Gayatri Devi

Prevalence of memory loss complaints and other symptoms associated with the menopause transition: A community survey

BACKGROUND Complaints of memory loss are increasingly noted as part of the constellation of symptoms experienced in the menopause transition. Studies evaluating such complaints in this population have yielded varying results. OBJECTIVE The aim of this study was to determine if complaints of memory loss are a component of the menopause transition and a part of the menopausal symptom complex in a population of women not selected for menopausal symptoms. METHODS Faculty members of a Long Island, New York, school district were asked to participate ina survey of menopausal symptoms. Demographic data were analyzed using chi(2) statistics. The presence or absence of memory complaints, hot flashes/night sweats, vaginal dryness, depression, reduced libido, and incontinence were analyzed as dichotomous variables in a logistic regression analysis after adjusting for demographic differences. RESULTS Seventy-two percent (375/521) of the faculty members in the school district were eligible;of these, 217 (58%) completed the survey. After excluding pregnant women, those with hysterectomies or other nonmenopausal causes of amenorrhea, and those aged <30 or >60 years, 151 women were included in the analysis. Of these, 103 (68%) were experiencing natural menopause or perimenopause and 48 (32%) had no changes in menstrual cycle (the comparison group). The menopausal women were significantly older than the women in the comparison group (mean [SD] 51.2 [5.0] years vs 39.6 [7.2] years; P < 0.001), and they were more likely to be white than the women in the comparison group (P < 0.001). Menopausal women were several-fold more likely to complain of memory loss (odds ratio [OR], 3.2; 95% CI, 1.2-8.8; P < 0.02), hot flashes/night sweats (OR, 4.3; 95% CI, 1.4-13.3; P < 0.01), and reduced libido (OR, 4.5; 95% CI, 1.3-15.7; P < 0.02) than were women in the comparison group, after adjusting for differences in age and race. There were no significant differences in the prevalence of depression, vaginal dryness, or incontinence. CONCLUSIONS In our exploratory survey, complaints of memory loss were a part of the symptom complex of the menopause transition, as were hot flashes and reduced libido. Longitudinal followup of women with these symptoms may be helpful in understanding the menopause transition in women.

Open-Label, Short-Term, Repetitive Transcranial Magnetic Stimulation in Patients With Alzheimer's Disease With Functional Imaging Correlates and Literature Review

Background: Accumulating evidence suggests repetitive transcranial magnetic stimulation (rTMS) may be beneficial in ameliorating cognitive deficits in Alzheimers disease (AD). Methods: AD patients received four high-frequency rTMS sessions over the bilateral dorsolateral prefrontal cortex (DLPFC) over two weeks. Structured cognitive assessments were administered at baseline, at 2 weeks after completion of rTMS, and at 4 weeks post treatment. At these same times, tolerant patients underwent functional magnetic resonance imaging (fMRI) while performing structured motor and cognitive tasks. We also reviewed literature regarding the effects of rTMS on cognitive function in AD. Results: A total of 12 patients were enrolled, eight of whom tolerated the fMRI. Improvement was seen in Boston Diagnostic Aphasia Examination tests of verbal and non-verbal agility 4 weeks post-treatment. The fMRI analysis showed trends for increased activation during cognitive performance tasks immediately after and at 4 weeks post-treatment. Our literature review revealed several double-blind, sham-controlled studies, all showing sustained improvement in cognition of AD patients with rTMS. Conclusions: There was improvement in aspects of language after four rTMS treatments, sustained a month after treatment cessation. Our results are consistent with other studies and standardization of treatment protocols using functional imaging may be of benefit.

