WOMEN 'S HEALTH AND MENOPAUSE : - National Heart, Lung ...

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outes of administration and different doses and combination of hormones to arrive at firm conclusions about the role of HRT in the prevention of CHD in postmenopausal women. CHD prevention is conventionally divided into primary and secondary prevention. Primary prevention addresses interventions in the absence of clinically recognized disease, although atherosclerosis may be present. In secondary prevention, a cardiovascular event has HRT is not a single already been documented. entity but encompasses In this chapter we have made no distinction a diverse number of between primary and sec- agents, which may have ondary prevention of CHD, differing effects on the since therapies that work for secondary prevention cardiovascular system. usually work for primary prevention and vice versa. Although HRT has been the focus of much attention in menopausal women, the approach to the prevention of CVD should be multifaceted. There is increasing information on the beneficial effects of lifestyle changes (e.g., nutrition and exercise), which can contribute greatly to the reduction in risk of CVD. One of the problems in CVD research in women is that some of the major pharmacologic studies have been conducted in men or have included only a small proportion of women. Nonetheless, a number of drug interventions, including beta-blockers, aspirin, statins, and ACE inhibitors, have been shown to decrease events associated with CHD in women as well as in men. Future studies have to include adequate numbers of women in order to make valid assessments of treatment effects in women. This chapter identifies important areas of CVD that have been studied and reported in women and that provide a basis for future research in this area of women’s health. Only with large, well-conducted clinical trials can important and accurate information be accrued on CVD in postmenopausal women. 142 2. RISK FACTORS FOR CORONARY HEART DISEASE IN WOMEN The term “risk factor” is used to describe characteristics found in healthy individuals that have been observed in epidemiological studies to be related to the subsequent occurrence of CHD. The risk factors for CHD are multifactorial, and many of these are similar in women and men. • Age • History of CHD, stroke, or peripheral vascular disease • Family history of premature CHD • Dyslipidemia • Cigarette smoking • Hypertension • Diabetes mellitus • Obesity (especially central) • Lifestyle—diet, physical activity, psychosocial factors, alcohol • Homocysteine and C-reactive protein (CRP) Some risk factors are modifiable, such as smoking habit, alcohol intake, lifestyle, and biochemical and physiological characteristics. Other personal characteristics, such as age, gender, and family history of early onset of CHD, are nonmodifiable. Countries with high rates of heart disease in men also have higher rates in women; and conversely, low rates in men correspond to low rates in women (fig. 8–1). In developed countries, death rates for CHD in women aged 35–74 are decreasing (fig. 8–2); in contrast, rates are static or increasing in developing and eastern European countries. Women appear to be protected from CHD especially at younger ages, and it has been postulated that sex-specific hormones may be implicated. 2 Data from the Framingham Heart Study 3 reveal that the risk of CHD in an asymptomatic woman who has both elevated systolic blood pressure and smokes cigarettes is significantly less than the risk
FIGURE 8–1 Age-Adjusted Death Rates* for Coronary Heart Disease by Country and Sex, Aged 35–74, 1996 ✝ HUN (95) ROM SCO IRE (95) BUL (94) NIR FIN (95) E&W NZE (94) DEN ‡ (93) POL NOR (95) AUS USA GER SWE AUL (95) CAN (95) NTH (95) GRE ITA (93) ISR SWI ‡ (94) POR SPA (95) FRA (95) JPN (94) 400 200 0 200 400 600 Deaths/100,000 Population * Age adjusted to European Standard. ✝ Data for 1996 unless otherwise noted in parentheses. ‡ Eighth revisions of the ICD. Female Male in a man of the same age. This applies to women and men at younger ages (age 50) but the differences between women and men no longer apply at older age (beyond the age of 80). 4 Established major modifiable risk factors for CHD in women, based on prospective studies, include raised total cholesterol (or LDL cholesterol), low high density lipoprotein (HDL) cholesterol, high blood pressure, cigarette smoking, diabetes, obesity, and physical inactivity. High triglycerides, raised Lp(a), and raised fibrinogen levels are also considered to be major risk factors by some authorities. The modifiable risk factors shown to be of cardiovascular benefit in randomized trials include 143
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National Heart, Lung, and Blood Ins
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CHAIRS AND EDITORS Chair and Editor
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Anne McTiernan, M.D., Ph.D. Associa
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Lenore Manderson, Ph.D. Director an
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Michael Mendelsohn, M.D. Director,
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TABLE OF CONTENTS Preface XIII 1 Ex
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PREFACE Women’s health and menopa
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CHAPTER 1: EXECUTIVE SUMMARY Nanett
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TABLE 1-1 Evidence Categories Evide
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TABLE 1-2 (continued) Possible Bene
