Florence Tremollieres

EMAS position statement: management of uterine fibroids.

INTRODUCTION Uterine fibroids (also termed leiomyomas or myomas) are the most common tumors of the female reproductive tract. AIM The aim of this position statement is to provide and critically appraise evidence on the management of women with uterine fibroids. METHODS Literature review and consensus of expert opinion. RESULTS AND CONCLUSIONS Many uterine fibroids are asymptomatic and require no intervention, although it is advisable to follow up patients to document stability in size and growth. Fibroid-associated symptoms include heavy menstrual bleeding and pain or pelvic discomfort. The association between infertility and fibroids increases with age. Fibroids do not increase the risk of malignant uterine disease and leiomyosarcomas are extremely rare (less than one in 1000). It is unknown at present whether leiomyosarcoma represents de novo growth or malignant transformation from benign uterine fibroids. Treatment options for symptomatic fibroids include pharmacologic, surgical and radiologically guided interventions. The range of medical treatments allows flexible management of fibroid-related symptoms; the options include tranexamic acid, non-steroidal anti-inflammatory drugs, contraceptive steroids, gonadotropin-releasing hormone analogs, antiprogesterone, and selective progesterone receptor modulators. However, these medical options do not remove the tumors and symptoms may return when treatment is stopped. Surgical and radiologically guided procedures may be tailored to age, general health, and individual patient wishes. Hysterectomy is the most effective treatment, although in some cases myomectomy may be sufficient to control symptoms. Alternatives to surgery include uterine artery embolization, myolysis and ablation by high-intensity focused ultrasound (guided with magnetic resonance imaging or ultrasound). The choice of treatment depends on fibroid size, the underlying symptoms and their severity and the womans desire for subsequent fertility and pregnancy, as well as efficacy and need for repeated interventions.

EMAS clinical guide: Low-dose vaginal estrogens for postmenopausal vaginal atrophy

Vaginal atrophy is common in postmenopausal women. This clinical guide provides the evidence for the clinical use of vaginal estrogens for this condition focussing on publications since the 2006 Cochrane systematic review. Use after breast cancer, before assessment of cervical cytology and prolapse surgery is also discussed.

EMAS position statement: The ten point guide to the integral management of menopausal health

With increased longevity and more women becoming centenarians, management of the menopause and postreproductive health is of growing importance as it has the potential to help promote health over several decades. Women have individual needs and the approach needs to be personalised. The position statement provides a short integral guide for all those involved in menopausal health. It covers diagnosis, screening for diseases in later life, treatment and follow-up.

EMAS position statement: Diet and health in midlife and beyond.

INTRODUCTION There is increasing evidence that life-style factors, such as nutrition, physical activity, smoking and alcohol consumption have a profound modifying effect on the epidemiology of most major chronic conditions affecting midlife health. AIMS To provide guidance concerning the effect of diet on morbidity and mortality of the most frequent diseases prevalent in midlife and beyond. MATERIALS AND METHODS Literature review and consensus of expert opinion. RESULTS AND CONCLUSIONS A healthy diet is essential for the prevention of all major chronic non-communicable diseases in midlife and beyond, both directly, through the effect of individual macro- and micronutrients and indirectly, through the control of body weight. Type 2 diabetes mellitus is best prevented or managed by restricting the total amount of carbohydrate in the diet and by deriving carbohydrate energy from whole-grain cereals, fruits and vegetables. The substitution of saturated and trans-fatty acids by mono-unsaturated and omega-3 fatty acids is the most important dietary intervention for the prevention of cardiovascular disease. Obesity is also a risk factor for a variety of cancers. Obese elderly persons should be encouraged to lose weight. Diet plans can follow the current recommendations for weight management but intake of protein should be increased to conserve muscle mass. The consumption of red or processed meat is associated with an increase of colorectal cancer. Adequate protein, calcium and vitamin D intake should be ensured for the prevention of osteoporotic fractures. Surveillance is needed for possible vitamin D deficiency in high risk populations. A diet rich in vitamin E, folate, B12 and omega-3 fatty acids may be protective against cognitive decline. With increasing longevity ensuring a healthy diet is a growing public health issue.

EMAS position statement: Managing menopausal women with a personal or family history of VTE.

INTRODUCTION Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is a serious cardiovascular event whose incidence rises with increasing age. AIMS To formulate a position statement on the management of the menopause in women with a personal or family history of VTE. MATERIAL AND METHODS Literature review and consensus of expert opinion. RESULTS AND CONCLUSIONS Randomized controlled trials have shown an increased risk of VTE in oral hormone therapy (HT) users. There are no randomized trial data on the effect of transdermal estrogen on VTE. Recent observational studies and meta-analyses suggest that transdermal estrogen does not increase VTE risk. These clinical observations are supported by experimental data showing that transdermal estrogen has a minimal effect on hepatic metabolism of hemostatic proteins as the portal circulation is bypassed. A personal or family history of VTE, especially in individuals with a prothrombotic mutation, is a strong contraindication to oral HT but transdermal estrogen can be considered after careful individual evaluation of the benefits and risks. Transdermal estrogen should be also the first choice in overweight/obese women requiring HT. Observational studies suggest that micronized progesterone and dydrogesterone might have a better risk profile than other progestins with regard to VTE risk. Although these findings should be confirmed by randomized clinical trials, they strongly suggest that both the route of estrogen administration and the type of progestin may be important determinants of the overall benefit-risk profile of HT.

