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RHO archives : Topics : Older Women

Annotated Bibliography

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Contraceptive options for older women

Berenson AB et al. Effects of hormonal contraception on bone mineral density after 24 months of use. Obstetrics and Gynecology. 2004;103(5 Pt 1):899-906.
In this study, 191 women aged 18 to 33 chose to use oral contraception, depot medroxyprogesterone acetate, or nonhormonal contraception (controls). Percent change in bone mineral density at the lumbar spine was analyzed by using analysis of covariance, adjusting for age, race/ethnicity, weight-bearing exercise, calcium intake, smoking status, and body mass index. Women using depot medroxyprogesterone acetate for 24 months experienced, on average, a 5.7 percent loss in bone mineral density (with a 3.2 percent loss occurring between months 12 and 24), which was significantly different from changes in bone mineral density in the pill and control groups. Smaller shifts in bone mineral density among pill users were not significant when compared with controls.

Best, K. As menopause approaches, needs change. Network 22(1) (2002). Available at: www.fhi.org/. Available in English, French, and Spanish, this article discusses the special contraceptive needs of older women who are approaching menopause. It reviews studies on the advantages and disadvantages of sterilization, the IUD, barrier methods, and hormonal methods for women over 35. Factors considered are changes in reproductive intentions and sexual behavior with age, the appearance of premenopausal symptoms, and health risks for cardiovascular disease and cancer.

Burkman, R.T. et al. Transitional management: the use of oral contraceptives in perimenopause. The Female Patient (January 2001). Available at: www.obgyn.net/f.
Perimenopausal women may reject oral contraceptives in the mistaken belief that they are no longer fertile or that OC use at older ages is associated with cardiovascular disease, breast cancer, or weight gain. In fact, OC use during perimenopause can reduce risks of ovarian, endometrial, and colorectal cancer later in life and protect bone health, in addition to controlling perimenopausal symptoms and protecting against the very real risk of pregnancy. Women should be informed that OC use until menopause or the mid-50s is safe for healthy, nonsmoking women and effective in easing perimenopausal symptoms. By extending their use of OCs until they switch to HRT, most women can enjoy improved health outcomes throughout their reproductive life cycle and beyond.

Chompootaweep, S. et al. The use of two estrogen preparations (a combined contraceptive pill versus conjugated estrogen cream) intravaginally to treat urogenital symptoms in postmenopausal Thai women: a comparative study. Clinical Pharmacology & Therapeutics 64(2):204-210 (1998).
Most women in developing countries cannot afford the conjugated estrogen cream commonly used intravaginally to treat urogenital symptoms after menopause. This randomized clinical trial tested a cheap, readily available substitute: a combined contraceptive pill administered vaginally once a week. Forty postmenopausal women suffering from urogenital symptoms of estrogen deficiency (vaginal dryness, burning, itching, dyspareunia, urinary frequency, urgency, and dysuria) were randomly assigned to either the cream or the pill. After eight weeks, both groups of women reported a marked and comparable improvement in their symptoms. Both groups also experienced similar decreases in vaginal pH and fecal-type bacteria, increases in lactobacilli, and changes in cellular indices of estrogen activity.

Cromer, B.A. Effects of hormonal contraceptives on bone mineral density. Drug Safety 20(3):213-222 (1999).
This article reviews clinical research on how various hormonal contraceptives affect bone mineral density in premenopausal women. Differences in research design, techniques for measuring bone density, age of study participants, and the type of oral contraceptive preparation all contribute to a large variance in results across studies. The balance of the evidence suggests that oral contraceptives have a positive effect on bone mineral density on women of all ages. Data on other contraceptive methods are more limited, but evidence suggests that levonorgestrel implants have a positive impact on bone density, while the depot medroxyprogesterone acetate injectable has a negative effect. The author urges caution in prescribing injectables to adolescents under age 16 who have not yet reached peak bone mass.

Cundy, T. et al. Menopausal bone loss in long-term users of depot medroxyprogesterone acetate contraception. American Journal of Obstetrics and Gynecology 186(5):978-983 (2002).
This small study compared changes in bone mineral density in 16 long-term users of DMPA who did not discontinue the contraceptive until menopause with a control group of 15 women who reached a natural menopause. Mean bone density at menopause was lower among DMPA users than the control group. During the three years after menopause, bone density was stable in the DMPA users, while bone loss was rapid in the control group. Presumably women who use DMPA through to menopause have low rates of bone loss because they have already lost the estrogen-sensitive component of bone. The authors conclude that women can safely use DMPA for contraception through menopause.

