Genitourinary syndrome of menopause in five Asian countries: results from the Pan-Asian REVIVE survey.

OBJECTIVES: The Pan-Asian REVIVE survey aimed to examine women's experiences with genitourinary syndrome of menopause (GSM) and their interactions with health-care professionals (HCPs). METHODS: Self-completed surveys were administered face-to-face to 5992 women (aged 45-75 years) in Indonesia, Malaysia, Singapore, Taiwan, and Thailand. RESULTS: Of 638 postmenopausal women with GSM symptoms, only 35% were aware of the GSM condition, most of whom first heard of GSM through their physician (32%). The most common symptoms were vaginal dryness (57%) and irritation (43%). GSM had the greatest impact on sexual enjoyment (65%) and intimacy (61%). Only 25% had discussed their GSM symptoms with a HCP, and such discussions were mostly patient-initiated (64%) rather than HCP-initiated (24%). Only 21% had been clinically diagnosed with GSM and only 24% had ever used treatment for their symptoms. Three-quarters of those who had used treatment for GSM had discussed their symptoms with a HCP compared to only 9% of those who were treatment-naïve. CONCLUSION: GSM is underdiagnosed and undertreated in Asia. As discussion of GSM with HCPs appears to be a factor influencing women's awareness and treatment status, a more active role by HCPs to facilitate early discussions on GSM and its treatment options is needed.

One-year follow-up of single-visit approach to cervical cancer prevention based on visual inspection with acetic acid wash and immediate cryotherapy in rural Thailand.

The aim is to evaluate 1) the visibility of cervical squamocolumnar junction (SCJ) after cryotherapy treatment and 2) to evaluate the effectiveness of cryotherapy treatment originally performed as part of a safety, acceptability, and feasibility (SAFE) demonstration project evaluating the SAFE of visual inspection with acetic acid (VIA) followed by immediate offer of cryotherapy among those who were tested positive and eligible for treatment. A total of 704 women presented at 1-year follow-up exam during which VIA was performed again by nurses. Six hundred and forty eight (92.0%) women received colposcopy and any kind of biopsy, if indicated, by trained physician colposcopists at a referral hospital. At 1 year, VIA nurses assessed 42 of 648 referred women (6.5%) as abnormal (test positive or suspected cancer). The SCJ was visible to the colposcopists in 91.7% (594/648) of the women. Among 42 women assessed as abnormal by the nurses, colposcopic findings were abnormal in 83.3% (35/42), with one low-grade squamous intraepithelial lesion, two high-grade squamous intraepithelial lesion (HSIL), and one adenocarcinoma confirmed later by biopsy. Among 606 VIA negative women, colposcopy was abnormal in only 23.4% (142/606), with two cases of HSIL confirmed later. Given that the SCJ was visible in the vast majority of women (91.7%) after cryotherapy, VIA could be used to provide follow-up for women previously treated. The disease negative rate after cryotherapy (no human papillomavirus infection, no cervical intraepithelial neoplasia, and no cancer) at 1 year after treatment was 85.5% (554/648).

Differential prevalence of quality-of-life categories (domains) in Asian women and changes after therapy with three doses of conjugated estrogens/medroxyprogesterone acetate: the Pan-Asia Menopause (PAM) study.

