Number of vaginal lactobacilli in postmenopausal women with vaginal atrophy before and after treatment with erbium-YAG laser: a randomized sham-controlled trial.

PRIMARY OBJECTIVE: To evaluate the effect of erbium-YAG laser on the number of vaginal lactobacilli in postmenopausal women. SECONDARY OBJECTIVES: To evaluate the effect of erbium-YAG laser on vaginal atrophy symptoms and vaginal pH in postmenopausal women. MATERIALS AND METHODS: A total of 44 postmenopausal women who met the inclusion criteria were randomized in the laser group (n = 22) and sham group (n = 22). Vaginal lactobacilli grading, vaginal pH, vaginal atrophy score, and vaginal atrophy symptoms were assessed before and after treatment with erbium-YAG laser for two consecutive times, with a four-week interval; the results were compared with the effects of the sham procedure. Any adverse events after the treatment were recorded. RESULTS: A total of 44 women were included, and five were lost to follow-up. Compared with sham procedure, vaginal lactobacilli grading improved in the laser group (5/20 in the laser group and 1/19 in the sham group). However, the improvement did not reach statistical significance (adjusted odds ratio = 5.32, 95% CI = 0.5-56.21). Vaginal atrophy symptoms measured by the visual analog scale (VAS) and vaginal pH were improved in both groups without a statistically significant difference between the two groups. Vaginal "dryness" VAS and vaginal atrophy score after treatment were significantly lowered in the laser group compared with the sham group. CONCLUSIONS: This study showed an improvement in vaginal lactobacilli grading after vaginal laser treatment. However, the difference in vaginal lactobacilli grading after treatment in both groups was not statistically significant.

Mental Health of Transmasculine Adults Receiving Gender-Affirming Hormone Therapy in Thailand.

Purpose: Many studies have shown conflicting results regarding mental health among transmasculine adults or transgender men (TM). This study aimed to identify the prevalence of depression among Thai TM receiving gender-affirming hormone therapy (GAHT). Methods: All TM, over 18 years of age, who received GAHT for at least three consecutive months were invited to complete a self-report questionnaire that covered participants' demographic and clinical data. Mental health, including depression, anxiety, and quality of life (QoL), was assessed. We reported the prevalence of mental illnesses and examined the correlations between mental health scores and other associated data. Results: A total of 84 TM were included in the analysis. Major depression and generalized anxiety disorder were detected in 14.3% and 3.6%, respectively. Depression severity was negatively associated with age and QoL. Depression and anxiety severity were found to be positively associated. Conclusions: Compared with the general Thai population, the prevalence of mental health problems among Thai TM receiving GAHT was higher. Age of maturity may be a potential mental health protective factor, and assessment in younger individuals may benefit mental health.

Thai Interest Group for Endometriosis (TIGE) consensus statement on endometriosis-associated pain.

This consensus statement has been developed by the Thai Interest Group for Endometriosis (TIGE) for use by Thai clinicians in the diagnosis and management of endometriosis. TIGE is a group of clinical and academic gynaecologists with a particular interest in endometriosis. Endometriosis is an oestrogen-dependent inflammatory disease which causes chronic symptoms such as dysmenorrhoea, chronic pelvic pain, dyspareunia and subfertility, and it is common in reproductive-age women. There is limited overall data on its prevalence in different clinical settings in Thailand, but it is clear that the disease causes significant problems for patients in terms of their working lives, fertility, and quality of life, as well as placing a great burden on national healthcare resources. Decisions about selecting the appropriate treatment for women with endometriosis depend on many factors including the age of the patient, the extent and severity of disease, concomitant conditions, economic status, patient preference, access to medication, and fertility need. Several hormonal treatments are available but no consensus has been reached about the best option for long-term prevention of recurrence. Bearing in mind differences in environment, genetics, and access to the healthcare system, this treatment guideline has been tailored to the particular circumstances of Thai women.

Evaluation of Mental Health and Satisfaction Following Transfeminine Gender-Affirming Surgery in Thailand.