International Medical Advisory Panel (IMAP). Statement on contraception for women over 35. London: International Planned Parenthood Federation (1997). Available at: www.ippf.org/medical/imap/statements/eng/1997_a.htm.
Contraceptive choices for women over 35 reflect the higher prevalence of obesity, diabetes, and hypertension; the general decline of fertility with age; and the rising incidence of menstrual disorders with age. While sterilization is safe, older women may want to weigh the risk of surgery against the number of years she needs protection. Uterine fibroids may prevent the proper placement of an IUD, and the levonorgestrel releasing IUD may be the best option since it may decrease menstrual bleeding. Older couples may be more motivated to use barrier methods correctly, and the lubricating effect of spermicides may be an advantage to older women suffering from dryness of the vagina. While periodic abstinence may be more acceptable to older women, they are not appropriate for premenopausal women with irregular cycles. Low dose combined oral contraceptives are safe for most older women, but they should be periodically screened for cardiovascular risk factors. While progestagen-only contraceptives eliminate estrogen-related side effects, they may cause bleeding problems that mask or simulate gynecological disease.

Kaunitz, A.M. Oral contraceptive use in perimenopause. American Journal of Obstetrics and Gynecology185(2):S32-S37 (2001).
While women continue to need effective contraception in the years preceding menopause, they also may need help with symptoms and health changes associated with perimenopause. This article reviews the evidence that oral contraceptives (OCs) offer important noncontraceptive benefits for older women, including the ability to preserve bone mineral density, regularize menses, produce a favorable lipid profile, and relieve vasomotor symptoms such as hot flashes and sleep disturbances. Healthy, nonsmoking women can continue taking OCs until they reach age 55 or older, when the probability of menopause is high. The author concludes that OCs can enhance the quality of life for perimenopausal women while also providing effective contraception and reducing some long-term health risks.

Michaelsson, K. et al. Oral-contraceptive use and risk of hip fracture: a case-control study. Lancet 353:1481-1484 (1999).
This population-based, case-control study collected histories from 1,327 Swedish women who had suffered hip fracture and 3,312 randomly selected controls. Ever-use of oral contraceptives (OCs) was associated with a 25 percent reduction in the risk of hip fracture. Ever-use of high-dose pills was associated with a 44 percent reduction in risk compared to never-users. There was no overall trend with the duration of use or time since last use. However, there was a protective effect related to the women's age when they used the pill: there was a significant 30 percent reduction in risk for women using OCs after age 40, a non-significant 20 percent reduction in risk for use between ages 30-39, and an increase in risk for use before age 30. The authors conclude that OC use late in reproductive life may reduce the risk of hip fracture by leaving women with a higher bone mass at menopause.

Scholes, D. et al. Injectable hormone contraception and bone density: results from a prospective study. Epidemiology 13(5):581-587 (2002).
This population-based prospective cohort study followed 457 women (183 DMPA users and 274 non-users) enrolled in a U.S. health maintenance organization over a three-year period. DMPA use was strongly associated with loss of bone density at the spine and hip, but women regained bone density after discontinuing the method. Thirty months after discontinuing DMPA, mean bone density among women who previously used DMPA was similar to that of non-users.

Seibert, C. et al. Prescribing oral contraceptives for women older than 35 years. Annals of Internal Medicine 138:54-64 (2003).
After thoroughly reviewing studies on the risks of venous thromboembolism, myocardial infarction, ischemic stroke, breast cancer, and gallstones, the authors conclude that it is safe to prescribe oral contraceptives for most older women. Oral contraceptives offer many health benefits to older women, including a reduced risk of ovarian, endometrial, and possibly colon cancer; relief of perimenopausal symptoms and menstrual irregularity; acne control; and possibly favorable effects on bone density. The article also discusses practical issues in prescribing OCs to older women, including the physical examination and lab tests, potential contraindications, types of OCs, common side effects, follow up, breakthrough bleeding, and how to diagnose menopause.

Shabaan, M. The perimenopause and contraception. Maturitas 23:181-192 (1996).
This literature review compares the advantages and disadvantages of various contraceptive options for women over age 40 who are approaching menopause. Sexually active older women are at risk of pregnancy until and even beyond menopause: 10 percent of women over age 45 who are amennorheic for one year subsequently menstruate and ovulate. While sterilization may be appropriate for older women who have completed their families, it is costly and carries some risks. Barrier methods have the advantages of offering lubrication when vaginal dryness is a problem and of protecting against STIs. In addition, their lower levels of effectiveness do not pose as big a problem among older, less fertile women. Irregular menstruation and ovulation make natural methods more problematic as women age. While the IUD offers the long-term protection many older women want, it may increase their already heightened risk of uterine bleeding. Combined oral contraceptives (COCs) offer both the greatest benefits and the greatest risks for women during perimenopause. COCs relieve many menopausal symptoms and reduce health risks related to menopause, including menstrual irregularity, heavy blood loss and anemia, vasovagal and urogenital symptoms, and osteoporosis. However, epidemiological studies have linked the use of high dose COCs by women over age 35 with cardiovascular disease. A new generation of low dose pills, combined with strict screening procedures for cardiovascular risk factors, may make COCs a good option for some older women.