OBJECTIVES: To assess the prevalence of four categories (domains) of menopausal symptoms as markers for quality of life in nine ethnic groups of Asian women. To evaluate changes in quality of life (MENQOL scores) in Asian women following hormone therapy. METHODS: A prospective, randomized, double-blind, multinational clinical trial in 1028 healthy postmenopausal women of nine ethnic groups from 11 Asian countries/regions. Following 2 weeks of baseline observation, the women received one of three conjugated estrogens (CE)/medroxyprogesterone acetate (MPA) doses (in mg) daily for 24 weeks: 0.625/2.5, 0.45/1.5, or 0.3/1.5. At baseline and at the end of weeks 4, 12 and 24 following the start of therapy, the study participants were asked to record, on a menopause-specific quality of life (MENQOL) questionnaire, 29 menopausal symptoms, as experienced during the preceding month. The symptoms were categorized into four domains: vasomotor, psychosocial, physical and sexual. RESULTS: The baseline (pretreatment) symptom scores in each of the four domains varied substantially among the different ethnic groups, ranging from 2.21 to 5.71 in the vasomotor, 2.37-5.96 in the psychosocial, 2.66-5.39 in the physical, and 2.11-6.55 in the sexual domain. Overall, Vietnamese and Pakistani women had the highest baseline scores, i.e. were most afflicted by each set of symptoms in a given domain, and Indonesian, Malay, Taiwanese and Thai women were least afflicted. In the overall population, intervention resulted in statistically significant decreases in the scores of all four domains within 4 weeks of intervention. The beneficial effects were similar in the three dose groups. CONCLUSIONS: The prevalence of four domains of menopausal symptoms, representative of quality of life as recorded on a MENQOL questionnaire, varies considerably among ethnic groups of Asian women. The MENQOL scores in the overall population were significantly lowered in the course of the study, indicating an improvement in quality of life. In the absence of a placebo group, the relative contribution of hormones and placebo in our intervention is unknown.

Guidelines for hormone replacement therapy of Asian women during the menopausal transition and thereafter.

These Guidelines summarize the position of an Expert Panel on Menopause in Asian Women regarding the use of hormone replacement therapy (HRT) during the menopausal transition and thereafter. They are intended to aid gynecologists, family physicians and other health-care professionals in providing optimal care to menopausal Asian women who desire HRT.

Diagnostic hysteroscopy at King Chulalongkorn Memorial Hospital: 7 years experience.

We reported our experience and results of diagnostic hysteroscopy performed on 294 patients between June 1994 and May 2000 at the Gynecologic Endoscopy Unit, King Chulalongkorn Memorial Hospital. Diagnostic hysteroscopy was performed successfully in 286 patients (97.3%), allowing thorough inspection of the uterine cavity. Cervical dilatation was required in 146 patients (49.6%). The most common indication was endometrial polyps (34.4%) followed by infertility (19.4%) and abnormal uterine bleeding (14.9%), respectively. Each of the hysteroscopic findings accounted for 103 patients (35%) in endometrial polyps and normal endometrium. The procedure failed in 8 patients (2.71%) due to uterine perforation. In conclusion, diagnostic hysteroscopy should be considered as a safe, effective and successful investigation procedure for suspected intrauterine pathology.

Pipelle versus fractional curettage for the endometrial sampling in postmenopausal women.

The experimental and cross over design study was performed to compare the pain, ability to sample the endometrial issue, and pathological results from pipelle and fractional curettage in post menopausal patients. Thirty naturally menopausal patients who visited King Chulalongkorn Memorial Hospital with abnormal bleeding per vagina from June 1 to December 31, 1997, were enrolled in the study. In group A,endometrial tissue sampling was first conducted by Pipelle and followed by fractional curettage. In group B, the fractional curettage was performed before Pipelle. The results showed that the pain derived by the visual analogue scale of Pipelle and fractional curettage were 3.34 +/- 1.44 (mean +/- SD) and 6.58 +/- 1.75 respectively (p<0.01). The sensitivity and specificity of Pipelle in endometrial tissue samplings compared with fractional curettage were 87.5 and 100 per cent, respectively. One from 3 cases of adeneocarcinoma of the endometrium could not be detected by Pipelle. In conclusion, Pipelle significantly produced less pain than fractional curettage. Even though Pipelle is a simple and easy method for endometrium sampling, the use of Pipelle to replace fractional curettage in the management of postmenopausal bleeding should be done with caution. False negative could occur in the focal disease of malignancy of the endometrium.

Accuracy of hysteroscopic diagnosis of endometrial polyps.

