Luiz Francisco Baccaro

The epidemiology and management of postmenopausal osteoporosis: a viewpoint from Brazil

Brazil has an aging population, with an associated increase in the prevalence of chronic diseases. Postmenopausal osteoporosis is of particular concern because it leads to an increased risk of fractures, with subsequent negative impacts on health in older women. In recent years, efforts have been made to better understand the epidemiology of osteoporosis in Brazil, and to manage both direct and indirect costs to the Brazilian health care system. The reported prevalence of osteoporosis among postmenopausal women in Brazil varies from 15% to 33%, depending on the study methodology and the use of bone densitometry data or self-reporting by participants. A diagnosis of osteoporosis can be made on the basis of fractures occurring without significant trauma or on the basis of low bone mineral density measured by dual energy X-ray absorptiometry. To reduce the risk of osteoporosis, all postmenopausal women should be encouraged to maintain a healthy lifestyle, which includes physical activity and a balanced diet. Smoking and alcohol use should also be addressed. Special attention should be given to interventions to reduce the risk of falls, especially among older women. Calcium intake should be encouraged, preferably through diet. The decision to recommend calcium supplementation should be made individually because there is concern about a possible increased risk of cardiovascular disease associated with this treatment. Brazilian women obtain a minimal amount of vitamin D from their diet, and supplementation is warranted in women with little exposure to solar ultraviolet-B radiation. For women diagnosed with osteoporosis, some form of pharmacologic therapy should be initiated. Compliance with treatment should be monitored, and the treatment period should be individualized for each patient. The Brazilian government provides medication for osteoporosis through the public health system free of charge, but without proper epidemiological knowledge, the implementation of public health programs is impaired.

Decrease in Bone Mass in Women After Liver Transplantation: Associated Factors

BACKGROUND In the future, an increasing number of female liver transplant recipients will reach the climacteric with osteoporosis as a common complication. We evaluated the factors associated with decreased bone mass among women after liver transplantation. METHODS A prospective, cross-sectional study of 23 outpatient transplant recipients followed from February 2009 to March 2010 included women of age ≥35 years after liver transplantations ≥1 year prior. We recorded patient histories, liver enzyme levels, as well as bone mineral densities measured at the lumbar spine and femur. Statistical analysis used Fishers exact test, simple odds ratio (OR), and Spearmans rank correlation coefficient. RESULTS The mean patient age was 52.5 ± 11 years with 30.4% premenopausal, and 69.6% perimenopausal or postmenopausal. Approximately 21% showed osteoporosis and 35%, a low bone mass. Postmenopausal women: OR 69.0 (95% CI 2.89-1647.18; P<.0001), aged ≥49 years: OR 13.33 (95% CI 1.78-100.15; P=.0123) and receiving a transplant after 44 years of age: OR 49.50 (95% CI 3.84-638.43; P<.0001) were associated with a lower bone mass. Having undergone transplantation for more than 5.8 years lowered the risk of bone mass change: OR 0.11 (95% CI 0.02-0.78; P=.0361). Clinical and laboratory variables, including corticosteroid use, were not associated with decreased bone mass. CONCLUSION Understanding the prevalence and factors associated with osteoporosis among female liver transplant recipients is important to enhance the strategies to diagnose and treat these women, seeking to improve their quality of life.

Efficacy of vaginally applied estrogen, testosterone, or polyacrylic acid on vaginal atrophy: a randomized controlled trial.

Objective:Vaginal atrophy is a common chronic condition among postmenopausal women that can affect their quality of life. Recent studies have evaluated new treatment alternatives for vaginal atrophy; however, few therapeutic options have been thoroughly evaluated. This study aimed to compare the effectiveness and adverse effects of estrogen, testosterone, polyacrylic acid, and placebo lubricant for the treatment of postmenopausal women with vaginal atrophy. Methods:We conducted a randomized clinical trial with 80 postmenopausal women aged between 40 and 70 years who were being followed up at the Menopause Clinic of CAISM UNICAMP between November 2011 and January 2013. Women were randomly assigned to topical vaginal treatment with estrogen, testosterone, polyacrylic acid, and placebo lubricant, three times a week for 12 weeks. We used the vaginal maturation index, pH, vaginal health score, vaginal flora, laboratory tests, and ultrasound to evaluate changes of vaginal atrophy at baseline and after 6 and 12 weeks of treatment. Results:After a 12-week treatment with topical estrogen and testosterone compared with the lubricant, an increased percentage of participants had vaginal pH less than 5, increased vaginal score, and an increase in the number of lactobacilli. Treatment with topical estrogen improved the vaginal maturation index and showed increased levels of estradiol in three women. No changes were observed in the endometrial evaluation of all treatment groups. Conclusions:After a 12-week treatment with testosterone and estrogen compared with placebo lubrication, there was a significant improvement in vaginal trophism in postmenopausal women with vaginal atrophy.

