Care after premenopausal risk-reducing salpingo-oophorectomy in high-risk women: Scoping review and international consensus recommendations.

Women at high inherited risk of ovarian cancer are offered risk-reducing salpingo-oophorectomy (RRSO) from age 35 to 45 years. Although potentially life-saving, RRSO may induce symptoms that negatively affect quality of life and impair long-term health. Clinical care following RRSO is often suboptimal. This scoping review describes how RRSO affects short- and long-term health and provides evidence-based international consensus recommendations for care from preoperative counselling to long-term disease prevention. This includes the efficacy and safety of hormonal and non-hormonal treatments for vasomotor symptoms, sleep disturbance and sexual dysfunction and effective approaches to prevent bone and cardiovascular disease.

Vulvodynia - an evolving disease.

Vulvodynia is a common vulval pain syndrome that occurs most commonly in reproductive women of all ages. It can, in some cases, present for the first time after menopause. Up to about 15% of adult women have had symptoms of vulvodynia, with 4-5% currently symptomatic. Since there are no specific tests for diagnosis, vulvodynia is a diagnosis of exclusion. The condition is commonly associated with other chronic pain disorders and can be exceedingly debilitating, resulting in sexual dysfunction, severe depression and/or anxiety. It can significantly impair quality of life. Goals for long-term team approach management should be discussed with the patient at the commencement of each intervention as effectiveness of therapy is not assured. Currently, there is no intervention that effects cure in all individuals and a combination of pharmacological therapy, psychotherapy and physiotherapy, reserving surgery as a last-line option, is the best option for treatment. There are no long-term data on how long women will have symptoms and, if resolved, what provokes symptoms again in the future, whilst correlation between the etiology of vulvodynia and efficacy of treatment is not known.

God, spirituality and religion in women dying from gynecological cancer.

Thoughts of death and dying will prevail constantly in the minds of women with gynecologic cancer. Invariably, there is the hope that, when the end comes, there will be 'a good death'. End-of-life decisions, with particular emphasis on what the patient and her family constitute 'a good death' to be, will be influenced by emotional, psychological, mental, physical, spiritual and religious backgrounds. It is important to allow patients to resolve their despair by communicating their innermost thoughts. Spirituality and religious belief are important components that may play major roles in enabling patients to obtain peace and require the participation of all members of the health-care team managing the cases. Clinicians should appreciate the patient's concerns, beliefs, fears, spiritual and religious needs and be sensitive to comments that may indicate spiritual distress. Active listening and supportive dialogue may help patients work through existential issues and find peace. Patients who are in spiritual distress should be referred to certified and trained spiritual care professionals, chaplains, counselors and clergy.

Lichen sclerosus of the vulva.

Lichen sclerosus of the vulva (LSV) is seen frequently enough to warrant knowing how to diagnose it and institute appropriate treatment strategies. LSV is a chronic skin disorder, very likely of autoimmune origin, which may affect various areas of the perineum, although some women may be affected in extragenital areas. The disease has significant adverse impact on quality of life and sexual activity and may undergo malignant transformation. History of symptomatology and clinical examination is sufficient to make the diagnosis. Skin biopsy is only necessary in specific scenarios. Topical corticosteroids are still the mainstay of therapy, initially to institute remission and then for maintenance. Long-term therapy and surveillance are invariably necessary. Surgery does have a role, but only in specific associated conditions. A number of alternative treatment options have been mooted, especially if the disease is resistant to topical corticosteroids, but these options are still being assessed and studied.

Endometriosis-associated cancer.

Endometriosis will affect about 10% of the female population and not only can it significantly impact adversely on quality of life and result in infertility, but data are accumulating that malignant transformation is an important consideration. Endometriosis can be histologically typical or atypical, ovarian, superficial peritoneal or deep infiltrating. The precursor for malignant transformation appears to be the ovarian atypical endometriosis component. Ovarian cancer is the most important associated cancer, primarily endometrioid and clear cell cancer. These are the only subtypes wherein a direct clonal relationship between endometriosis, as a direct precursor, and cancer has been made. There is no substantive evidence to support an altered association of borderline cancers of the ovary, serous ovarian cancers and breast, endometrial or cervical cancers. This review provides an overview of the prevailing data pertaining to the molecular and genetic aberrations that accompany the transformation of atypical endometriosis to malignancy and the accumulated epidemiologic evidence which supports the association.