Purpose: Although many studies have shown that transgender women (TW) tend to have more depressive symptoms compared with the general population, the exact prevalence of major depressive disorder and contributing risk factors have not yet been studied, especially in those who have undergone gender-affirming genital surgery (GAS). Methods: Every TW aged 20-60 years attending transgender clinics in the Thai Red Cross Society for postoperative checkup were invited to complete a self-report questionnaire, including (1) demographic data, (2) the Thai Patient Health Questionnaire 9 (PHQ-9), (3) satisfaction with psychosocial factors (relationship in family, friends, and society), sexual experiences and outcomes of gender-affirming treatments before and after GAS, and (4) contributing factors to depressive symptoms. Correlations between demographic data and depressive scores were tested. Paired t-test was used to compare pre- and post-GAS data. Results: A total of 97 TW were analyzed, with 22.7% considered to have "major depression" (PHQ-9≥9) after GAS. Postoperative improvement in satisfaction with psychosocial factors and gender-affirming treatment outcomes were observed, especially in sexual experience. Depression severity was found to be negatively correlated with age and sexual satisfaction. Notably, presence of male characteristics before surgery, poor social support and understanding, and postoperative surgical complications were greatly considered as factors contributing to depressive symptoms. Conclusion: Compared with non-GAS TW, depression among those who underwent GAS in Thailand was lower but still significant and was linked to younger age and poor postoperative sexual experiences. These findings were supported by the number of qualitative assessments in the psychosexual domain and postoperative treatment outcomes. Clinical Trial Registration Number - TCTR20190904003.

Effects of early estradiol valerate administration on bone turnover markers in surgically induced menopausal women.

BACKGROUND: Compared with a natural process, surgically induced menopausal women have a higher bone loss rate. This study aims to evaluate early treatment with estradiol valerate on bone turnover markers after surgically induced menopause. METHODS: This prospective study included 41 pre and perimenopausal women who underwent hysterectomy with oophorectomy for benign gynecologic conditions. Two weeks after the operation, all participants were assessed for menopausal hormone therapy (MHT) indications. Estrogen therapy was prescribed for those who had indications and accepted treatment (hormone treatment group). The others who had no MHT indication were allocated to the no-treatment group. Serum CTX and P1NP levels at preoperative and 12 weeks postoperative were measured and set as the primary outcome. Within the same group, serum CTX and P1NP before and after surgical menopause were analyzed using Wilcoxon signed-rank test. ANCOVA was used to compare serum CTX and P1NP at 12 weeks after surgical menopause between the two groups. Spearman's rank correlation coefficient analysis analyzed the correlation between age and baseline bone turnover markers. A p-value of < 0.05 was considered statistically significant. RESULTS: At 12 weeks after surgery, there were no significant differences in serum CTX and P1NP levels in the hormone treatment group compared to baseline. In contrast, serum CTX and P1NP levels were significantly elevated among women who did not receive hormone treatment (p-value < 0.001 and 0.002, respectively). Serum CTX and P1NP at 12 weeks were significantly different between the two groups (p-value < 0.001 and 0.004, respectively). CONCLUSION: Early estrogen administration with oral estradiol valerate could significantly suppress the high bone remodeling in surgically induced menopausal women. Trial registration Thai Clinical Trial Registry identification number TCTR20190808004, retrospective registered since 2019-08-08. http://www.thaiclinicaltrials.org/show/TCTR20190808004 .

Anti-Androgenic Effects Comparison Between Cyproterone Acetate and Spironolactone in Transgender Women: A Randomized Controlled Trial.

BACKGROUND: Spironolactone and cyproterone acetate are commonly used in feminizing hormone therapy to achieve the goal of female range testosterone level; however, the data on the efficacy comparing between these two anti-androgens are scarce. AIM: To compare the anti-androgenic effects between spironolactone and cyproterone acetate as the component of feminizing hormone therapy among transgender women population. METHODS: The study was single-blinded randomized controlled trial involved 52 transgender women from two transgender health clinics. Each participant received oral estradiol valerate 4 mg/day combined with anti-androgen, spironolactone 100 mg/day or cyproterone acetate 25 mg/day, depending on which group they were randomized to. Clinical and biochemical variables were obtained at baseline and at 12 weeks of feminizing hormone therapy. MAIN OUTCOME MEASURES: The change of testosterone level from baseline. Other changes including free testosterone, estradiol, prolactin and lipid profile after the therapy. RESULTS: After a 12 weeks of feminizing hormone therapy, the change of testosterone level in the cyproterone acetate group [558.0 ng/dL (IQR 352.0 to 783.3)] was significantly higher than the spironolactone group [226.2 ng/dL (IQR,-4.3 to 480.1)](p value <0.001). Testosterone and calculated free testosterone in the cyproterone acetate group were significantly lower than the spironolactone group. Consequently, a proportion of the participants who achieved the female range testosterone (<50 ng/dL) was significantly higher in cyproterone acetate group (90%) compared to the spironolactone group (19%). Serious adverse effects observed in cyproterone acetate users were drug-induced liver injury and asymptomatic hyperprolactinemia. CLINICAL IMPLICATIONS: The data on the differences between the two anti-androgen could be benefit for the transgender health-care providers in medication selection and adverse-effects counseling. STRENGTHS & LIMITATIONS: The study design was randomized controlled trial and controlled the estrogen component by prescribed the same type and dose for each participant. However, the study was suffered from the confound feminizing effects from previous hormone therapy and the high drop-out rate. CONCLUSION: For feminizing hormone therapy, cyproterone acetate had a higher testosterone suppression efficacy than spironolactone. Burinkul S, Panyakhamlerd K, Suwan A, et al. Anti-Andorgenic Effects Comparison Between Cyproterone Acetate and Spironolactone in Transgender Women: A Randomized Controlled Trial. J Sex Med 2021;18:1299-1307.

