Camil Castelo-Branco

Quality of life after the menopause: a population study

OBJECTIVE To assess the impact of menopause and some sociodemographic variables on quality of life (QoL). MATERIALS AND METHODS Four hundred and eighty-one women aged 40-59 years attending the Southern Metropolitan Health Service in Santiago de Chile were studied using the Specific Quality of Life Questionnaire for Menopause from Toronto University. RESULTS Univariate analysis showed that menopausal women have worse QoL scores than women conserving cycles in the four areas of the questionnaire: They show a 10.6-fold higher risk for suffering vasomotor disorders affecting QoL, a 3.5-fold higher risk for psychosocial impairment, a 5.7-fold higher risk for physical disorders, and a 3.2-fold higher risk for sexual disorders (P < 0.0001). Regarding the influence of social markers (age, marital status, school years, work, number of children and sexual activity), housewives were found to have higher, worse, scores than working women in all test components (vasomotor, 3.11+/-1.90 versus 2.57+/-1.71, P < 0.003; psychosocial, 3.44+/-1.59 versus 2.92+/-1.45, P < 0.0007; physical, 3.45+/-1.36 versus 2.96+/-1.20, P < 0.0001; sexual, 3.63+/-2.23 versus 2.49+/-1.95, P < 0.0001). However, logistic regression demonstrated that the only variable found to cause a significant impairment in QoL was menopause. CONCLUSION Menopause causes a decrease in quality of life, which is independent from age and other sociodemographic variables.

Skin collagen changes related to age and hormone replacement therapy

A total of 76 nulliparous women who had been hospitalized for minor operations, classified according to age group (by decade from 20s to 60s) and 118 postmenopausal women randomly allocated to one of four groups were studied. In all, 312 skin biopsies were taken from the lower abdomen at 0 and 12 months and the skin collagen changes noted. Collagen content decreased significantly with age beyond the 40s (P < 0.001) and after the menopause (P < 0.01). The decrease was preventable by the use of hormone replacement therapy. All the therapeutic regimens induced increases in skin collagen content, whereas in the control group a significant decrease was observed (P < 0.05).

Comparative effects of estrogens plus androgens and tibolone on bone, lipid pattern and sexuality in postmenopausal women.

BACKGROUND The main goals of estrogen replacement therapy (ERT) are the prevention of osteoporosis and cardioprotection and the improvement of quality of life (QL). Androgens and tibolone therapy may increase bone mineral density (BMD) to a greater extent than ERT and offer an increase in QL. Lipid and cardiovascular effects, however, are still a major concern. AIM To evaluate whether the addition of a weak androgen to ERT may improve postmenopausal bone loss and sexual activity without adverse effects on lipid pattern and to compare these effects with those observed after tibolone therapy. SUBJECTS AND METHODS This prospective study enrolled 120 surgical postmenopausal women; of these, 96 completed the 1-year follow-up. Patients were allocated to one of four groups. The first group (A; n = 23) received 4 mg of estradiol valerate plus 200 mg of enanthate of dihydroandrosterone im monthly. The second group (E; n = 26) received 50 microg/day of transdermal 17-b-estradiol continuously; the third (T; n = 23) received 2.5 mg of tibolone every day; and finally, the fourth group (C; n = 24) constituted a treatment-free control group. Bone mass (dual X-ray absorptiometry), serum total cholesterol, HDL, LDL, triglycerides, apolipoproteins A1 and B and sexual activity were evaluated before starting therapy and at the end of follow-up. RESULTS All active treatment groups showed an increase in BMD. This increase was higher in the A treatment group (4.08% P < 0.01). Sexuality improved significantly with therapy; however, tibolone and androgens increased scores to a greater extent than ERT. Androgen therapy was associated with significant increases in total cholesterol, LDL and triglycerides. Cholesterol and LDL fall into groups E and T, HDL into groups A and T and triglycerides in group T only. CONCLUSION The combined regimen of androgens and ERT increased vertebral bone mass and enhance sexual activity in postmenopausal women equal to that of tibolone and to a greater extent than ERT alone; its effects on lipids, however, are clearly adverse.