EMAS position statement: Non-hormonal management of menopausal vasomotor symptoms

AIM To review non-hormonal therapy options for menopausal vasomotor symptoms. The current EMAS position paper aims to provide to provide guidance for managing peri- and postmenopausal women who cannot or do not wish to take menopausal hormone therapy (MHT). MATERIAL AND METHODS Literature review and consensus of expert opinion. RESULTS Non-hormonal management of menopausal symptoms includes lifestyle modifications, diet and food supplements, non-hormonal medications and application of behavioral and alternative medicine therapies. There is insufficient or conflicting evidence to suggest that exercise, supplements or a diet rich in phytoestrogens are effective for vasomotor menopausal symptoms. Selective serotonin-reuptake inhibitors (SSRIs), serotonin norepinephrine-reuptake inhibitors (SNRIs) and gabapentin could be proposed as alternatives to MHT for menopausal symptoms, mainly hot flushes. Behavioral therapies and alternative medicine interventions have been tried, but the available evidence is still limited. CONCLUSIONS A number of interventions for non-hormonal management of menopausal vasomotor symptoms are now available. For women who cannot or do not wish to take estrogens, non-hormonal management is now a realistic option.

EMAS clinical guide: Vulvar lichen sclerosus in peri and postmenopausal women

INTRODUCTION Vulvar lichen sclerosus (LS) is a chronic inflammatory disease which affects genital labial, perineal and perianal areas, producing significant discomfort and psychological distress. However there may be diagnostic delay because of late presentation and lack of recognition of symptoms. AIMS The purpose of this clinical guide is to provide advice on early recognition and treatment. MATERIAL AND METHODS Literature review and consensus of expert opinion. RESULTS AND CONCLUSIONS The etiology of LS in peri and postmenopausal women is unknown, although autoimmune, genetic and infectious factors have been implicated. Definitive diagnosis of non-malignant disorders depends on the histology of biopsied tissue. LS associated with cellular atypia should be classified as intraepithelial neoplasia. Topical corticosteroids are the most effective treatment, although prolonged treatment may be associated with dermal atrophy. Topical calcineurin inhibitors, such as tacrolimus or pimecrolimus, may be a safe and effective alternative treatment without risk of corticosteroid-related vulvar atrophy since they do not affect collagen synthesis. LS recurrences are frequent, and can lead to significant physical discomfort and emotional distress that affect mood and sexual relationships. Anatomical changes may require surgical management.

EMAS position statement: Managing the menopause in women with a past history of endometriosis

INTRODUCTION Endometriosis is a common disease in women of reproductive age. The symptoms usually disappear after a natural or a surgical menopause. Estrogen-based hormone therapy is required in women with premature or early menopause until the average age of the natural menopause and should be considered in older women with severe climacteric symptoms. However use of hormone therapy raises concerns about disease recurrence with pain symptoms, need for surgery and possibly malignant transformation of residual endometriosis. AIM To formulate a position statement on the management of the menopause in women with a past history of endometriosis. MATERIALS AND METHODS Literature review and consensus of expert opinion. RESULTS AND CONCLUSIONS The data regarding hormone therapy regimens are limited. However it may be safer to give either continuous combined estrogen-progestogen therapies or tibolone in both hysterectomised and nonhysterectomised women as the risk of recurrence may be reduced. The risk of recurrence with hormone therapy is probably increased in women with residual disease after surgery. Management of potential recurrence is best monitored by responding to recurrence of symptoms. Women not wanting estrogen or those who are advised against should be offered alternative pharmacological treatment for climacteric symptoms or skeletal protection if indicated. Herbal preparations should be avoided as their efficacy is uncertain and some may contain estrogenic compounds.

EMAS position statement: Individualized breast cancer screening versus population-based mammography screening programmes

INTRODUCTION Breast cancer is the most prevalent cancer in women, with slightly more than ten percent developing the disease in Western countries. Mammography screening is a well established method to detect breast cancer. AIMS The aim of the position statement is to review critically the advantages and shortcomings of population based mammography screening. MATERIALS AND METHODS Literature review and consensus of expert opinion. RESULTS AND CONCLUSION Mammography screening programmes vary worldwide. Thus there are differences in the age at which screening is started and stopped and in the screening interval. Furthermore differences in screening quality (such as equipment, technique, resolution, single or double reading, recall rates) result in a sensitivity varying from 70% to 94% between studies. Reporting results of screening is subject to different types of bias such as overdiagnosis. Thus because of the limitations of population-based mammography screening programmes an algorithm for individualized screening is proposed.

EMAS position statement: managing the menopause in women with epilepsy.

INTRODUCTION Epilepsy is a major public health problem worldwide which is clinically characterized by recurrent seizures. AIM The aim of this position statement is to provide evidence-based advice on management of the menopause in postmenopausal women derived from the limited data available. MATERIALS AND METHODS Literature review and consensus of expert opinion. RESULTS AND CONCLUSIONS Women with epilepsy may undergo an earlier natural menopause, between 3 and 5 years depending on seizure frequency, but the data are limited. Data regarding the effects of the perimenopause and menopause on epilepsy are conflicting: some studies show an increased risk of seizures but others do not. With regard to hormone therapy (HT) one study has shown an increase in seizures with oral therapy with conjugated equine estrogens and medroxyprogesterone acetate, but no data are available for other regimens. Women starting HT should be closely monitored as their antiepileptic drug (AED) needs may change. As vitamin D and calcium metabolism can be affected by AEDS, supplements should be considered. Herbal preparations should be avoided as their efficacy is uncertain and they may interact with AEDs.