Subjective urinary urgency in middle age women: A population-based study

AIMS There are few population-based studies evaluating the epidemiology of overactive bladder syndrome (OAB) in women, especially in the climacteric stage where there is a decrease in estrogen production. This study aimed to assess the prevalence of OAB and associated factors in climacteric Brazilian women. METHODS A descriptive, exploratory, cross-sectional study was conducted between September 2012 and June 2013 with 749 women (a population-based household survey). The dependent variable was OAB, defined as the presence of urinary urgency, with or without urinary incontinence, and when there was no concomitant stress urinary incontinence. The independent variables were sociodemographic data, health related habits and problems, self-perception of health, and gynecological background. Statistical analysis was carried out by Chi-square test and Poisson regression using the backward selection criteria. RESULTS Mean age was 52.5 (± 4.4) years. With regard to menopausal status, 16% were premenopausal, 16% perimenopausal and 68% postmenopausal. The prevalence of OAB was 7.8%. The vast majority of women had only urinary urgency. Only two women who responded to the interview reported urge incontinence. In the final statistical model, vaginal dryness (PR 1.75; 95% CI 1.13-2.69; p=0.012) and bilateral oophorectomy (PR 2.21; 95% CI 1.11-4.40; p=0.025) were associated with a greater prevalence of OAB. CONCLUSIONS Health professionals should adopt a proactive behavior in surgically menopausal women and those with a history of genital atrophy to identify and treat OAB, thus contributing to an improved quality of life and healthier aging.

Cancer in Women over 50 Years of Age: A Focus on Smoking

The increase in life expectancy worldwide has resulted in a greater prevalence of chronic non-communicable diseases. This study aims to evaluate the prevalence and factors associated with the occurrence of cancer among Brazilian women over the age of 50. A cross-sectional study with 622 women over the age of 50 was performed using a population survey. The outcome variable was the occurrence of a malignant tumor in any location. The independent variables were sociodemographic characteristics, self-perception of health, health-related habits and morbidities. Statistical analysis was carried out using the chi-square test and Poisson regression. The mean age of the women was 64.1 years. The prevalence of cancer was 6.8%. The main sites of occurrence of malignant tumors were the breast (31.9%), colorectal (12.7%) and skin (12.7%). In the final statistical model, the only factor associated with cancer was smoking > 15 cigarettes/day either currently or in the past: PR 2.03 (95% CI 1.06–3.89). The results have improved understanding of the prevalence and factors associated with cancer in Brazilian women aged 50 years or more. They should be encouraged to maintain a healthy lifestyle and pay particular attention to modifiable risk factors such as smoking.

Epidemiologia da menopausa e dos sintomas climatéricos em mulheres de uma região metropolitana no sudeste do Brasil: inquérito populacional domiciliar

