:1–16 (December 2001). Available in English at: www.helpage.org/images/pdfs/ageways/AW58.pdf, and in Spanish at: www.helpage.org/images/pdfs/ageways/HZ58.pdf.
This special issue of Ageways describes different models of home care, involving volunteers and/or paid staff, which can provide older people with help with household chores, emotional support, and health care. As examples, programs in Moldova, Mozambique, and Sri Lanka are profiled. Other articles offer advice on how to develop and implement such a program, including how to recruit staff.

Imogie, A.O. Sustenance of womens health after the age of 45 years at the University of Benin, Benin City, Nigeria. Health Care for Women International 21:717–726 (2000).
Results are reported from a brief survey of 50 women aver the age of 45 who work at the University of Benin as administrators, lecturers, cleaning women, clerical workers, and nurses. The women ranked their most important health problems as stress (66%), poor vision (64%), joint pain (64%), weight gain (58%), headaches (58%), hot flashes (56%), fatigue (56%), and excessive sweating (56%). About one-third of the women reported coping with health problems by getting adequate sleep, physical exercise, adequate rest, and religious fellowship; few reported going for a medical check-up (26%) or attending a weight loss program (18%). Only 16 percent of the respondents were knowledgeable about health concerns generally or about menopause in particular.

International Medical Advisory Council (IMAP). Statement on health needs of perimenopausal women. London: International Planned Parenthood Foundation (1997). Available at: www.ippf.org/medical/imap/statements/eng/1996_10a.htm.
The health needs of perimenopausal women, including menopausal symptoms, bone mineral loss, cardiovascular diseases, and malignancies, have not been properly addressed in developing countries. Family planning associations should consider providing perimenopausal counseling and health care or at least be able to refer women to other facilities. The family planning setting offers opportunities for counseling on smoking, exercise, and diet early in life; for informing women what to expect during perimenopause; for screening women for reproductive cancers and abnormal uterine bleeding; for offering sound advice on appropriate contraception; and for prescribing hormone replacement therapy.

McVeigh, C. Menopause and healthy aging: a pilot project. Australian and New Zealand Journal of Public Health 20(1):95–96 (1995).
A 6-week health promotion program with 23 perimenopausal women (40–57) uncovered deep frustrations with the care provided by their doctors. The women felt ill-equipped to talk openly with their doctors about their menopausal concerns, said their doctors did not offer enough information to make an informed decision, and suggested that their doctors devalued their feelings and concerns. The author recommends the establishment of health promotion programs on menopause and healthy aging as well as peer support groups for perimenopausal women.

Modeste, N.N. et al. Barriers to early detection of breast cancer among women in a Caribbean population. Revista Panamericana de Salud Publica 5(3):152–156 (1999).
A survey of 265 women aged 20 and older on Tobago examined barriers to early detection of breast cancer. Results show that only 37 percent of women conduct breast self-examinations more than twice a year, and only 23 percent of women report that a clinical breast exam is routinely included in doctors visits. Only 8 percent of women had ever attended a breast cancer awareness program. Mammography services are not available on Tobago, so women must travel (at high cost and inconvenience) to Trinidad. Women also believe that there is nothing they can do to prevent breast cancer. Health education programs are needed as well as better access to services.

Nzarubara, R.G. Control of breast cancer using health education. East African Medical Journal 76(12):661–663 (1999).
A survey of over 3,000 women in Uganda visiting health facilities for antenatal immunization or family planning services found low levels of knowledge about breast cancer. Midwives then conducted weekly health education sessions on breast cancer at 15 clinics. A follow-up survey found that the proportion of women who knew the risk factors for breast cancer increased from less than 25 percent to 100 percent, and the proportion who could describe and demonstrate breast self-examination rose from 0 to 90 percent. Women also learned that the best treatment is an operation and said they would seek care at the health centers and request breast examinations. The author concludes that health personnel can cheaply educate women on breast cancer and initiate mass screening at the grassroots level via breast self-examination.

Ohaeri, J.U. et al. The psychosocial burden of caring for some Nigerian women with breast cancer and cervical cancer. Social Science & Medicine 49:1541–1549 (1999).
In Nigeria, relatives (generally husbands or children) are responsible for caring for women with cancer. Interviews with 73 caregivers found that they felt the financial burden to be more of a problem than the disruption of family routines. Both contributed significantly to the caregivers perception of burden. Three-quarters of caregivers rated the familys difficulty with coping as moderate, and their social networks remained largely intact. The authors conclude there is good potential for a system of community-based care, but that family caregivers need support from the health care sector.