OBJECTIVE: To evaluate the diagnostic accuracy of endometrial polyps by hysteroscopy. MATERIAL AND METHOD: One hundred and sixty five women undergoing diagnostic hysteroscopy between January 1996 and December 1998 at the Gynecologic Endoscopy Unit, King Chulalongkorn Memorial Hospital were recruited in this study. The hysteroscopic diagnosis was compared with the histopathology by endometrial curettages performed after hysteroscopy. RESULTS: Endometrial polyps were diagnosed by hysteroscopy in 54 patients (32.73%). When compared to tissue pathology, we found an accuracy of 81.21 per cent, sensitivity of 92.59 per cent, specificity of 78.98 per cent, positive predictive value of 46.29 per cent, negative predictive value of 98.19 per cent, false positive of 17.57 per cent and false negative of 1.21 per cent. CONCLUSION: For endometrial polyps, diagnostic hysteroscopy yields a high accuracy but low positive predictive value. Therefore, endometrial biopsy is necessary to confirm diagnosis of endometrial polyps by hysteroscopy.

The metabolic and bone density effects of continuous combined 17-beta estradiol and noresthisterone acetate treatments in Thai postmenopausal women: a double-blind placebo-controlled trial.

OBJECTIVE: To compare the changes of lipid parameters, liver function tests, fasting plasma glucose and bone density in Thai postmenopausal women who received this combined hormonal treatment and placebo. STUDY DESIGN: Double-blinded, randomized controlled trial study. MATERIAL AND METHOD: Sixty postmenopausal women attending the menopause clinic at Chulalongkorn Hospital from July, 1996 to December, 1996, were enrolled in the study. The patients were randomized to receive the placebo or drug (17 beta-estradiol 2 mg and norethisterone acetate 1 mg) continuously. Patient characteristics, physical examination, liver function tests, fasting plasma glucose, lipid parameters (fasting total cholesterol, low density lipoprotein cholesterol (LDL), high density lipoprotein (HDL) and triglyceride level) and bone densitometry were performed before beginning the study. The lipid parameters were repeated at 3, 6 and 12 months. Fasting plasma glucose, liver function tests and bone densitometry were repeated at 12 months. RESULTS: In the drug group, there were significant changes in the cholesterol at 3, 6 and 12 months when compared to the baseline. There were significant differences at 3, 6 and 12 months when compared between groups. The HDL values were not significantly different within groups. The LDL values at 3, 6, 12 months were significantly lower than the baseline in the drug group when compared within groups and at 6, 12 months in the placebo group. The triglyceride values were not significantly different between groups and within groups. There was no significant change between groups and within groups of fasting plasma glucose, total bilirubin, direct bilirubin, AST, ALT, albumin and globulin. The alkaline phosphatase values were significantly decreased at 12 months in the drug group. The bone density of total BMD and T-score at the spine of the drug group increased significantly at 12 months. The per cent change per year was +5.1. In contrast, the values in the placebo group decreased significantly, the per cent change per year was -0.9. The same pattern was also found in the bone density of the total hip. But when focused to the femoral neck, we found no significant change in both groups. CONCLUSION: This continuous combined treatment resulted in beneficial changes of bone density and lipid profiles. The therapy prevented bone loss and the changes in serum lipoprotein were concordant with a lipid profile associated with a decreased risk of coronary heart disease in Thai postmenopausal women.

Prevalence of osteopenia and osteoporosis in Thai women.