PURPOSE To determine the average age at the onset of menopause and to investigate menopausal symptoms in women in a metropolitan region in Southeastern Brazil. METHODS A descriptive, exploratory, cross-sectional study was conducted with 749 women (a population-based household survey). The dependent variable was the intensity of menopausal symptoms assessed by th Menopause Rating Scale (MRS). The independent variables were sociodemographic data, health-related habits and problems, self-perception of health, and gynecological background. Statistical analysis was carried out by the χ2 test and Poisson regression using the backward selection criteria. RESULTS The mean age of the women was 52.5 (± 4.4) years. With regard to menopausal status, 16% were premenopausal, 16% perimenopausal and 68% postmenopausal. The mean age at the onset of menopause was 46.5 (± 5.8) years. The intensity of menopausal symptoms was defined according to the median MRS score and was considered severe for values ​​above 8. Depression/anxiety (PR = 1.8; 95%CI 1.5-2.2; p < 0.01), rheumatic diseases (PR 1.5; 95%CI 1.2-1.7; p < 0.01), self-perception of health as fair/poor/very poor (PR 1.4; 95% CI 1.2-1.7; p < 0.01), history of abortion (PR 1.3; 95%CI 1.1-1.4; p < 0.01), current or previous treatment for menopausal symptoms (PR 1.2; 95%CI 1.1-1.4; p < 0.01), peri- or postmenopausal status (PR 1.4; 95%CI 1.1-1.7; p < 0.01), number of normal deliveries > 1 (PR 1.2; 95%CI 1.02-1.4; p < 0.01) and asthma (PR 1.2; 95%CI 1.01-1.4; p < 0.01) were associated with more severe menopausal symptoms. Older age (PR 0.96; 95%CI 0.96-0.97; p < 0.01) was associated with less severe symptoms. CONCLUSION The severity of menopausal symptoms was related to a wild range of factors, especially presence of chronic diseases, a larger number of pregnancies, use of hormone therapy, and worse self-rated health. A better understanding of these factors can help to reduce the impact of symptoms on quality of life, and to identify groups of women who are likely to need more care during and beyond menopause.PURPOSE: To determine the average age at the onset of menopause and to investigate menopausal symptoms in women in a metropolitan region in Southeastern Brazil.METHODS: A descriptive, exploratory, cross-sectional study was conducted with 749 women (a population-based household survey). The dependent variable was the intensity of menopausal symptoms assessed by th Menopause Rating Scale (MRS). The independent variables were sociodemographic data, health-related habits and problems, self-perception of health, and gynecological background. Statistical analysis was carried out by the χ2 test and Poisson regression using the backward selection criteria.RESULTS: The mean age of the women was 52.5 (±4.4) years. With regard to menopausal status, 16% were premenopausal, 16% perimenopausal and 68% postmenopausal. The mean age at the onset of menopause was 46.5 (±5.8) years. The intensity of menopausal symptoms was defined according to the median MRS score and was considered severe for values ​​above 8. Depression/anxiety (PR=1.8; 95%CI 1.5-2.2; p 1 (PR 1.2; 95%CI 1.02-1.4; p<0.01) and asthma (PR 1.2; 95%CI 1.01-1.4; p<0.01) were associated with more severe menopausal symptoms. Older age (PR 0.96; 95%CI 0.96-0.97; p<0.01) was associated with less severe symptoms.CONCLUSION: The severity of menopausal symptoms was related to a wild range of factors, especially presence of chronic diseases, a larger number of pregnancies, use of hormone therapy, and worse self-rated health. A better understanding of these factors can help to reduce the impact of symptoms on quality of life, and to identify groups of women who are likely to need more care during and beyond menopause.

Quality of life and menopausal symptoms in women with liver transplants

PURPOSE To assess quality of life and climacteric symptoms in women with and without liver transplants. METHODS This was a cross-sectional study of 52 women undergoing follow-up at a university hospital in southeastern Brazil from February 4th, 2009 to January 5th, 2011. Twenty-four of these women were 35 years old or older and had undergone liver transplantation at least one year before study entry. The remaining 28 women had no liver disease and were matched by age and menstrual patterns to the patients with transplants. The abbreviated version of the World Health Organization (WHOQOL-BREF) questionnaire was used to assess quality of life. Menopausal symptoms were assessed using the Menopause Rating Scale (MRS). Statistical analysis was carried out by Students t-test, Mann-Whitney test and analysis of variance. Correlations between MRS and the WHOQOL-BREF were established by correlation coefficients. RESULTS The mean age of the women included in the study was 52.2 (± 10.4) years and the mean time since transplantation was 6.1 (± 3.3) years. Women with liver transplants had better quality of life scores in the environment domain (p=0.01). No difference was noted between the two groups in any domain of the MRS. For women in the comparison group, there was a strongly negative correlation between somatic symptoms in the MRS and the physical domain of the WHOQOL-BREF (p<0.01; r=-0.8). In contrast, there was only a moderate association for women with liver transplants (p<0.01; r=-0.5). CONCLUSIONS Women with liver transplants had better quality of life scores in the domain related to environment and did not exhibit more intense climacteric symptoms than did those with no liver disease. Climacteric symptoms negatively influenced quality of life in liver transplant recipients, although less intensely than in women without a history of liver disease.