Neovaginal and Anal High-Risk Human Papillomavirus DNA Among Thai Transgender Women in Gender Health Clinics.

BACKGROUND: Although human papillomavirus (HPV)-related lesions in the neovagina of transgender women have been well documented, information on high-risk HPV (hrHPV) in the neovagina has been very limited. The objective of this study was to determine hrHPV DNA detection rate in the neovagina of transgender women. METHODS: Neovaginal and anal swab were collected in liquid-based cytology fluid from transgender women visiting Gender Health Clinic and Tangerine Community Health Clinic in Bangkok, Thailand. Samples were processed for hrHPV DNA (reported as subtypes 16 and 18 or the pooled result of subtypes 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 66) by automated real-time polymerase chain reaction and for neovaginal cytology according to the Bethesda system. Demographic data and sexual history were obtained, and physical examination was conducted. HIV status was obtained from existing medical records. RESULTS: Samples were collected from 57 transgender women (mean age, 30.4 years [interquartile range, 8 years]). From 35 of 57 valid neovaginal samples, 8 (20%) tested positive for hrHPV DNA. From 30 of 57 valid anal samples, 6 (19.4%) tested positive for hrHPV DNA. HIV status was known for 52 transgender women, 1 of which were HIV infected; neovaginal hrHPV was invalid in that patient. CONCLUSIONS: One of 5 transgender women visiting sexual health clinics in Bangkok was found to have hrHPV DNA in neovaginal and anal compartments. Studies are needed to look at incidence and persistence of hrHPV infection to inform anogenital precancerous and cancerous screening programs for transgender women.

Effects of vaginal administration of conjugated estrogens tablet on sexual function in postmenopausal women with sexual dysfunction: a double-blind, randomized, placebo-controlled trial.

BACKGROUND: Female sexual dysfunction (FSD) is prevalent in women with genitourinary syndrome of menopause (GSM). Vaginal estrogen is effective GSM treatment. This study was primarily aimed to evaluate the effects of vaginal administration of conjugated estrogens tablet on postmenopausal FSD using the Female Sexual Function Index (FSFI). Secondary aims were to evaluate vaginal pH, Vaginal Maturation Value (VMV), Normal Flora Index (NFI) and Most Bothersome Symptoms (MBS) changes. METHODS: A double-blind trial was conducted in postmenopausal women with FSD (FSFI ≤26.55). Sixty-seven participants were randomized into two arms; vaginally administered conjugated estrogens tablet (0.625 mg, daily for 3 weeks then twice weekly for 9 weeks, n = 33), or placebo (n = 34). RESULTS: There was no significant improvement of FSFI observed in estrogens arm compared to placebo in each domain and overall index (p = 0.182). The estrogens significantly improved vaginal pH and VMV, toward more acidity (p = < 0.001), higher VMV (p = < 0.001) and more superficial cells (p = < 0.001). We observed no significant difference in NFI and MBS between arms (p = 0.282, 0.182). CONCLUSION: We found no significant changes in FSFI, NFI, and MBS, but significant improvement in vaginal pH and VMV in postmenopausal women with FSD treated with vaginally administered conjugated estrogens tablet. Few side-effects were reported. TRIAL REGISTRATION: Thai Clinical Trial Registry identification number TCTR20180219001 , prospectively registered since 2018-02-19 11:33:21.

