Mette H. Moen

Diagnostic delay in women with pain and endometriosis

Background.  Women with endometriosis claim that delayed diagnosis is a problem. Anglo‐American studies have shown a delay from 3 to 11 years between the onset of pain symptoms and the final diagnosis of endometriosis. The aim of this study was to find the time difference between the onset of pelvic pain symptoms and the final diagnosis of endometriosis among Norwegian patients.

Epidemiology of endometriosis in a Norwegian county

Objective. To estimate the prevalence and incidence of endometriosis in Norwegian women aged 40 to 42, and to evaluate reproductive events and life‐style as risk factors for endometriosis as well as to evaluate related health‐problems.

The endocrine transition around menopause--a five years prospective study with profiles of gonadotropines, estrogens, androgens and SHBG among healthy women.

OBJECTIVE The purpose of this study was to investigate the hormonal changes during the menopausal transition in a non-clinical population. METHODS Fifty-nine healthy Norwegian women participated in a five year prospective longitudinal study during the transition from pre- to post-menopause, starting one to four years before menopause, and ending one to four years postmenopausal. None of these women were given hormone replacement therapy (HRT). Blood samples were collected every 12 months and luteinizing hormone (LH), follicle stimulating hormone (FSH), steroid hormone binding globuline (SHBG), prolactin (PRL), estradiol (E2), estrone (E1), testosterone, androstendione, dehydroepiandrostendione-sulphate (DHEA-S), and thyroid stimulating hormone (TSH) were analyzed. RESULTS The serum levels of FSH and LH, E2 and E1 profile essentially confirmed previous data obtained in cross-sectional studies. A continuous increase in serum FSH and LH and a concomitant fall in E2 and E1 were observed in all women before menopause and in the two postmenopausal years. Both androstendione and testosterone showed a decline three years before menopause. After the menopause, however, there were fluctuations in the testosterone levels. Androstendione correlated positively with both E2 and E1 and testosterone postmenopausally. Body mass index (BMI) did correlate with testosterone, but not with androstendione. BMI correlated negatively with SHBG. No correlation was found between BMI and E2, E1, FSH and LH. CONCLUSION This longitudinal prospective study of hormonal changes during the transition from pre- to postmenopause indicates that not only estrogen hormonal changes, but androgen hormonal changes as well, precedes the menopause by several years.

Androgens and estrogens in relation to hot flushes during the menopausal transition

In this paper, the association of hormones to vasomotor complaints during the menopausal transition is discussed. Fifty-seven regularly menstruating women without history of hormone replacement therapy (HRT) were selected for a longitudinal, prospective study around the menopausal transition. The mean age at the start of the study was 51.3 (+/-2.0) years. At intervals of 12 months all women went through a semi-structured interview and filled in questionnaires. Venous blood samples were collected every 12-month for analyses of estradiol (E2), testosterone, androstendione, dehydroepiandrosterone-sulphate (DHEA-S), follicle stimulating hormone (FSH), thyrotropin (TSH), and luteinizing hormone (LH). Vasomotor complaints were tested using questions about hot flushes and bouts of sweating in terms of occurrence, frequency and degree of distress. Forty-six percent of the subjects reported hot flushes and bouts of sweating before menopause, increasing to 67% during the first year after menopause and 49% in the second year postmenopause. Low levels of estradiol and high levels of FSH were associated with vasomotor complaints before menopause. During menopause high levels of TSH were related to vasomotor complaints. The first year after menopause, women, who at this point achieved hot flushes, were characterised by high levels of E2, but declining and low levels of FSH, but increasing. Postmenopausal, high levels of testosterone and DHEA-S seemed to protect against vasomotor symptoms. Our most important finding was, that among women who achieved hot flushes at the first assessment postmenopause, the high androgen levels was a significant predictor of recovery from hot flushes at the last assessment, 1 year later.

Endometriosis in women at interval sterilization.

The prevalence of endometriosis was investigated in 108 Norwegian women admitted for interval tubal sterilization. The mean age of the patients was 37 years. Endometriosis was detected in 19 (18%) of the women. About one‐half of these had no symptoms from the disease. A positive correlation was found between a retroversion of the uterus and endo‐metriosis. The women with endometriosis showed a longer period of uninterrupted menstrual cycles prior to the time of sterilization, when compared with the controls (89 unaffected women). Sisters and mothers of patients with endometriosis displayed a higher frequency of benign gynecological disorders than the corresponding relatives of the control group. The prevalence of endometriosis appeared to be independent of the following clinical parameters: onset of menarche, age at first pregnancy, number of pregnancies, previous use of hormonal contraceptives or IUD, and actual age at the time of sterilization.

Histologic confirmation of endometriosis in different peritoneal lesions

The aim of this study was to compare the macroscopic evaluation of peritoneal abnormalities suspected of endometriosis with the histologic examination of the tissue. Peritoneal biopsies from 152 patients investigated for gynecological problems (94) or undergoing tubal sterilization (58) were taken from macroscopically abnormal peritoneum, and examined for the presence of endometriosis. Endometriosis was histologically confirmed by the presence of both endometrioid glands and stroma. Endometriosis was confirmed in 78 of the patients (51%). If the diagnostic criteria were extended also to include endometrioid stroma lacking glands, but containing iron pigment and/or hemorrhage, 82 patients (54%) were positive for endometriosis. Endometriosis was histologically confirmed in 76% of pigmented lesions, in 57% of clear or red papules, in 12% of peritoneal pockets, and in 16% when only fibrosis or scarring was observed. Half of the samples with confirmed endometriosis exhibited cyclic activity. The reproducibility of the histologic evaluation was satisfactory. A high rate of negative biopsies emphasizes the need of taking biopsies from peritoneal lesions suspected of endometriosis for confirmation of the diagnosis.