Current attitudes on self-use and prescription of hormone therapy among New York City gynaecologists

Objective The results of the Women’s Health Initiative studies dramatically altered hormone therapy use around the world. In countries outside the United States, self-use in physicians remained unaltered while prescription use declined, implying that physicians may not concur with the findings. We wished to explore prevailing attitudes among American physicians by examining New York City obstetrician-gynaecologists’ self-use and prescription use of hormone therapy. Study design All board-certified obstetrician-gynaecologists in New York City were invited to complete and return a detailed, previously validated questionnaire concerning hormone therapy use. Results Two hundred and nine questionnaires were returned, for a response rate of 12% (209/1797). Gynaecologists agreed with the findings from the Women’s Health Initiative studies regarding indications and contraindications to hormone therapy use. Even so, three-quarters of female gynaecologists and female partners of male gynaecologists (74%; 67/91) use or have previously used hormone therapy. However, only 27.3% (21/77) of male gynaecologists and 12.3% (14/114) of female gynaecologists recommend hormone therapy to all menopausal women regardless of contraindications. Gynaecologists remain divided in their attitude toward hormone therapy; 30% of gynaecologists felt that hormone therapy use generally prolonged women’s lives, 36% felt it was not useful in prolonging women’s lives, and 33% were unsure. Conclusion Since the publication of the Women’s Health Initiative findings, New York City gynaecologists prescribe hormone therapy to fewer patients. However, they continue to self-use hormone therapy at much higher rates, even as they seem to concur with Women’s Health Initiative recommendations, contributing to the ongoing controversy surrounding the validity of the Women’s Health Initiative findings.

AMWA position statement: cervical cancer prevention.

153 THE AMERICAN MEDICAL WOMEN’S ASSOCIATION (AMWA) is a community of physicians, residents, and medical students who advocate for women’s rights to health and wellness centered on evidence-based data rather than political or religious beliefs. Thus, AMWA is most interested in establishing and advocating for health standards that allow girls and women to achieve their optimal potential in all arenas of life. This stalwart support of gender-based health is evident in AMWA’s position statement in a crucial area of women’s health and sexuality: cervical cancer prevention. Globally, cervical cancer is second only to breast cancer as the leading cause of cancer in women, and it is the third most common cause of female cancer-related mortality worldwide currently. There are approximately 510,000 women newly diagnosed with cervical cancer and 288,000 fatalities from this disease.1 Even in areas where most women have access to routine screening, such as the United States, Canada, and Europe, an estimated 30,000 women die each year from this infirmity.2 Although direct causality of cervical cancer by human papillomavirus (HPV) has not been definitively proven, the association between prior infection with HPV and subsequent development of cervical cancer has been overwhelmingly supported, with nearly 70% of cervical cancer biopsies showing viral genetic information from viral strains HPV-16 and HPV-18 incorporated into cervical cancer cells. The establishment of HPV infection as a probable cause of cervical precancers and cancers provides a means of prevention through vaccines that immunize against HPV infection.3 It has been estimated that a vaccine containing the seven most common types of HPV could prevent 87% of cervical cancers worldwide. In order to be effective, these vaccines should be administered to girls and young women prior to initial sexual contact, as the potential benefit diminishes with the number of sexual partners. According to the American Cancer Society, routine HPV vaccination is recommended for girls aged 11–12 years (range: 9–18 years).1 In Australia, for example, all girls aged 12–18 will be vaccinated at no cost at their local schools.4 AMWA strongly promotes appropriate and early use of the HPV vaccine to prevent cervical cancer. A common preconception and potential barrier against routine HPV vaccination use in adolescents is that it will promote sexual promiscuity. For example, in Texas, a bill was passed that blocked state officials from requiring all sixth-grade girls to receive the HPV vaccination.5 Considering the prevalence and severity of cervical cancer, however, AMWA believes that vaccination will prevent young girls and women from being unnecessarily exposed to a potentially lethal disease. When girls and women have access to proper treatment and preventive measures, they are better able to live healthy, productive lives and better able to care for themselves and their families. Therefore, AMWA advocates easy access to inexpensive HPV vaccines in the United States for girls and women at risk. National adoption of a middle-school vaccination program, as done in Australia, without any moralistic judgments, will help keep our young girls and women safer from cervical cancer

A Double-Blind, Placebo-Controlled Trial of Donepezil for the Treatment of Menopause-Related Cognitive Loss