OBJECTIVE: To determine the age-specific and age-adjusted prevalence of osteopenia and osteoporosis in pre- and postmenopausal Thai women. METHODS: This was a descriptive study of 1,935 Thai women ranging in age from 40 to 80 years, with randomly selected strata using multistage sampling and stratifying from six representative provinces of the country. After recruiting, all the women were interviewed by a well-trained interviewer using structured questionnaires. Bone mineral density (BMD) of lumbar spine 1-4 and nondominant hip was measured by a dual energy photon absorptiometer. The investigators were trained and standardized; inter- and intraobserver variations were measured periodically. Every BMD outcome was re-examined by the specialist. Age-specific prevalence of osteoporosis and osteopenia were determined using both Thai and Western standard BMD values. Age-adjusted prevalence of osteopenia and osteoporosis was calculated using the age-adjusted direct method. RESULTS: Using the Thai BMD reference, the age-specific prevalence of osteoporosis among Thai women rose progressively with increasing age to more than 50% after the age of 70. The age-adjusted prevalence of osteoporosis also rose progressively. It was 19.8%, 13.6%, and 10% for lumbar spine, femoral neck, and intertrochanteric. The age-adjusted prevalence of osteoporosis indicates the overall magnitude of that condition in the population or country. In our study, using a Western BMD reference resulted in a misleadingly high prevalence of osteoporosis in the population of Asian countries. CONCLUSION: It is important to calculate the age-adjusted prevalence of osteopenia and osteoporosis to address the overall magnitude of the problem in Thai women. This will allow us to predict the socioeconomic impact of preventable chronic conditions such as osteoporosis. The results obtained from this study are important data for public health policy: maximizing bone mass throughout life as well as detection of important risk factors is essential.

An effect of hormone replacement therapy on skin thickness in early postmenopausal women.

BACKGROUND: It is well known that dermal thickness, the major component of skin thickness, will decrease progressively after menopause. Bone and dermis share a similar organic constituent (collagen type I). The effect of hormone replacement therapy on bone has been established, whereas, its effects on skin are less well-described. This study was performed to determine the effect of combined estrogen-progestin replacement therapy in a sequential regimen on skin thickness in women during the early postmenopausal period. METHOD: One hundred early postmenopausal women who met the eligibility criteria and had already signed a consent form were non-randomly allocated in two groups. Group A; sixty women who received cyclic hormone replacement therapy in each 28-day cycle for 6 cycles. Group B; forty women who received 1,000 mg of calcium carbonate daily. Skin thickness was measured by ultrasonography before and after treatment and the Student's t-test was used to compare the results. RESULTS: A statistically significant increase in skin thickness over baseline was noted after combined estrogen-progestin replacement therapy had been administered for 24 weeks compared to the control and baseline groups. The skin thickness was also significantly decreased after calcium had been administered for 24 weeks when compared to baseline. CONCLUSION: Skin thickness was increased in early postmenopausal women subjected to hormone replacement therapy with an alternating dose of estrogen and progestin.

Bone mineral density of lumbar spine and proximal femur in normal Thai women.

OBJECTIVE: To find the reference data for age-specific normal bone mineral density in a Thai female population. STUDY DESIGN: Cross-sectional, Descriptive study. MATERIAL AND METHOD: 1773 Thai women aged between 11-80 years were recruited, using multistage cluster sampling and stratifying from six represented provinces in the country, each strata was randomly selected. After recruiting, the women were interviewed by well-trained personnel using structured questionnaires. Bone mineral density of the lumbar spine 1-4 and nondominant hip were measured by Dual Energy Photon Absorptiometer. The scientists, X-rays technician were trained and standardized inter and intra observers variation. Quality control of examination was measured periodically. Every BMD outcome was re-examined by a specialist. RESULTS: The peak bone mineral density of both spines and hips was between the age of 30 to 34 years old. Mean Value for spine and femoral neck was 0.957 and 0.814 g/cm2 respectively. The BMD of spine and hip was significantly decreased after the age of 35 and the loss was accelerated at age 50. Osteoporosis for spine and femoral neck is considered when BMD are below 0.682 and 0.569 g/cm2 respectively. CONCLUSION: The results are important data for public health policy, by maximizing bone mass during skeletal growth before menopause and minimizing bone loss throughout life as well as for detection of important risk factors.

Uterine blood flow response to hormonal replacement therapy in asymptomatic postmenopausal women: a transvaginal Doppler study.