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symptom measures, cultural factors,
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5. PHYSIOLOGICAL ROLE OF ESTROGEN A
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The atherogenic risk profile of old
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• Hormone replacement therapy: Fi
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tion of the remaining ridge in area
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9.3.1 Interventions • In many cas
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Parkinson’s disease, no overall p
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TABLE 1-3 (continued) Sexuality •
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CHAPTER 2: THE MENOPAUSE AND AGING
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oped and are less prepared to addre
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FIGURE 2-4 Diabetes Mellitus. Estim
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Sarcopenia, defined as reduced musc
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Perimenopause WHO The term “perim
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decrease about 2 years before the F
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4.3 Menstrually Defined Menopausal
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to be under stress and to hold part
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21 Brincat MP. Hormone replacement
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62 Orentreich N, Brind JL, Rizer RL
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CHAPTER 3: SYMPTOMS AND THE MENOPAU
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women who may have reached natural
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numb-tingling feelings, headaches,
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(47 percent), problems sleeping (39
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FIGURE 3-2 Proportion of Women Both
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tomized hypogonadotropic women expe
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5.1 Exercise It has been suggested
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to consume 20-150 mg/day of isoflav
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REFERENCES 1 Stewart AL, Hays RD, W
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48 Avis NE, Crawford SL, McKinlay S
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92 Albertazzi P, Pansini F, Bonacco
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Hällström wrote that the psycholo
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countries. Perhaps, as the authors
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Beyene used a systematic ethnograph
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ange of variables, such as genetic
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REFERENCES 1 Gannon L, Ekstrom B. A
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47 George T. Women in a south India
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9. Estrogen and inhibins produced b
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HRT) display tissue-selective estro
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a partial agonist. In contrast, wit
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3. UROGENITAL TRACT ERα and ERβ a
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4. BONE: DEVELOPMENT AND HOMEOSTASI
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in response to estrogen. 106,105 In
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lation of sleep, motor behavior, an
Page 108 and 109: 7. HORMONE REPLACEMENT THERAPY: TRA
Page 110 and 111: REFERENCES 1 Jensen EV, Jacobsen HI
Page 112 and 113: 40 Power RF, Mani SK, Codina J, Con
Page 114 and 115: 83 Oursler MJ, Pederson L, Fitzpatr
Page 116 and 117: 125 Gabrielsson BG, Carmignac DF, F
Page 118 and 119: 169 Renier MA, Vereecken A, Buytaer
Page 120 and 121: FIGURE 6-1 Structural features of E
Page 122 and 123: ound, the conformation of the recep
Page 124 and 125: with extremely potent estrogenic ac
Page 126 and 127: Its potency as an antiestrogen was
Page 128 and 129: The observation that the degree of
Page 130 and 131: findings were remarkable because a
Page 132 and 133: Recently, the use of phage display
Page 134 and 135: 20 Crawley G. Non steroidal estroge
Page 136 and 137: 65 Qu Q, Zheng H, Dahllund J, et al
Page 138 and 139: in their survey of postmenopausal w
Page 140 and 141: where over half the world’s popul
Page 142 and 143: The Danish study of Koster and Gard
Page 144 and 145: Many studies of sexual interest in
Page 146 and 147: 7. ASSESSING SEXUAL ACTIVITY Clinic
Page 148 and 149: None of these studies evaluated the
Page 150 and 151: estrogen-androgen group during the
Page 152 and 153: REFERENCES 1 Sarrel PM, Whitehead M
Page 154 and 155: 52 Utian WH. The true clinical feat
Page 156 and 157: 140
Page 160 and 161: FIGURE 8-2 Change in Age-Adjusted D
Page 162 and 163: fied as overweight or obese. 32 The
Page 164 and 165: TABLE 8-1 148 Guide to Risk Reducti
Page 166 and 167: TABLE 8-1 (continued) 150 Recommend
Page 168 and 169: TABLE 8-1 (continued) 152 Recommend
Page 170 and 171: Interesting differences in atherosc
Page 172 and 173: similar effects in both patients wi
Page 174 and 175: a lowering of triglycerides, 140 an
Page 176 and 177: may account for a substantial propo
Page 178 and 179: associated with an independent prot
Page 180 and 181: eases preoperatively. Quality of li