Effect of multivitamin on serum 25-hydroxy vitamin D level in postmenopausal women: A randomized, double-blind, placebo-controlled trial.

OBJECTIVES: To determine the effects of multivitamin vitamin D 300 or 600 units on serum 25 hydroxyvitamin D (25(OH)D) level after 4 weeks of supplementation in postmenopausal women with vitamin D insufficiency. STUDY DESIGN: Randomized double-blind, placebo-controlled trial. METHODS: Postmenopausal women who had vitamin D insufficiency were recruited into the study. The participants were randomized to 3 groups of 4-week treatment period with multivitamin (GPO, Governmental Pharmacy Organization) 2 tablets (contained vitamin D2 amount 600 units), multivitamin 1 tablet (contained vitamin D2 amount 300 units) or placebo. At baseline and after 4 weeks of supplementation, serum 25(OH)D were determined with electrochemilumines-cence immunoassay (Cobas, Roche Diagnostics) and level change of 25(OH)D level were compared among the groups. RESULTS: Out of 144 participants, 49.3% had vitamin D deficiency (<20 ng/ml) and 50.7% had vitamin D insufficiency (<30 ng/ml). However, after 4 weeks of the GPO oral multivitamin, serum 25(OH)D levels significantly increased from 19.4 ± 6.3 ng/ml at baseline to 22.2 ± 5.2 ng/ml (p = 0.01) and from 19.5 ± 5.0 ng/ml to 23.3 ± 5.2 ng/ml (p < 0.01) in the groups receiving vitamin D 300 IU and 600 IU/day, respectively. Approximately, 10% of those who took vitamin D had serum 25(OH)D level above the insufficiency level within 4 weeks. There was no significant changes of serum 25(OH)D after 4 weeks in the placebo group. CONCLUSIONS: Daily supplementation of the generic multivitamin containing vitamin D2 300 and 600 IU daily for 4 weeks significantly increased mean serum 25(OH)D from baseline up above the deficiency level.

Effectiveness of a low dose testosterone undecanoate to improve sexual function in postmenopausal women.

BACKGROUND: Adding testosterone to hormonal therapy could improve sexual function and general well-being among women during climacteric. We evaluated the effectiveness of testosterone undecanoate on sexual function in postmenopausal women utilizing the standardized questionnaire FSFI score. METHODS: Postmenopausal women with sexual complaints and Female Sexual Function Index (FSFI) ≤ 26.5 were enrolled in to this randomized, double-blinded, placebo-controlled trial. Participants were randomly assigned to 8-week treatment with either oral testosterone undecanoate 40 mg or placebo twice weekly with daily oral estrogen. The FSFI scores before and after treatment were compared to assess any improvement of sexual function. RESULTS: Seventy women were recruited of which each group had 35 participants. The baseline characteristics and baseline FSFI scores were comparable between both groups. After 8 weeks of treatment, the FSFI scores significantly improved in both groups when compared to the baseline but the FSFI scores from the testosterone group were significantly higher than in the placebo group post-treatment (28.6 ± 3.6, 25.3 ± 6.7, respectively, p = 0.04). There was no difference in adverse effect between the two groups CONCLUSIONS: The twice weekly addition of testosterone undecanoate to daily oral estrogen was associated with a significant improvement in sexual function among postmenopausal women than the use of the estrogen alone. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01724658 (February 17, 2012).

The factors associated with mild cognitive impairment (MCI) in surgical menopause women.

BACKGROUND AND OBJECTIVE: As a sizeable proportion of persons with mild cognitive impairment will progress to frank dementia, early detection is an important strategy to prevent and decelerate the progression of cognitive decline. In Thailand, the prevalence of mild cognitive impairment in surgical menopause women has not been well established. The objectives of the present study were to determine the percentage and factors associated with mild cognitive impairment in women with surgical menopause. MATERIAL AND METHOD: Between October 2013 and July 2014, 200 eligible women at King Chulalongkorn Memorial Hospital were enrolled. The self-reported questionnaires were used to obtain the demographic data and the Thai version of the Montreal Cognitive Assessment (MoCA) was used to detect mild cognitive impairment (MCI). The MCI was diagnosed when the MoCA score was less than 25. The data were statistically analyzed using SPSS version 17 for student t-test, Chi-square test, and multiple regression analysis. RESULTS: The percentage of MCI in the present study was 43.5%. The univariate analysis showed that factors significantly related to MCI were marital status, educational levels, occupation, monthly income, and duration of hormone replacement therapy (HRT). Nevertheless, multiple regression analysis revealed that only older age at enrollment, marital status, low educational level, and low monthly income were significantly related to MCI. CONCLUSION: Almost half of the surgical menopause women in the present study had MCI. Older age at enrollment, marital status, low educational level, and low monthly income were significantly related to MCI. Age at surgical menopause and HRT were not found to be associated with MCI in this study.