Taechakraichana, N. et al. A randomized trial of oral contraceptive and hormone replacement therapy on bone mineral density and coronary heart disease risk factors in postmenopausal women. Obstetrics & Gynecology 95(1):87-94 (2000).
This study randomly assigned 80 healthy Thai women who had experienced menopause within the past five years either to HRT or to oral contraceptives for 12 months. The authors were looking for a less expensive alternative to HRT that would be equally safe and effective. Both regimens caused significant increases in bone mineral density, but only OC therapy was associated with a significant increase in bone density in the femoral neck. Both also favorably affected risk factors for coronary heart disease, but OCs caused greater reductions in total and LDL cholesterol and diastolic blood pressure than HRT. The drop-out rate was higher in OC group because of minor side effects. The authors conclude that OCs are a good alternative to HRT, especially for women with rapid bone demineralization.

Wildemeersch, D. et al. Contraception and treatment in the perimenopause with a novel "frameless" intrauterine levonorgestrel-releasing drug delivery system: an extended pilot study. Contraception 66:93-99 (2002).
This study evaluated the contraceptive performance and impact on menstrual blood loss of a frameless intrauterine drug delivery system (IUS). The IUS was inserted in 109 perimenopausal women. The continuation rate at one year was 98 percent, there were no pregnancies, and the IUS reduced excessive menstrual bleeding even when medium to large fibroids were present. The frameless design of the IUD reduced compatibility problems, while its low dosage reduced hormonal side effects and spotting.

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Menopause

Chirawatkul, S. et al. Perceptions of menopause in northeast Thailand: contested meaning and practice. Social Science and Medicine 39(11):1545-1554 (1994).
The ethnographic research reported here included interviews, focus groups, and participant observation with Thai villagers as well as physician interviews. After menopause, women welcomed their freedom from menstruation, pregnancy, and childbirth, but they also viewed menopause as a sign of aging and an incipient decline in health. Women did not consider the physical symptoms associated with menopause to be illnesses and generally did not seek treatment. The doctors' understanding of menopause was different: they viewed menopause as a pathology that causes health problems and emotional disturbances which need to be treated. Westernization is changing women's perceptions of menopause, so that some are beginning to view menopause more negatively and to seek medical attention for symptoms.

Clinical challenges of perimenopause: consensus opinion of the North American Menopause Society. Menopause 7(1):5-13 (2000). Available at: www.menopause.org/.
Perimenopause is a largely unstudied and ill-defined period. To develop these guidelines, the North American Menopause Society sponsored a conference of experts to review the literature and share clinical experiences. Most women do not require specific medical management but concerns raised by perimenopausal changes provide an opportunity for healthcare providers to discuss lifestyle issues, including smoking, exercise, diet, calcium intake, weight maintenance, and stress reduction. It is also an appropriate time to counsel women on changes in sexual function, psychological effects of menopause, osteoporosis, and cardiovascular disease. Treatments for acute vasomotor symptoms and sleep disturbances are discussed.

Damodaran, P. et al. Profile of a menopause clinic in an urban population in Malaysia. Singapore Medical Journal 41(9):431-435 (2000). Available at: www.sma.org.sg/.
While many Malaysian women welcome menopause, rising awareness is leading more women to attend menopause clinics. This study examines a series of 164 women attending the Menopause Clinic at the University Hospital in Kuala Lumpur, 49 of whom were perimenopausal, 74 in early menopause, and 41 in late menopause. None had used HRT. The most common symptom overall and in Chinese women was hot flushes, but Malay and Indian women complained more of tiredness and joint pains. Elevated serum cholesterol levels were observed in 84 percent of women, and both cholesterol and triglyceride levels were highest in late menopause. There were two cases of intraductal carcinoma, eight cases of fibrocystic breast disease, and seven cases of suspicious breast lumps. Routine ultrasound revealed two cases of ovarian cysts and eight cases of uterine fibroids. Over half (52%) the women had mild osteoporosis while 3 percent had moderate osteoporosis.