Factors associated with fragility fractures in women over 50 years of age: a population-based household survey

PURPOSE To analyze the prevalence of and factors associated with fragility fractures in Brazilian women aged 50 years and older. METHODS This cross-sectional population survey, conducted between May 10 and October 31, 2011, included 622 women aged >50 years living in a city in southeastern Brazil. A questionnaire was administered to each woman by a trained interviewer. The associations between the occurrence of a fragility fracture after age 50 years and sociodemographic data, health-related habits and problems, self-perception of health and evaluation of functional capacity were determined by the χ2 test and Poisson regression using the backward selection criteria. RESULTS The mean age of the 622 women was 64.1 years. The prevalence of fragility fractures was 10.8%, with 1.8% reporting hip fracture. In the final statistical model, a longer time since menopause (PR 1.03; 95%CI 1.01-1.05; p<0.01) and osteoporosis (PR 1.97; 95%CI 1.27-3.08; p<0.01) were associated with a higher prevalence of fractures. CONCLUSIONS These findings may provide a better understanding of the risk factors associated with fragility fractures in Brazilian women and emphasize the importance of performing bone densitometry.

Treatment for menopausal symptoms and having health insurance were associated with a lower prevalence of falls among Brazilian women

OBJECTIVES Brazil has an aging population. This study aims to raise awareness of the prevalence and factors associated with falls among Brazilian women. STUDY DESIGN Cross-sectional study with 622 women over 50 years of age was conducted between 05/10/11 and 10/31/11 in the city of Campinas/São Paulo/Brazil in the form of a population survey. MAIN OUTCOME MEASURES The dependent variable was the occurrence of falls in the past 12 months. The independent variables were sociodemographic data, health-related habits and problems, self-perception of health and evaluation of functional capacity. Statistical analysis was carried out by Chi-square test and Poisson regression using the backward selection criteria. RESULTS The mean age of the women was 64.1 years. The prevalence of falls in the past 12 months was 24.6%. Having trouble keeping balance when walking: PR 1.87 (95% CI 1.33-2.63, P<0.001); alcohol consumption: PR 1.69 (95% CI 1.25-2.28, P<0.002); having been admitted to a hospital in the last 12 months: PR 1.46 (95% CI 1.09-1.96, P=0.012); and having cataract: PR 1.40 (95% CI 1.05-1.87, P=0.021) were associated with a higher prevalence of falls. Having health insurance: PR 0.67 (95% CI 0.50-0.89, P=0.007) and using some form of medication to treat menopausal symptoms: PR 0.42 (95% CI 0.19-0.92, P=0.031) were associated with a lower prevalence of falls. CONCLUSION Having health insurance and using some form of medication to treat menopausal symptoms were associated with a lower prevalence of falls among Brazilian women.

Disability and multimorbidity in women older than 50 years: a population-based household survey

ObjectiveThis study aims to evaluate the prevalence of disability and associated factors in Brazilian women older than 50 years. MethodsWe conducted a cross-sectional study (in the form of a population survey) of 622 women older than 50 years and residing in Campinas, Brazil. Disability was assessed through a questionnaire with seven items and defined as “being completely unable to perform any of them.” Independent variables included self-perception of health, sociodemographic data, health-related habits, and morbidities. Statistical analysis was carried out by &khgr;2 test and Poisson regression. ResultsThe mean age of women was 64.1 years, and the prevalence of disability was 43.4%. Age (prevalence ratio [PR], 1.02; 95% CI, 1.01-1.03), fear of falling (PR, 1.59; 95% CI, 1.17-2.16), higher body mass index (PR, 1.03; 95% CI, 1.01-1.05), personal history of myocardial infarction (PR, 1.36; 95% CI, 1.06-1.76), smoking more than 15 cigarettes per day (PR, 1.34; 95% CI, 1.04-1.72), hospitalization in the past year (PR, 1.29; 95% CI, 1.03-1.62), multimorbidity (PR, 1.43; 95% CI, 1.02-2.02), and use of any medication prescribed by a doctor (PR, 1.57; 95% CI, 1.02-2.41) were associated with a higher prevalence of disability. Self-perception of health as good/very good (PR, 0.67; 95% CI, 0.52-0.86), use of alternative medications (PR, 0.54; 95% CI, 0.33-0.90), and more years of schooling (PR, 0.65; 95% CI, 0.45-0.93) were associated with a lower prevalence of disability. ConclusionsThe results improve our understanding of the factors associated with disability in Brazilian women and may help identify those who need multidisciplinary support to reduce effects on quality of life.