Inter-correlation of knowledge, attitude, and osteoporosis preventive behaviors in women around the age of peak bone mass.

BACKGROUND: As silent and preventable in nature, postmenopausal osteoporosis awareness should be raised among young women prior to an irreversible period of declining bone mass. We therefore decided to assess the inter-correlation of knowledge, attitude and osteoporosis preventive behaviors in women around the age of peak bone mass. METHODS: A cross-sectional study was conducted in 430 women aged 20-35 years. The participants' knowledge, attitude and behaviors concerning osteoporosis prevention were assessed along with demographic data using a four-part questionnaire. The items in this questionnaire were established by extensive literature review, including the Guideline for Management of Osteoporosis of the Thai Osteoporosis Foundation (TOPF) 2010. The content was validated by experts in osteoporosis and reliability was obtained with a Cronbach's alpha score of 0.83. RESULTS: The mean age of women in this study was 29.4 ± 4.6 years. Half of the participants (49.5%) had heard about osteoporosis, mostly from television (95.3%, n = 203/213) and the internet (72.8%, n = 155/213). Most women had certain knowledge (85.2%) and positive attitude towards osteoporosis (53.3%). Nevertheless, 80% of the studied population did not have appropriate osteoporosis behaviors. We found significant correlation between the level of attitudes and osteoporosis behaviors (adjusted odd ratio = 3.3 with 95% confidence interval of 1.9-5.7); attitude and educational level (adjusted odd ratio = 2.2 with 95% confidence interval of 1.4-3.4); and attitude and knowledge (adjusted odd ratio = 3.5 with 95% confidence interval of 1.8-6.8). CONCLUSION: Despite having certain knowledge about osteoporosis, the young women did not seem to have appropriate osteoporosis preventive behaviors. Developing a right attitude towards osteoporosis may be a key determinant to improving health practices in order to prevent osteoporosis.

Osteoporosis in different age-groups and various body mass index (BMI) ranges in women undergoing bone mass measurement at King Chulalongkorn Memorial Hospital.

OBJECTIVE: To determine percentage of osteoporosis at femoral neck and lumbar spine (L1-L4) in women with different age group and various BMI ranges. MATERIAL AND METHOD: The present study was conducted in 4528 women of > or =40 years who underwent first BMD measurement at King Chulalongkorn Memorial Hospital between 2000 and 2010. Bone mineral density (BMD) of femoral neck (nondominant side) and lumbar spine (Li-L4) was measure by Dual-energy x-ray Absorptiometer (DXA). The percentage of osteoporosis was determined by WHO cutoff value using Thai nationwide reference database. RESULTS: The percentages of osteoporosis at femoral neck (FN) in age group of 40 to 49, 50 to 59, 60 to 69, and > or =70 years were 6.2%, 7.4%, 24.4%, and 51.8% respectively The corresponding figures for lumbar spine (LS) were 3.4%, 5.6%, 12.7%, and 20.9% respectively. The percentage of osteoporosis seems to increase strikingly after 60 years at both sites. The percentage of osteoporosis at FN in underweight, normal weight, overweight and obesity were 52.1%, 20.3%, 15.7%, and 9.4% respectively. The corresponding figures for LS were 22.8%, 12%, 4.8%, and 5.9% respectively. Over 30% of women of age > or =60 years with BMI of less than 23 kg/m2 had osteoporosis by the studied criteria. CONCLUSION: The percentage of osteoporosis seemed to be increasing with age and declining with BMI. Using the WHO cutoff value and Thai reference database, the percentage of femoral neck osteoporosis appeared to be higher than the lumbar spine. In the present study, the authors found that women of > or =60 years with BMI of less than 23 kg/m2 posed a substantial percentage of osteoporosis.

Clinical responses to the combination of estradiol and drospirenone in symptomatic postmenopausal Thai women.