Defey, D. et al. The menopause: women's psychology and health care. Social Science and Medicine 42(10):1447-1456 (1996).
This article reports findings from a series of community-based focus group discussions with 78 women in Uruguay and from questionnaires completed by 45 doctors who serve middle- and lower-class patients. The doctors emphasized the dark side of menopause and thought women were concerned about anxiety, depression, growing old, symptoms and therapies, and deterioration of their sex life. In contrast, the women viewed menopause as a life crisis that offered opportunities for positive changes in their lives. All of the women, regardless of their level of education, lacked information on the medical aspects of menopause.

Dennerstein, L. Well-being, symptoms and the menopausal transition. Maturitas 23:147-157 (1996).
This article reviews population studies of women's health during the menopausal transition. The patterns and prevalence of symptoms vary dramatically from one country to another. Menopause is not associated with women's sense of well-being, major depression, or negative moods. While the data suggest a decline in sexual functioning after menopause, this may be due to other factors, such as aging or health status. The author recommends promoting positive attitudes toward menopause and aging, healthy lifestyles, and stress reduction.

Frackiewicz, E.J. and Cutler, N.R. Womens health care during the perimenopause. Journal of the American Pharmaceutical Association 40(6):800-811 (2000). Available at: www.medscape.com/viewarticle/406706. (Medscape requires free online registration.)
This article exhaustively reviews the published literature on the physiology and symptoms of perimenopause and its associated health risks. Perimenopause is an ideal time to evaluate a womans health risks for common chronic mid-life conditions, such as heart disease and osteoporosis, and to start preventive health measures. Self-help measures and lifestyle changes that can alleviate discomfort and reduce health risks include vaginal lubricants, Kegel exercises, changes in fluid intake and diet, regular exercise, and quitting smoking. Women may benefit from hormonal therapy, in the form of oral contraceptives, estrogen supplements, progesterone replacement, or testosterone replacement, but it must be tailored to the individual womans hormone deficiencies. Limited evidence is available about the efficacy of alternative treatments, such as phytoestrogens and herbal treatments.

Gelfand, M.M. Sexuality among older women. Journal of Women's Health & Gender-Based Medicine 9 (Suppl. 1):S15-S20 (2000).
Sexuality is an important quality of life issue for the elderly. Changes in hormone levels during and after menopause lead to decreased sexual libido, sensitivity, and response; vaginal atrophy; and diminished vaginal lubrication, all of which interfere with sexual pleasure. Illness and medications (especially antihypertensive agents, antipsychotics, and antidepressants) also may cause sexual dysfunction in an older woman by impairing her self-image, her own physiological response, or her partner's response to her. Data on the prevalence of sexual dysfunction in menopausal women vary widely, but substantial numbers report problems with vaginal dryness and dyspareunia, decreased sexual desire, and vaginal infection. The article reviews diagnostic considerations for treating these problems.

Haines, C., et al. The perception of the menopause and the climacteric among women in Hong Kong and southern China. Preventive Medicine 24:245-248 (1995).
This study found that most of 200 Chinese women in Hong Kong and southern China could define menopause, but none were aware of the problems of osteoporosis or cardiovascular disease in postmenopausal women. Less than 8 percent of the women knew about hormone replacement therapy (HRT). Concerned that Chinese women do not protect themselves with HRT, the author recommends an education program on menopause for both women and providers in order to improve the life expectancy and quality of life of postmenopausal women.

Lobo, R.A. Menopause Management for the Millennium. Medscape Women's Health Clinical Management, Volume 1 (1999). Available at: www.medscape.com/viewprogram/213. (Medscape requires free online registration.)
This continuing medical education module updates physicians about state-of-the-art treatment protocols and clinical strategies for preventing and managing menopausal symptoms and the long-term consequences of estrogen deficiency. It exhaustively reviews current evidence on the physiology of menopause, women's perceptions of menopause, diet, exercise, and therapeutic interventions. Coverage of SERMs (Selective Estrogen Receptor Modulators) and hormone replacement therapy is especially comprehensive. There is a lengthy bibliography.

Lock, M. and Kaufert, P. Menopause, local biologies, and cultures of aging. American Journal of Human Biology 13:494-504 (2001).
This article challenges the current medical view of menopause as a universal and pathological event with a distinct set of symptoms. A comparison of research from Japan, Canada, and the United States reveals that menopausal symptoms and postmenopausal diseases vary widely between populations. The authors conclude that social, cultural, and physical differences create "local biologies," in which women experience menopause differently and are subject to different health risks.