Life after a diagnosis with endometriosis ‐ a 15 years follow‐up study

Objective. Previous studies have elucidated the negative impact of endometriosis on life, but the patient selection may have contributed to a skewed picture. The aim of this study was to investigate longitudinally the consequences of the disease in women diagnosed with endometriosis 15 years ago. Design. Retrospective descriptive. Setting. Trondheim 2007. Sample. One hundred thirty women diagnosed with endometriosis at St. Olavs Hospital in Trondheim between 1991 and 1993. Methods. Questionnaires. Response rate of 60%. Main outcome measures. Consequences of living with endometriosis. Results. Of the women, 19.2% never experienced pelvic pain and 21.8% did not have any further visits to the gynecological department after being diagnosed. Almost 70% had received pharmaceutical treatment and positive effect on pain was reported by 41% for NSAIDs and oral contraceptives, and by 62% for progestins and GnRH‐analogues. Satisfactory effect on pain after surgical interventions at the time of diagnosis was reported by 60.9%, and by 89.9% after later surgeries. Of the infertile patients, 75.6% succeeded in delivering one or more biological children. Half of the women reported that endometriosis had some negative impact on their lives. After menopause, 96.9% were free from pain. Conclusion. This study confirms that endometriosis is a condition that often has considerable impact on a womans life. However, the study also found that endometriosis does not always cause pain, that treatment in many cases is effective, that infertility may be overcome, and that almost all postmenopausal women were free from endometriosis‐associated pain.

EMAS position statement: Managing the menopause in the context of coronary heart disease

INTRODUCTION Cardiovascular disease (CVD) including coronary heart disease (CHD) and stroke is the most common cause of female death. Premenopausal CHD is very rare but when women enter the menopause the incidence of CHD increases markedly. CHD presents 10 years later in women than in men. The reason is still unclear but the protective effects of estrogens have been suggested. AIMS To formulate a position statement on the management of menopause women in the context of coronary heart disease. MATERIALS AND METHODS Literature review and consensus of expert opinion. RESULTS AND CONCLUSIONS Based on long term randomized placebo-controlled studies hormone therapy (HT) is not recommended for the primary or secondary prevention of CHD in postmenopausal women. In most countries the only indication for HT is the treatment of menopausal symptoms. Women with known CHD or with many coronary risk factors seeking HT because of troublesome climacteric symptoms should be evaluated for their individual baseline risk of developing breast cancer, venous thromboembolism and CHD recurrence. The same applies to non hormone therapy-based treatments where long term clinical studies are lacking. Risks should be weighed against expected benefit from symptom relief and improved quality of life. The lowest effective estrogen dose should be used during the shortest possible time. Transdermal administration is preferred if risk factors for VTE exist. Different progestogens might differ in their cardiovascular effects. Observational studies suggest that micronized progesterone or dydrogesterone may have a better risk profile than other progestogens with regard to thrombotic risk.

EMAS position statement: Managing obese postmenopausal women

INTRODUCTION Obesity is a public health problem, with overweight individuals representing approximately 20% of the adult world population. Postmenopausal status is associated with higher prevalence of obesity, as 44% of postmenopausal women are overweight, among whom 23% are obese. Obesity often co-exists with other diseases, the most important being diabetes mellitus, dyslipidemia and hypertension. Furthermore, obesity increases the risk of gynecologic cancer, cardiovascular disease, venous thromboembolism, osteoarthritis and chronic back pain. AIM To formulate a position statement on the management of the menopause in obese women. MATERIALS AND METHODS Literature review and consensus of expert opinion. RESULTS AND CONCLUSIONS Obese women seeking hormone therapy should be evaluated for their individual baseline risk of developing breast cancer, cardiovascular disease and venous thromboembolism. These risks should be weighed against expected benefit from symptom relief, improved quality of life and osteoporosis prevention. The lowest effective estrogen dose should be used (CEE 0.300-0.400 mg or estradiol 0.5-1 mg orally daily or 25-50 microg estradiol transdermally). With regard to progestogens, although no RCT data exist, there are observational studies showing that micronized progesterone or dydrogesterone may have a better risk profile with respect to breast cancer risk. There are no RCT data comparing various progestogens with regard to VTE risk. There are observational data, however, suggesting that micronized progesterone or pregnane derivatives may be associated with a lower VTE risk in postmenopausal women taking HT compared to nonpregnane derivatives. There is a rationale in suggesting the use of transdermal HT in obese women, since this route of administration has been associated with a lesser risk of venous thromboembolism than oral therapy.

Inhibin A and B as markers of menopause: a five-year prospective longitudinal study of hormonal changes during the menopausal transition

Objectives.  A more direct and precise hormonal marker of the menopause has been required for some time. The aim of this study was to identify the most accurate marker of the menopause, based on analyses of inhibin A and B, FSH, LH and estradiol (E2), among 59 healthy women without hormonal treatment during the perimenopause and early postmenopause.