OBJECTIVES: To investigate the efficacy and tolerability of the oral hormone replacement therapy (HRT) containing 1 mg estradiol (E2) plus 2 mg drospirenone (DRSP) in Thai women with postmenopausal symptoms. MATERIAL AND METHOD: Fifty-five Thai women with postmenopausal symptoms participated in this multicenter, open-label, non-comparative Phase IV study. The primary endpoint was the reduction of hot flushes after 12 weeks of treatment. Secondary endpoints included changes infrequency and intensity of menopausal symptoms as well as safety assessments after 4, 8, and 12 weeks of treatment. RESULTS: Treatment with 1 mg E2 plus 2 mg DRSP reduced the frequency of hot flushes in 94.6% of women at the end of the 12-week treatment period. In 60% of women, the frequency of hot flushes was reduced to 10% or less, compared to baseline findings and 49.1% of women had no remaining hot flushes. Other postmenopausal symptoms such as vaginal dryness, urinary incontinence, dysuria, and dyspareunia improved The most common adverse events were vaginal bleeding or spotting and breast tenderness. CONCLUSION: The oral HRT of 1 mg E2 plus 2 mg DRSP was effective and well tolerated by Thai women suffering from postmenopausal symptoms.

The combination of body mass index and age as a new index for identifying osteoporosis in Thai postmenopausal women.

OBJECTIVE: The purpose of this study was to evaluate the application of the combination of bone mass index (BMI) and age as a new screening tool to identify osteoporosis in Thai postmenopausal women. DESIGN: Diagnostic study. MATERIAL AND METHOD: Bone mineral density (BMD) data of Thai postmenopausal women, age 40-80 years old who attended the outpatient clinic, Thammasat University Hospital, Thailand, between January 2004 and December 2008 were enrolled. The participants with history of metabolic bone disease or use of drugs associated with secondary osteoporosis and/or history of treatment for osteoporosis were excluded. Each had BMD records of lumbar spine, femoral neck and intertrochanter. The data were completely collected in all 372 women. A diagnosis of osteoporosis made according to WHO criteria. RESULTS: The prevalence of osteoporosis at lumbar spine, femoral neck and intertrochanter were 8.1%, 20.2% and 15.3% respectively. The combination of BMI and age as the index to detect osteoporosis had a sensitivity at 76.67%, 76% and 77.19%, respectively. The OSTA index at the standard cut-point of -1 had a sensitivity at 80%, 70.67% and 70.17%, respectively. Raising the cut-point to < or =0 would had a sensitivity at 90%, 85.33% and 78.95%, respectively. CONCLUSION: The application of the combination of BMI and age as a screening tool is another option to identify osteoporosis in Thai postmenopausal women. Change the cut-point of < or =0, OSTA index could improve the detection of osteoporosis at a very high level of the sensitivity.

Impact of women's health initiative study on attitude and acceptance of hormone replacement therapy in Thai women attending menopause clinics.

OBJECTIVE: To assess the attitude and acceptance of Thai women attending menopause clinics on hormone replacement therapy (HRT) after the Women's Health Initiative (WHI) publication. MATERIAL AND METHOD: A standardized questionnaire was used to assess attitude and acceptance of HRT in 1,206 women who visited menopause clinics in six hospitals between September 2005 and February 2006. RESULTS: Of the total respondents, 92% were in the age of 40-70 years, 75% were in their peri- and post menopause, 25% were current users and the average duration of hormone use was 5.6 +/- 5.3 years. The women's perception of hormone benefits on osteoporosis prevention, skin improvement, and hot flashes treatment were 39.1%, 31.7%, and 28.9%, respectively. The most common concern of hormone use was malignancy. Hormone side effects were found to be the most common reason for switching hormone regimen. Of all the past users, 85% stopped HRT because they changed to another treatment regimen. Only 3.7% had been aware the WHI, of which 43.5% were influenced by its results. The most common source of HRT information was from doctors. For the ever users, 72.3% had some knowledge about HRT. CONCLUSION: The present survey revealed that very few women had been aware of the WHI study. Nevertheless, the prevalence of HRT current users was lower compared to a prior survey before the WHI publication. Doctors appeared to be the important source of HRT information, which may indirectly have an influence over women's attitude and acceptance on HRT.

Pregnancy in biliary atresia after kasai operation complicated by portal hypertension.