Menopause and aging: Changes in the immune system—A review

BACKGROUND The higher risk of women developing autoimmune diseases suggests that immune system is mediated by sex steroids. OBJECTIVE To review the effects of aging and menopause in immune system. METHODS A systematic review of in vitro, animal and human studies involving aging and menopause and immune system was carried out. An electronic search based on Internet search engines, MEDLINE (1966-June 2010) and the Cochrane Controlled Clinical Trials Register was done. RESULTS After crossing-cleaning the reference lists, a total of 688 studies dealing with immune system and menopause were identified. Of them, 30 were considered selectable. The concept of immunosenescence reflects changes in both cellular and serological immune responses throughout the process of generating specific response to foreign antigens. This may be related with a higher incidence of infectious and chronic diseases. After menopause, there is an increase in pro-inflammatory serum markers (IL1, IL6, TNF-alpha), an increase in response of the immune blood cells to these cytokines, a decrease in CD4 T and B lymphocytes and a decrease in the cytotoxic activity of NK cells. Additionally, IL-6 is a key factor in bone resorption and also seems to be associated with other diseases more common after menopause such as diabetes, atherosclerosis and cardiovascular disease. CONCLUSIONS Most of the studies suggested that in addition to age, in postmenopausal women, changes of the immune system have been attributed to estrogen deprivation. Furthermore, recent studies point out changes in immune response related to use or cessation of hormone replacement at menopause.

The immune system and aging: a review.

Abstract The concept of immunosenescence reflects age-related changes in immune responses, both cellular and serological, affecting the process of generating specific responses to foreign and self-antigens. The decline of the immune system with age is reflected in the increased susceptibility to infectious diseases, poorer response to vaccination, increased prevalence of cancer, autoimmune and other chronic diseases. Both innate and adaptive immune responses are affected by the aging process; however, the adaptive response seems to be more affected by the age-related changes in the immune system. Additionally, aged individuals tend to present a chronic low-grade inflammatory state that has been implicated in the pathogenesis of many age-related diseases (atherosclerosis, Alzheimers disease, osteoporosis and diabetes). However, some individuals arrive to advanced ages without any major health problems, referred to as healthy aging. The immune system dysfunction seems to be somehow mitigated in this population, probably due to genetic and environmental factors yet to be described. In this review, an attempt is made to summarize the current knowledge on how the immune system is affected by the aging process.

Relationship between skin collagen and bone changes during aging.

There is evidence that skin collagen content and bone mass are influenced by estrogen deficiency, both of them declining in the years following menopause. The aim of our study was to analyze the relationship between changes in skin collagen content and bone mass during aging. A total of 76 nulliparous women who had been admitted for surgery of non-malignant processes were studied. All subjects were arranged into five age-groups (from 20 to 60 years). Bone mineral density was measured by dual photon absorptiometry and expressed in g/cm2 as the mean of the second to fourth lumbar vertebrae. Additionally, in all patients skin biopsies were taken from a non-sun exposed site in the lower abdomen (4 cm above the pubic symphysis) and osteocalcin levels were determined. Collagen decreased significantly with age after the 40s (P < 0.001) and after menopause (P < 0.001). Changes in bone mass were closely related to those detected in collagen (r = 0.586; P < 0.0001). In conclusion, our data suggest that bone mass and skin collagen decline in parallel with aging and that the hypoestrogenism developing in postmenopausal years has a significant effect on skin collagen content. Nevertheless, the question of whether osteoporosis is an intrinsic collagen disorder remains to be demonstrated.

Prevalence of sexual dysfunction in a cohort of middle-aged women: influences of menopause and hormone replacement therapy.

In order to determine the prevalence of sexual dysfunction (SD) and related risk factors in a cohort of middle-aged women the Laumanns test (DSM-IV) was passed to 534 healthy women between 40 and 64 years old (mean: 52.4 ± 5.7) attending the Southern Metropolitan Health Service in Santiago de Chile. Of all the women, 82.8% were peri- or postmenopausal, 23% had received hormone replacement therapy (HRT) and 79.2% were sexually active. Among those who were sexually active a total of 51.3% presented SD. The prevalence of SD increased with age (from 22.2% in the 40–44-year age group to 66% in the 60–64-year age group). HRT users and healthy women presented a lower risk of SD (OR: 0.1 CI: 0.0–0.1 and OR: 0.6 CI: 0.3–0.9, respectively). The risk increased after the menopause (OR: 3.3 CI: 1.6–6.9) and with age older than 49 years (OR: 3.4 CI: 1.8–6.4), hysterectomy (OR: 3.7 CI: 1.3–10.6) and when male partners presented erectile dysfunction (OR: 3.2 CI: 1.2–8.6). In conclusion sexual dysfunction affects more than 51% of middle-aged women who are sexually active and increases with age. Ovarian function and HRT significantly influence sexual activity.

Satisfaction and tolerance with office hysteroscopic tubal sterilization.