Midlife women's health consequences associated with polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is one of the most common female endocrinopathies. Its symptoms may appear as early as adolescence and may include irregular menstrual periods, amenorrhea, hirsutism and obesity. Regardless of their phenotypic appearance, women with PCOS are metabolically obese. PCOS is associated with metabolic syndrome, type 2 diabetes, depression, cardiovascular disease and gynecological cancers. The metabolic disorders in obese women with PCOS are invariably due to insulin resistance, while inflammation, oxidative stress and possible interaction with environmental factors are among the features linking women with PCOS alone to metabolic disorders. The current review aims to highlight the relationship between PCOS and midlife women's health complications.

Foot problems in older women.

Between 20 and 45% of women aged over 65 years of age will develop one or more foot problems, which, although not specific to older women, are more common in that age group than in younger women. These include structural defects of the toes including hallux valgus, hammer, mallet or claw toes, skin disorders, fungal infection of the toes and toe nails, thickened toe nails, ulcers, fissures or cracks between the toes, corns and calluses, flat or high-arched feet. Foot pain is common and may be associated with other co-morbid diseases of the foot. Inappropriate footwear has an unfortunate role in the etiology of these problems and may also play a prominent role in slips, trips and falls, which may result in fractures of the lower or upper limbs. Simple interventions and wearing of appropriate shoes can play an important role in improving foot health and minimizing falls in older women. This review provides a brief overview of foot problems in older women and their sequelae.

CLarifying vaginal atrophy's impact On SEx and Relationships (CLOSER) survey in South Africa.

OBJECTIVE: With a paucity of information from sub-Saharan Africa, the impact of postmenopausal vaginal atrophy on women and male partners in South Africa was investigated. METHODS: Four hundred individuals in South Africa (200 postmenopausal women who had experienced symptoms of vaginal atrophy, and 200 male partners) completed a structured questionnaire. RESULTS: Sixty-eight percent of women had avoided intimacy because of vaginal discomfort; 62% of men described observing this behavior in their partners. Consequently, 52% of women and 51% of men reported decreased sexual activity - 20% of women and 18% of men believed vaginal discomfort had 'caused a big problem'. Significantly higher proportions of women than men (p < 0.05) described being 'put off' having sex (27% vs. 14%) and feeling emotionally distant from their partners (21% vs. 11%). Twenty-one percent of women had used local estrogen therapy, reporting benefits including feeling 'happy' that their body was 'working again' (76%) and increased confidence as sexual partners (71%). CONCLUSION: For many postmenopausal women and their partners, symptoms of vaginal atrophy adversely affected sex and relationships, physically and emotionally. Substantial improvements were reported by women who received local estrogen therapy, supporting greater efforts to improve awareness and accessibility of such treatment in South Africa.

Hormone therapy after prophylactic risk-reducing bilateral salpingo-oophorectomy in women who have BRCA gene mutation.

Women with a BRCA1 or BRCA2 gene mutation have substantially higher risk for developing not only breast and ovarian cancers, but also for primary peritoneal, Fallopian tube, colonic, pancreatic cancers, uterine papillary serous adenocarcinoma and malignant melanoma. The risk for ovarian cancer ranges from 39 to 49% by 70 years of age in BRCA1 mutation carriers and from 11 to 18% for those with a BRCA2 mutation, whilst breast cancer increases similarly within women who have either the BRCA1 mutation or the BRCA2 mutation, from about 20% in women in their forties, 37% by the age of 50 years, 55% by 60 years and more than 70% by the age of 70 years. Prophylactic risk-reducing bilateral salpingo-oophorectomy (RRBSO) provides significantly greater benefits with the view of reducing the risk for gynecological and breast cancer (decreasing ovarian cancer risk by 85-95%, breast cancer risk by about 53-68% and removes occult or undetected cancers in 2-18% of such women) compared to other conservative options, namely screening/surveillance or use of chemopreventative agents. RRBSO will result in significant menopausal symptoms, increased risk for bone mineral loss, increasing risk for osteopenia and osteoporosis, and cognitive dysfunction. Risk for cardiovascular disease is also increased if the procedure is performed in women less than 50 years of age. This article analyzes the role of RRBSO in women with BRCA1/BRCA2 mutations with no personal history of breast cancer and the impact of hormone therapy on risk for breast and gynecological cancers if used after the procedure to alleviate the resulting menopausal symptoms.

Gender differences in sleep in older men and women.

Sleep disturbances increase with increasing age in both males and females and become fairly common in the older community when compared to their younger counterparts. Even though these sleep disturbances increase with advancing age, there are nevertheless inherent differences in sleep disturbances between males and females. When compared to older men, older women will have a longer sleep latency (number of minutes it takes to fall asleep), more daytime sleepiness, will sleep about 20 min less per day, have less NREM stages 1 and 2 sleep, have more slow-wave sleep, and are more predisposed to REM sleep. Women have at least a 40% increased risk for developing insomnia, are at twice the risk for restless legs syndrome, will have different obstructive sleep apnea symptoms and more partial obstructions during sleep compared to men. They are also less likely to use antidepressants but will metabolize zolpidem 50% slower than men.