Hepatic portoenterostomy or Kasai operation has been widely accepted as the standard therapy for biliary atresia. Recently, more female patients have grown up and reached adulthood; therefore, pregnancy in women with biliary atresia is sometimes inevitable. The authors report a 17-year-old woman with biliary atresia post Kasai operation at 3 months of age. After the operation, she became jaundice-free but developed portal hypertension with abnormal liver function. She had several episodes of esophageal variceal bleeding and was treated by beta-blocker and endoscopic sclerotherapy. Since then, she was lost to follow up for nearly 2 years. She came back again with 12 weeks of gestation with no symptoms of gastrointestinal bleeding for antenatal care. At 32 weeks of gestation, she presented with severe hematemesis from variceal bleeding and had thrombocytopenia from hypersplenism. She was treated with somatostatin analogue, fluid and blood component replacement and other supportive treatments. Cesarean section was performed when she was stable at 33 weeks of gestation. After the operation, her clinical status was improved and had no other complications. Her baby experienced complications of prematurity but improved after treatment. Pregnancy may affect the natural course of portal hypertension and worsen the clinical outcome. Pregnancy should be avoided in patients with portal hypertension, however it is not contraindicated. Pregnancy in biliary atresia patients needs intensive prenatal care.

Hormone replacement therapy: attitude and acceptance of Bangkokian women.

OBJECTIVE: To conduct a hospital-based survey to assess women's attitude and acceptance towards menopause and hormone replacement therapy (HRT). METHOD: The authors conducted a survey in women who visited the menopause clinic in 5 university and public hospitals in Bangkok. A group of 615 women who lived in those catchment areas and voluntarily cooperated in responding to a set of standardized questionnaires was randomly selected. RESULTS: Of the total respondents, 97.0 per cent were in the age range between 40-70 years, 51.7 per cent were in the peri- and postmenopausal period, 65.7 per cent believed that menopause is a natural change but some may need medical treatment, 53.9 per cent were current users of which the average duration of HRT use was 4.70 +/- 3.36 years. The most common reasons for HRT initiation were osteoporosis, hot flashes, and vaginal dryness. The most common side effects found in the current users were breast pain, headache, and vaginal bleeding. Of all the current users, 43.2 per cent wanted to switch from HRT. Most of the respondents (95.4%) based their decision on the choices of treatment on medical advice. Of the total respondents, 62.0-74.7 per cent reported not having enough clear information on menopause and HRT. CONCLUSION: According to the present study, most of the women regarded menopause as a natural change of life although some need treatment. The most common indications for HRT were osteoporosis, hot flashes and vaginal dryness. Nearly half of the current users wanted to switch from HRT. Most of the respondents based their treatment decision on medical advice.

Climacteric: concept, consequence and care.

Climacteric is the period of life starting from the decline in ovarian activity until after the end of ovarian function. According to the definition, the period includes peri-menopause, menopause and post-menopause. Climacteric is considered to be a natural change of life which may be accompanied by various health consequences i.e., menopausal symptoms, osteoporosis, coronary heart disease, or Alzheimer's disease. The key concept is that women enter menopause with different menopausal status for instances, natural menopause, surgical menopause, early menopause or even premature ovarian failure. Women may experience various health consequences due to the difference in genetic and environmental interaction. The prevalence and incidence of menopausal problems vary according to ethnic groups. For instance, Asian women seem to have less problems after menopause than their occidental counterparts. Nevertheless, the problems do exist and seem to be increasing due to the longer life expectancy and lifestyle changes of people in the region. Clinical decision in menopausal therapy can be determined according to health risk stratification. Appropriated menopausal therapeutic strategies include medical and non-medical modalities. The non-medical modalities are mainly focussed on lifestyle modification, while the medical modalities are classified as hormone replacement therapy (HRT) and non-HRT. Those in the high risk group will probably benefit most from medication besides lifestyle modification. There are various types, doses, routes and regimens of medication which need to be appropriately matched with the proper women's characteristics. Those who have contraindications to HRT or can not tolerate its side effects may choose other alternatives eg, selective estrogen receptor modulators, bisphosphonates, calcitonin or calcium and vitamin D. The success of menopausal therapy is to give an appropriate therapeutic option to the right woman. The future direction of research will remain focussing on the development in diagnosis and menopausal therapy particularly the main three areas of health promotion, disease prevention and treatment. The trend of research and development will probably be concentrated on new pharmaceutical agents with more specific action and high selectivity in an attempt to maximize its efficacy and safety. Attention may be paid more on the convenience of drug administration to increase its compliance. Alternative medicine and appropriated technologies are also the fields of special interest of which research is underway.