BACKGROUND Perimenopausal and menopausal women are more likely to complain of memory loss than are premenopausal women, although the association between menopause and cognitive loss remains controversial. Recently published studies on the risks of hormone therapy have left many women and their physicians seeking effective nonhormonal treatments for menopausal symptoms, including cognitive loss. OBJECTIVE This study investigated the efficacy of the cholinesterase agent donepezil in the treatment of menopause-related cognitive loss. METHODS Community-dwelling women in natural menopause were recruited for a randomized, double-blind, placebo-controlled study of donepezil. To qualify for enrollment, the Brief Cognitive Rating Scale was used to determine cognitive symptoms, and women with depression were excluded. Subjects were randomized to receive either donepezil, commencing at 5 mg/d, or placebo. At week 6 of randomization, the dosage of donepezil was increased to 10 mg/d. Treatment continued throughout the 26-week study. The primary outcome measure was the overall change in neurocognitive test results over time. Outcome variables of test scores were analyzed before and after receipt of donepezil or placebo. RESULTS A total of 28 women aged 46 to 60 years were enrolled. Fourteen women were randomized to receive active drug, 14 to placebo. Two women dropped out of the placebo group. There were no statistically significant differences between treatment groups in post-/pre-dose mean score ratios. No interactions were statistically significant. The P values for tests of equal variances did not reveal a difference in the means. Subjective measures did show some trends toward improvement in memory and cognition. CONCLUSION Donepezil was no more effective than placebo in treating the symptoms of menopause- related memory and cognitive loss.

Creativity in medicine

“My legs given out on me,” said Edgar, the metal sculptor, with his fringe of white hair growing like a collar around his bald head.

Which Presidents Are Most Memorable

Background/rationale. Episodic memory loss is a hall-mark of Alzheimer’s disease (AD), with recall of recent events becoming progressively difficult. A commonly used tool, the recollection of US presidents, was assessed in evaluating episodic versus semantic memory loss among AD patients compared with spouse controls. Methods. A total of 36 patients (12 men, 24 women) with possible or probable AD were asked to “give the names of 5 US presidents” and concurrently administered the Mini-Mental State Examination (MMSE). Twenty-three spouses (12 men, 11 women) were controls. The year 1980 demarcated “remote” versus “recent” presidents. Results. Patients were older, had lower MMSE scores (P < .001), and recalled fewer presidents than controls (P < .005), after controlling for age. Among patients, men were more educated than women (P < .05) and recalled more presidents (P < .001). No gender differences were observed in controls. Conclusions. Patients with AD preferentially recalled remote presidents, supporting retention of semantic memory in this group. There were no gender differences between groups.

AMWA Position Statement on Abortion and Reproductive Rights

The American Medical Women’s Association (AMWA) promotes the health and wellness of women and girls in every aspect of their lives and believes that the decision whether or not to carry a child to term is a personal decision belonging solely to the woman. Thus, AMWA supports the appropriate use of legal, safe abortions and considers such procedures to be a part of comprehensive healthcare for women. The abortion rate is dependent on the availability of abortions and declined by 9% between 2000 and 2005 because of reasons such as distance, gestational limits, and cost. Women’s access to abortions is also limited by the stigma attached to abortions and by the violence and harassment that may be present on entering and leaving many abortion clinics. AMWA believes that moving abortion back into mainstream medical practice will reduce barricades to the availability of this important option for women’s health. Violence against physicians performing abortions peaked in the 1990s with the shooting deaths of several physicians and staff at abortion clinics nationwide. Since then, several states have enacted legislation to deter further antiabortion crimes. Despite these attempts, antiabortionists continue to harass abortion clinic staff and patients. According to a Feminist Majority Foundation’s 2000 National Clinic Violence Survey Report, abortion providers responded that 7% of the clinics that responded were targets of major violence and 9% of minor violence, 7% were the victims of major vandalism and 27% of minor vandalism, and 44% were targets of harassment. A disheartening consequence of the antiabortionrelated crimes is that there are a limited number of physicians who will perform the abortion procedures, which may cause women to resort to desperate and dangerous methods to attempt to terminate their pregnancies. One way in which AMWA intends to position abortion in mainstream medicine is by promoting the training of medical students and physicians in abortion procedures. AMWA also aims to increase the number of abortion providers by supporting initiatives that will allow nurse practitioners and physician assistants to perform abortion procedures. In addition to an increase in well-trained and willing abortion practitioners, more options in early abortion will also make it easier for women to obtain abortions. AMWA aims to expand a woman’s early abortion options by supporting research into new, safe, and more effective methods of abortion. One example of the benefit of this type of research is the use of mifepristone, a safe and effective method of chemically inducing abortion. By avoiding large abortion clinics, patients and practitioners will be less vulnerable to harassment and violence. AMWA opposes all bills that ban specific abortion procedures, mandate waiting periods, or require parental consent for minors’ abortions. These limitations interfere with a woman’s decision and ability to obtain an abortion. Resorting to illegal means of obtaining abortions with substandard equipment and untrained practitioners may lead to morbidity and even death. AMWA also strongly endorses programs that promote contraceptive use and believes that contraceptives and family planning information should be available to anyone requesting them, which will prevent unwanted pregnancies at the outset. AMWA believes that the ability to control fertility is an essential and basic need of girls and women and a crucial component of their health and wellness. Access to abortion and to the proper education and means to control fertility should be a birthright of every girl and woman.