Page 182 and 183: excess risk of 6-18 per 10,000 per
Page 184 and 185: REFERENCES 1 NHLBI Morbidity and Mo
Page 186 and 187: 36 Samaras K, Hayward CS, Sullivan
Page 188 and 189: 79 Collins P, Rosano GM, Jiang C, L
Page 190 and 191: 121 Mäkelä S, Savolainen H, Aavik
Page 192 and 193: 162 Clarke S, Kelleher H, Lloyd-Jon
Page 194 and 195: 201 Rahimtoola SH, Bennett AJ, Grun
Page 196 and 197: 243 Varas-Lorenzo C, Garcia-Rodriqu
Page 198 and 199: 7. A connection between menopausal
Page 200 and 201: 3. PATHOGENESIS OF FRACTURE Fractur
Page 202 and 203: Diagnosis of osteoporosis according
Page 204 and 205: density and has a favorable effect
Page 206 and 207: How should this information be inco
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emergence of proved treatment alter
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Data on the relation between skelet
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REFERENCES 1 Osteoporosis Preventio
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42 Gluer CC. Quantitative ultrasoun
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85 Ettinger B, Pressman A, Silver P
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130 Jeffcoat MK, Lewis CE, Reddy M,
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1. INTRODUCTION Perimenopausal wome
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for breast cancer are at increased
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findings on biopsy in women with an
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thra. Patients typically describe l
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Biofeedback: Used in conjunction wi
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There has been one systematic revie
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ence in pelvic organ prolapse. The
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21 Ferenczy A. Endometrial carcinom
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65 Wyman JF, Fantl JA, McClish DK,
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222
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1. INTRODUCTION Worldwide, breast c
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difficult to compare because of com
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Although HRT has been related to an
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cyclic use and 2.9 (95 percent CI 2
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TABLE 11-3 Selected Studies on Horm
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TABLE 11-3 (continued) Thus, a stro
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TABLE 11-4 236 Cohort Studies on Ho
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TABLE 11-5 238 Case-Control Studies
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TABLE 11-5 (continued) 240 Adjustme
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When the same women in NSABP were r
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REFERENCES 1 Pisani P, Parkin DM, B
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47 Day NE. Epidemiology: the role o
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93 Rodriguez C, Patel AV, Calle EE,
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139 Parazzini F, La Vecchia C, Negr
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1. INTRODUCTION Menopause is associ
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inverse relation with nonverbal mem
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ease decreased significantly with i
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of households selected to be repres
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standard antipsychotic drugs increa
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5. FUTURE NEEDS • Explore the pos
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19 Berman KF, Schmidt PJ, Rubinow D
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64 Lerner A, Koss E, Debanne S, Row
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114 Smith R, Studd JW. A pilot stud
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162 Klein BE. Lens opacities in wom
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patients with strong personal convi
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Therefore, convincing evidence of t
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3.1.1 Risk Factors Many factors are
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278 lower dosages of estrogen will
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• Diabetes: Women with diabetes b
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Lipids and lipoproteins • LDL cho
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284 persists but is less steep in w
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5.2.3 Pharmacotherapy Breast Cancer
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• There is no clinical trial evid
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Sirtori CR, Pazzucconi F, Colombo L
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Hansson L, Zanchetti A, Carruthers
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Dementia and Mental Health Forette
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CRP C-reactive protein CT computed
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PTCA percutaneous transluminal coro
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U.S. DEPARTMENT OF HEALTH AND HUMAN
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