Mashiloane, C.D. et al. Awareness of and attitudes toward menopause and hormone replacement therapy in an African community. International Journal of Gynecology & Obstetrics 76:91-93 (2001).
A structured questionnaire was used to gather information about menopause from 102 women aged 45 or over in Durban, South Africa. Two-thirds were menopausal. Four-fifths of women were aware of the existence of menopause; half of them got their information from family and friends, while half learned from health care providers. All of them believed it was a normal, culturally acceptable period in a womans life. Among women who knew of menopause, 29 percent said they knew the symptoms of menopause and that treatment was available. Although women commonly experienced symptoms of menopause, such as hot flushes and vaginal dryness, relatively few understood that they were related to menopause.

Meyer, V.F. The medicalization of menopause: critique and consequences. International Journal of Health Services 31(4):769-792 (2001).
This commentary argues against the medicalization of menopause, that is, the idea that natural menopause is a deficiency condition requiring replacement hormones to maintain health. An examination of mortality and morbidity statistics across countries, over time, and between genders suggests that, contrary to prevailing wisdom, menopause does not put women at increased risk of heart disease, osteoporosis, and Alzheimers disease. There are six major consequences of medicalizing menopause. First, it leads to unequal approaches to disease prevention for men and women, with research and interventions for women focused on hormone use at the expense of more important lifestyle factors. Second, it allows for the widespread acceptance of hormone use as a primary prevention strategy without proof of efficacy from large-scale, long-term randomized clinical trials. Third, it encourages women to accept the adverse consequences of hormones, such as an increased risk of breast cancer. Fourth, it further medicalizes womens lives, as other drugs are prescribed to counter the adverse effects of estrogen use. Fifth, it diverts attention from real factors affecting womens health, such as the environment, socioeconomic status, and violence against women. Sixth, it harms women psychologically and socially by implying that womens bodies are flawed.

Obermeyer, C.M. et al. Menopause in Morocco: symptomatology and medical management. Maturitas 41:87-95 (2002).
A representative sample of 300 women aged 45-55 living in the capital city of Rabat were interviewed about their medical history and current menopausal symptoms. Women complained most frequently about fatigue (61%), hot flashes (61%), headaches (57%), joint pain (54%), anxiety (44%), and irritability (42%). Peri- and postmenopausal women were significantly more likely than premenopausal women to report five or more symptoms. Menopausal status was associated with hot flashes, dizziness, fatigue, and nerves. Few women use medical services for menopause: 5 percent take hormone therapy and 4 percent take calcium. More educated and socioeconomically better off women are more likely to report some symptoms and to use medical services for menopause, reflecting the medicalization of menopause among the upper classes.

Soares, C. and Cohen, L.S. The perimenopause, depressive disorders, and hormonal variability. Sao Paulo Medical Journal 119(2):78-83 (2001).
This review article concludes that there is a relationship between perimenopause and symptoms of depression, although the hormonal mechanism remains unclear. Women with a prior history of depression are especially vulnerable. Estrogen therapy may play an important role in treating depressive symptoms during perimenopause but further clinical trials are needed.

Taechakraichana N et al. Hormone replacement therapy: attitude and acceptance of Bangkokian women. Journal of the Medical Association of Thailand. 2003;86(suppl 2):S385-S398.
A group of 615 women visiting menopause clinics at five Bangkok hospitals completed standardized questionnaires on their knowledge and attitudes towards menopause and hormone replacement therapy (HRT). Nearly all were aged 40 to 70 (97%), and half were peri- or postmenopausal (52%). Two-thirds believed that menopause was a natural change but sometimes required medical treatment. Most were currently using HRT (54%) or had used it in the past (21%). Commonly cited reasons for starting HRT were osteoporosis (86%), hot flashes (59%), and vaginal dryness (41%). Almost half of current users reported moderate to severe side effects, including breast pain, headache, and vaginal bleeding. Of the current users, 43% wanted to switch from HRT, generally because of concerns about cancer or fear of hormone accumulation. Among past users, reasons for discontinuation included lack of further symptoms (27%), cancer concerns (25%), a change in treatment (27%), and side effects (17%). While almost all of the women (95%) relied on medical advice to choose a treatment, about two-thirds said they could not get enough clear information on menopause and HRT.

Wasti, S. et al. Characteristics of menopause in three socioeconomic urban groups in Karachi, Pakistan. Maturitas 16:61-69 (1993).
This Pakistani survey included postmenopausal women from a wide variety of socioeconomic backgrounds: 250 women living in a squatter settlement, 250 women who accompanied patients to the hospital, and 150 wives of retired defense officers. Poor women were less likely to report most menopausal symptoms, especially hot flushes and night sweats. While few women in any group sought treatment or advice, better-off women were more likely to seek care than poor women.

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