AMWA position statement: genetic testing.

Over 200,000 American women will be newly diagnosed with breast or ovarian cancer in 2008, 90% with breast cancer. Over 40,000 of these women will die from their disease. Given these overwhelming statistics, early diagnosis and treatment of these cancers are imperative, as is prevention, particularly in those women who are at high risk. Approximately 5%–10% of breast and ovarian cancers are related to an inherited gene mutation. Through the advances of cancer research, it has been discovered that most of the hereditary cancers (84% of hereditary breast cancer and>90% of hereditary ovarian cancer) are attributable to mutations in the BRCA1 or BRCA2 genes, tumor-suppressor genes that code for proteins involved in cellular growth and differentiation. Therefore, genetic testing for BRCA mutations is becoming used more frequently in clinical practices to test for cancer susceptibility. By identifying any genetic alterations that may predispose individuals to breast and ovarian cancer, the American Medical Women’s Association (AMWA) firmly believes that genetic testing is a necessary measure for maintaining the health and well-being of anyone at a potential cancer risk. Various methodologies have been developed to identify mutations in BRCA1 and BRCA2 genes. A well-documented personal and family medical history is part of the initial assessment for determining a hereditary predisposition to breast cancer. Any family history of early-onset breast cancer, ovarian cancer, bilateral breast cancer, breast and ovarian cancer in one patient, or male breast cancer should increase suspicion of inherited cancer. As women with known BRCA mutations are managed differently from the general population, genetic testing allows for more tailored care of the patient. Women who have the mutation are offered intensified surveillance for early detection, chemoprevention, and riskreducing surgeries as compared with women without increased risk. Potential disadvantages of genetic testing include technological limitations. Some results are of unknown clinical significance and cannot be used in clinical decision making. Women may experience survivor guilt when their test results are negative while their siblings or other family members carry the mutation. Patients testing negative may not understand that they still have the odds of general risk to the population at large and may experience a false sense of security. Finally, for some patients, identification of a mutation may cause psychological distress. AMWA makes certain recommendations in order to ensure the ethical and responsible use of genetic testing. AMWA believes that legislation should be enacted that requires counseling for any patients submitting to genetic testing. Currently, the American Society of Clinical Oncology (ASCO) has set forth specific recommendations regarding genetic testing. ASCO strongly recommends that genetic testing be done only when paired with pretest and posttest counseling to ensure that patients are aware of the potential implications of their test results and to ensure that patients make informed medical decisions on receipt of test results. AMWA supports complete confidentiality of any information obtained from genetic testing as well as legislation that prohibits health and life insurers from denying or limiting coverage and from establishing different rates for individuals based on genetic testing information. AMWA is very much in favor of legislation that prohibits employers from discriminating against an individual because of genetic testing results.