To evaluate the effect of continuous hormonal replacement therapy (HRT) on Doppler parameters of uterine blood flow in asymptomatic postmenopausal women. Thirty-eight asymptomatic postmenopausal women were recruited into the study from the outpatient menopause clinic, Department of Obstetrics and Gynaecology, Faculty of Medicine, Chulalongkorn University. The study population was divided into 20 cases without any HRT (group 1) and 18 cases using continuous conjugated equine estrogen 0.625 mg/day combined with medroxyprogesterone acetate 2.5 mg/day (group 2). The duration of HRT was 21.3 +/- 9.5 (13-56) months. A transvaginal colour flow imaging system (ALOKA SSD-2000 MultiView, Tokyo, Japan) was used to assess uterine blood flow. Quantitative data from areas of colour were evaluated by pulsed Doppler spectrum analysis. Resistance indices (RI) were measured as indicators of uterine perfusion. Both groups were statistically similar with respect to age, parity, age at menopause, height and weight. The endometrial thickness in group 1 and 2 were 3.8 +/- 0.8 and 4.1 +/- 0.6 millimetres, respectively. The left uterine artery RIs of group 1 and 2 were 0.86 +/- 0.08 and 0.84 +/- 0.07, respectively (p = 0.33). The right uterine artery RIs of group 1 and 2 were 0.87 +/- 0.07 and 0.83 +/- 0.06, respectively (p = 0.06). In conclusion, continuous HRT had a non-significant influence on uterine blood flow in the postmenopausal women.

Clinical effects of 17 beta-estradiol and norethisterone acetate in postmenopausal Thai women.

OBJECTIVE: To compare the climacteric symptoms, the bleeding patterns, side effects, endometrial thickness, serum follicular stimulating hormone (FSH) and estradiol level in postmenopause Thai women who received this drug and placebo. STUDY DESIGN: Double blind, randomized placebo controlled trial. MATERIAL AND METHOD: Sixty postmenopausal women attending the menopause clinic at Chulalongkorn Hospital from July, 1996 to December, 1996, were enrolled in the study. The patients were randomized to receive the placebo or drug (17 beta-estradiol 2 mg and norethisterone acetate 1 mg) continuously. After 12 months, 13 patients in the drug group were switched to have placebo and 13 patients in the placebo were switched to the drug group. Recording of patient characteristics, physical and gynecologic examination, pap smear, breast examination and mammogram, climacteric symptom scores, transvaginal ultrasonography, serum FSH and Estradiol level were performed prior to the study. Physical examinations, breast palpitations, measurement of body weight and blood pressure, climacteric symptom scores and side effects were repeated at 3, 6, 12, 18 months. Gynecologic examination, pap smear, serum FSH and estradiol, transvaginal ultrasonography, were repeated at 12 months. RESULTS: The women in the drug group had fewer climacteric symptoms than baseline after 6 months. The incidence of amenorrhea was 74.0 per cent at 12 months. The incidence of abnormal uterine bleeding (spotting and breakthrough bleeding) was 37.0 per cent at 3 months, 29.6 per cent at 6 months, 25.9 per cent at 12 months and 7.1 per cent at 18 months. The women in the drug group had fewer climacteric symptoms than baseline after 6 months. Breast tenderness was the most common side effect. The endometrial thickness decreased significantly in the drug group. Serum FSH decreased and serum estradiol increased significantly in the drug group. CONCLUSION: This combined regimen was more effective in relieving the climacteric symptoms in women who used the drug than those who used the placebo. There was a high incidence of amennorhoea after 12 months. But there was also a high frequency of abnormal bleeding in the first 3 months of treatment. Counseling on the bleeding pattern and common side effects should be conducted before starting the treatment to increase the compliance. This combined regimen proved to be a useful alternative for postmenopausal Thai women who prefer to avoid cyclic bleeding from sequential therapy.