Working women and the menopause.

Women are living longer, working more and retiring later. About 45% of the over 50-year-old workforce in virtually all forms of employment are women, all of whom will experience the menopause and its symptoms, which in some women will be mild to moderate, whilst in others they may be severe and debilitating. About half of these women will find it somewhat, or fairly difficult, to cope with their work, about half will not be affected and only about 5% will be severely compromised. Poor concentration, tiredness, poor memory, depression, feeling low, lowered confidence, sleepiness and particularly hot flushes are all cited as contributing factors. As with any longstanding health-related condition, the need for support and understanding from line management is crucial and can make a major difference to how a woman will deal with the adverse impact the menopausal symptoms may have on her productivity, her job satisfaction and her efficiency. A number of plausible strategies have been proposed that can be realistically implemented in the workplace and which could certainly make a significant difference. Careful thought, planning, consideration and effort may be required but, if instituted, they will, in the final analysis, benefit both employer and employee.

Estrogen therapy in gynecological cancer survivors.

Treatment of gynecological cancer has significant impact on a woman's quality of life because it commonly includes removal of the uterus and ovaries, both being the core of a woman's femininity, whilst irradiation and chemotherapy, be they as primary therapy or when indicated as postoperative adjuvant therapy, will lead to ablation of ovarian function if the ovaries had not been removed. This will lead to an acute onset of menopausal symptoms, which may be more debilitating than those occurring as a result of natural aging, and of which hot flushes, night sweats, insomnia, mood swings, vaginal dryness, decreased libido, malaise and a general feeling of apathy are the most common. About 25% of gynecological cancers will occur in pre- and perimenopausal women, a large percentage of whom will become menopausal as a result of their treatment. There are also the gynecological cancer survivors who are not rendered menopausal as a result of the treatment strategy but who will become menopausal because of natural aging. Concern among the medical attendants of these women is whether use of estrogen therapy or estrogen and progestogens for their menopausal symptoms will reactivate tumor deposits and therefore increase the rate of recurrence and, as a result, decrease overall survival among these women. Yet the data that are available do not support this concern. There are eight retrospective studies and only one randomized study that have analyzed outcome in endometrial cancer survivors who used hormone therapy after their surgery, whilst, among ovarian cancer survivors, there are four retrospective studies and one randomized study. The studies do suffer from small numbers and, although the studies pertaining to endometrial cancer analyze mostly women with early-stage disease, a number of the studies in both the endometrial and ovarian cancer survivors do have a sizeable follow-up. These studies seem to support that estrogen therapy after the treatment for gynecological cancer does not impact negatively on outcome in endometrial and ovarian cancer survivors and that estrogen therapy can be considered as a plausible therapeutic option in survivors who are debilitated by their menopausal symptoms. It is prudent not to offer estrogen therapy to survivors of endometrial stromal sarcoma and women with granulosa cell tumors of the ovaries. Vulval, vaginal and cervical cancers are not considered hormone-dependent and therefore estrogen therapy can be given.

Sleep and sleep disorders in menopausal women.

Sleep disorders in the menopause are common. Although these disorders may be due to the menopause itself and/or the associated vasomotor symptoms, the etiology is multifactorial and includes a number of other associated conditions. They may simply arise as part of the aging process and not be specifically related to the decrease in estrogen levels or, alternatively, because of breathing or limb movement syndromes, depression, anxiety, co-morbid medical diseases, medication, pain and/or psychosocial factors. The most commonly encountered sleep disorders in menopausal women include insomnia, nocturnal breathing disturbances and the associated sleep disorders that accompany the restless leg syndrome, periodic leg movement syndrome, depression and anxiety. This review article addresses sleep and the sleep disorders associated with menopause and briefly the role that hormone therapy may play in alleviating these disorders.

Screening for ovarian cancer.

Ovarian cancer is the leading cause of death from gynecologic cancer. Despite aggressive cytoreductive surgery and platinum-based chemotherapy, the 5-year survival for patients with clinically advanced ovarian cancer is only 15 to 20 percent, although the cure rate for stage I disease is usually greater than 90 percent. These statistics provide the primary rationale for ovarian cancer screening. This overview of the current literature serves to show that mass screening for ovarian cancer is far from being established and fraught with management and procedural dilemmas. The reasonable assumption being that there is little evidence to support widespread screening of large populations of women who do not have familial or genetic risk factors for ovarian cancer.