Ohki, K. et al. [The effects of a health promotion program on physical, mental, and dietetic health status in climacteric women.] Nippon Koshu Eisei Zasshi 48(1):3–15 (2001). (Article is in Japanese.)
Over a six-month period, 72 women living in Tokyo attended a series of 16 lecture and exercise programs. Each two-hour session included basic information on diet, exercise and relaxation, and prevention of lifestyle-related diseases as well as an active exercise program. After completing the program, the womens total cholesterol levels, blood pressure, body weight, and body mass index had all improved significantly. In addition, they were eating better, engaging in more physical exercise, and had reduced stress levels. The authors conclude that good dietary habits, physical activities, and psychological support are all essential to the quality of life of climacteric women.

Pinotti, J.A. et al. Comprehensive health care for women in a public hospital in Sao Paulo, Brazil. Reproductive Health Matters 9(18):69–78 (2001).
Described here is a model of integrated reproductive health services for women at the primary care level, which was implemented in a Sao Paulo hospital from 1991 to 1998. The program increased the number of patients seen by training nurse-assistants to screen and instruct patients, thus reducing the amount of time physicians needed to spend with each woman. Program components addressed reproductive and lung cancers, STIs and HIV/AIDS, family planning, menopausal symptoms and postmenopausal conditions, and endometriosis. More than 30,000 women over age 45 were seen in a six-month period in 1998. Most sought services for menopausal and perimenopausal disorders, but routine screening also identified many asymptomatic conditions, including hypertension (21 percent of older women), reproductive tract infections (33%), and osteoporosis (20%).

Ramoso-Jalbuena, J. Menopausal medicine under difficult circumstances: the Philippines. Philippine Journal of Obstetrics & Gynecology 22(3):79–85 (1998).
Only recently have physicians in the Philippines shown interest in the health issues facing menopausal women. Barriers exist to the effective treatment of menopause include: lack of data on Filipino woman, low compliance with hormone replacement therapy (HRT), and poverty. In addition, most Filipino women accept menopause-related disorders as an unavoidable and normal stage of a woman's cycle. Other concerns include women’s view of medicine as curative rather than preventive, surgically induced menopause, breast cancer, and cardiovascular disease. However, progress is being made in establishing a medical specialty and creating a strategy to manage the problems of menopause.

Sieu, C.T. A caring system: community-based schemes may be the answer for a graying region. Asiaweek 26(29) (July 28, 2000). Available at: www.asiaweek.com/asiaweek/magazine/2000/0728/cs.health.reform.html.
Rapid population aging is creating a challenge for healthcare spending in Asia, since older people require more and more expensive types of care. Health insurance and pension schemes in Japan are already close to bankruptcy. Elsewhere the migration of younger people from rural to urban areas is undermining the traditional support system for the elderly. Traditional values, which hold children responsible for caring for their parents, also are eroding. The solution may be community-based systems of care, which keep older people out of hospitals and enable them to help one another.

Tannenbaum CB et al. Understanding older women’s health care concerns: a qualitative study. Journal of Women & Aging. 2003;15(4):103–116.
Focus groups were conducted with 36 women aged 65 or older in Montreal, Canada, to collect information on how to improve health care services and support women’s efforts to age successfully. Participants felt that health care professionals adequately addressed their physical health but not their emotional and psychological health. They complained that providers did not take their physical symptoms and concerns as seriously as when they were younger, and they asked to be treated with respect. The women had many fears about aging and wanted providers to recognize and address their anxieties. They also wanted more information and education on what they could do to stay healthy. To promote successful aging, the authors recommend designing clinical programs that address both the physiological and psychosocial needs of older women. Key elements include preventive as well as acute medical management, validation of older women’s roles as active participants in the health care relationship, patient-centered communication, and information sharing.

Zotov, V., and Shyyan, R. Introduction of breast cancer screening in Chernihiv oblast in the Ukraine: report of a PATH breast cancer assistance program experience. Breast Journal 9(Suppl. 2):S75–S80 (2003).
In response to the high incidence of breast cancer and related mortality in Ukraine, a pilot breast cancer–screening project was launched in 1997. The project worked to increase public awareness of breast cancer, train health care providers in clinical breast examination (CBE) and mammography, open a dedicated mammography facility, build diagnostic capacity, and foster the formation of psychosocial support groups for patients with breast cancer. Implementation challenges included reservations about showing bare breasts in educational materials, the lack of an established system for collecting screening data, and the reluctance of women with positive screening results to follow up on referrals to cancer center physicians. From 1998 to 2002, 18,000 women were screened with CBE and 8,778 with mammography. Mammography was more effective in detecting small and nonpalpable lesions: 8.7 percent of cancers detected by mammography were in situ compared with 0 percent of those detected by CBE. However, CBE required fewer financial resources. The authors conclude that in the Ukraine—and other low resource settings—priority should be given to CBE. The transition to mammography can take place first in regions and cities that have a higher incidence of the disease and larger health care budgets.

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