OBJECTIVE To evaluate womens satisfaction and tolerance of hysteroscopic sterilization. DESIGN Prospective analysis of case series. SETTING Gynecology department in a teaching hospital. PATIENT(S) A total of 1,630 women who underwent hysteroscopic sterilization by placement of Essure microinserts (Conceptus, Inc., Mountain View, CA) from January 2003 to June 2006. INTERVENTION(S) Transvaginal ultrasound examination, pelvic x-ray examination, and hysterosalpingography 3 months after sterilization with Essure microinserts. Satisfaction was assessed by a visual analog scale. Adverse effects and tolerance also were recorded. MAIN OUTCOME MEASURE(S) Transvaginal ultrasound and pelvic x-ray confirmation of correct localization of microinserts and patients satisfaction and tolerance after a 3-month follow-up. RESULT(S) The rate of successful insertion was 99%. Most of women returned to their daily activities on the same day of insertion, and 86.5% considered the procedure painless or scarcely painful. All the patients were highly satisfied after hysteroscopic sterilization: 91% of subjects by visual analog scale (on a 0 to 10 scale) rated the method at 10 (high satisfaction degree), and none of the subjects rated it under 8. For patients, the most valuable aspects of the procedure were absence of surgery room (52.7%), methods quickness and comfort (19.9%), and permanent sterilization (18.2%). More than 97% of the patients said that they would recommend the procedure to others. CONCLUSION(S) This study provides evidence that Essure microinserts can be placed in a usual gynecologic consultation room in standard conditions without any type of anesthesia or sedation and are associated with great overall patient satisfaction. Women also have high tolerance for the procedure and describe minor postoperative pain.

Facial wrinkling in postmenopausal women. Effects of smoking status and hormone replacement therapy

BACKGROUND There is some evidence that hormone replacement therapy may produce significant improvements in fine wrinkling, while aging skin is more frequently found in smokers. However, studies of the combined effect of a protective factor, such as HRT, and a damaging factor, such as smoking, are rare. OBJECTIVES To determine in postmenopausal women the relationship between smoking status and the average number of packets of cigarettes since the subject took up smoking (packs-years) on the one hand, and facial wrinkling on the other, and to evaluate the role of hormone replacement therapy in the prevention of wrinkles in smokers and non-smokers. METHODS All subjects were recruited from our menopause clinic at Hospital Clínic i Provincial in Barcelona and were placed into one of three groups according to their smoking status: 215 life-long non-smokers, 306 former smokers and 209 current smokers. Smoking status, pack-years and hormone replacement were assessed by direct questioning. Facial wrinkle scores were estimated by standardized visual assessment. RESULTS The relative risk of moderate-severe wrinkling for current smokers compared to that for life-long non-smokers was 2.57 (confidence interval: 1.83-3.06; P < 0.0005). Pack-years was positively related to facial wrinkles. Life-long non-smokers receiving HRT had lower facial wrinkle scores than Life-long non-smokers who had never received HRT. HRT did not, in general, modify the facial wrinkle score in current smokers. CONCLUSION Our results suggest that the risk of facial wrinkles is greater in smokers and that HRT does not diminish this risk.

Tolerability of different oral iron supplements: a systematic review.

Abstract Objective: A systematic review was conducted to analyze the tolerability of several oral iron supplements based on data obtained in available publications and to report the incidence of adverse effects (AEs) for each supplement both overall and gastrointestinal. Methods: Electronic databases – Medline, the Cochrane Library, and Embase were searched for studies published up to January 2009. Clinical or observational studies reporting data on the tolerability of oral iron supplements were included. Results were described statistically and a quasi-binomial logistic regression model was developed to evaluate and compare the tolerability of the supplements studied. Results: For this review 111 studies were included, with data on 10,695 patients. Ferrous sulfate with mucoproteose had the lowest incidence of AEs (4.1% for overall AEs, 3.7% for gastrointestinal AEs [GAEs]) and was used as the reference supplement in the regression model. Incidence rates of overall AEs for the other supplements were 7.3% for iron protein succinylate [GAEs: 7%; OR for AE compared to the reference supplement, 1.96], 23.5% for ferrous glycine sulfate [GAEs: 18.5%; OR: 5.90], 30.9% for ferrous gluconate [GAEs: 29.9%; OR: 11.06], 32.3% for ferrous sulfate without mucoproteose [GAEs: 30.2%; OR: 11.21], and 47.0% for ferrous fumarate [GAEs: 43.4%; OR: 19.87]. The differences in incidence of AEs between extended-release ferrous sulfate with mucoproteose and all other supplements except iron protein succinylate were statistically significant at p < 0.001. These findings are subject to some limitations as the designs and methodologies of the studies included show heterogeneity among them that has partially been counteracted by the large sample size provided by the substantial number of trials, which is considered a strength in tolerability studies. Conclusion: Extended-release ferrous sulfate with mucoproteose appears to be the best tolerated of the different oral iron supplements evaluated.