Screening for cervical cancer.

It is well accepted that conscientious and widespread use of cervical cytology will significantly decrease the incidence and mortality rates of cervical cancer. The Papanicolaou smear for cervical cytology fulfills all the criteria for an ideal screening test. Not only is it cost effective, acceptable to most patients, and adaptable to widespread screening, it is sensitive enough to detect preinvasive disease resulting in decreased morbidity and mortality. Nevertheless, in developing countries cervical cancer still occurs at epidemic proportions, where an estimated 460,000 new cases per annum will be diagnosed, a significant proportion of which will be in advanced stages. First world notions pertaining to screening have proved unrealistic for the developing health care system of third world nations. This article provides an overview of screening for cervical cancer and considers cytological smearing, cervicography and direct visualization of the cervix, be it without or with the application of 4 percent acetic acid.

Management of snake and spider bite in pregnancy.

The fact that venomous snakebites during pregnancy result in a high fetal wastage and that both venomous snake and spider bites may cause maternal mortality, makes this an important, albeit uncommonly encountered, entity in obstetrics. Perhaps the most difficult aspect of dealing with this clinical situation is that care must be rendered simultaneously to two patients with a complex interrelationship. The object is to optimize maternal care and increase the chances of successful pregnancy. Adherence to the tenet that what is best for the mother is best for the fetus will probably produce the most satisfactory outcome.

46,XY pure gonadal dysgenesis (Swyer-James syndrome)--Y or Y not?: a review.

The designation "pure gonadal dysgenesis" is applied to a particular variety of defective organo-genesis, in which phenotypically female patients with a 46,XY karyotype have complete lack of functioning gonadal tissue. The latter are represented anatomically by the presence of bilateral, elongated, nonfunctioning, rudimentary "streak" gonads composed of fibrous tissue, although normal female internal genitalia are present. The purpose of this review is to present the existing literature accumulated from 1955 to 1992 pertaining to 46,XY pure gonadal dysgenesis (Swyer-James syndrome), add the findings of a personally observed patient, and highlight the complexities in attempting to determine the etiology of this rare condition.

Estrogen replacement therapy in breast cancer survivors.

OBJECTIVE: To determine whether estrogen replacement therapy (ERT) adversely affected outcome of breast cancer survivors. METHOD: A prospective descriptive study of all breast cancer survivors who requested ERT because of intractable menopausal symptoms. All patients presented voluntarily as gynecological outpatients and were all given oral continuous opposed ERT: 20 premarin and medroxyprogesterone and four tibolone. RESULTS: Twenty-four patients who had previously been treated for breast cancer 8-91 months prior to their initiating ERT have been observed for 24-44 months. There were 15 patients with stage 1, eight with stage 2 and one with stage 4 breast cancer. The mean age of the patients at commencement of ERT was 48 years (range 42-61). Two patients had a biopsy of a suspicious breast nodule: both of which were benign. There have not been any recurrences to date. CONCLUSION: Breast cancer survivors did not have their outcome adversely affected by ERT during an observation period of 24-44 months.

Maternal mortality in a tertiary center after introduction of free antenatal care.

OBJECTIVE: Determination of maternal mortality rate (MMR) and the main causes of maternal death after the implementation of free antenatal care in a tertiary center in South Africa. METHODS: Retrospective case study on maternal deaths from 1 January 1993 to 31 July 1997. RESULTS: The maternal mortality rate was 128/100000 births. Hypertension disorders (18%), hemorrhage (18%) and sepsis (13%) were the most important causes of death; 44% of all deaths were considered preventable. CONCLUSIONS: The high percentage (44%) of preventable deaths is a cause of concern and is the result of increased workload, decreased staff numbers and late referrals with low socio-economic class of the patient. The discrepancy in the mortality rate between patients booked at the tertiary institution (29.8/100000) and patients booked elsewhere (304.7/100000) or not booked at all (348.5/100000) indicates the need for improving antenatal care in the periphery.

Management of diabetic pregnant patients in a tertiary center in the developing world.

OBJECTIVES: To audit our insulin regimen in our antenatal diabetics. METHODS: 170 pregnant diabetic patients were retrospectively analyzed. RESULTS: The perinatal mortality rate was 37/1000, vs. a perinatal mortality rate of 30/1000 in our setting. Cesarean section rate was 49%. Strict blood-glucose control reduced the incidence of macrosomia and polyhydramnios. Routine amniocentesis for fetal-lung maturity was not practiced. CONCLUSION: Satisfactory results in pregnant diabetic patients are achievable with an established insulin regimen in a developing country.