Persistent gap in menopause care 20 years after the WHI: a population-based study of menopause-related symptoms and their management.

OBJECTIVES: To assess the current management of menopause in France with regard to menopause-related and genitourinary symptoms, with a focus on use of menopause hormone therapy (MHT). DESIGN, SETTING, AND PARTICIPANTS: The ELISA Study is a population-based survey of 5004 French representative women aged 50 to 65 years. From July to August 2020, the participating women answered an online computer-assisted web interview on menopause-related and genitourinary symptoms and their management, including use of MHT. MAIN OUTCOMES AND MEASURES: Prevalence of menopause-related and genitourinary symptoms in postmenopausal women. Management of these symptoms, including the reasons for not doing so, management by health care providers, and use of MHT. RESULTS: Among the 5004 selected women, 4041 whose postmenopausal status was confirmed were included in the final analyses. Of the untreated 3685 women, 87 % reported at least 1 menopausal symptom, with a significantly higher percentage of symptomatic women in the 50-54 age group (92 %, p < 0.05) than in the other two age groups (55-59 years: 89 % and 60-64 years: 82 %). 68 % of the surveyed women experienced on average 2.5 symptoms of the genitourinary syndrome of menopause (GSM). Using a visual analogue scale (VAS) from 0 (no impact) to 10 (high impact) to evaluate the impact of menopausal/GSM symptoms on their quality of life, mean VAS score was 5.9 (SD: 2.2), with 25 % of the women aged 55-59 years rating their quality of life between 8 and 10. 61 % of the surveyed women reported being regularly followed by a health care professional. 44 % of women reported never having discussed their menopausal/GSM symptoms with a health care provider. The main reasons were because menopause is "a normal part of women's lives", because it was not "necessary to do so", or their symptoms were "not serious enough". Only 242 women (6 %) were current MHT users, of whom 49 % were using estrogen-alone therapy and 71 % were using transdermal estrogens. Fear of hormones (35 %) and MHT side-effects (25 %) were the main reasons given for not using MHT. 62 % of the women reported that the decision not to take MHT was supported by their physician. CONCLUSIONS AND RELEVANCE: This large population-based survey confirmed not only the high prevalence of menopause-related and GSM symptoms in postmenopausal women within the first 10-15 years after menopause, but also the very low percentage of MHT users in France. Twenty years after the publication of the initial Women's Health Initiative (WHI) results, management of postmenopausal women is still characterized by unmet needs in menopausal care. Therefore, there is a strong need to educate the public and health care providers about menopause-related problems and possible solutions, including MHT, through dedicated educational programs.

Elective abortion: Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF).

The number of elective abortions has been stable for several decades. Many factors explain women's choice of abortion in cases of unplanned pregnancies. Early initiation of contraceptive use and a choice of contraceptive choices appropriate to the woman's life are associated with lower rates of unplanned pregnancies. Reversible long-acting contraceptives should be favored as first-line methods for adolescents because of their effectiveness (grade C). Ultrasound scan before an elective abortion must be encouraged but should not be obligatory (professional consensus). As soon as the embryo appears on the ultrasound scan, the date of pregnancy is estimated by measuring the crown-rump length (CRL) or, from 11 weeks on, by measuring the biparietal diameter (BPD) (grade A). Because reliability of these parameters is ±5 days, the abortion may be done if measurements are respectively less than 90 mm for CRL and less than 30 mm for BPD (professional consensus). A medically induced abortion, performed with a dose of 200 mg mifepristone combined with misoprostol, is effective at any gestational age (Level of Evidence (LE) 1). Before 7 weeks, mifepristone should be followed 24-48 h later by misoprostol, administered orally, buccally, sublingually, or even vaginally followed if needed by a further dose of 400 µg after 3 h, to be renewed if needed after 3 h (LE 1, grade A). After 7 weeks, administration of misoprostol by the vaginal, sublingual, or buccal routes is more effective and better tolerated than by the oral route (LE 1). Cervical preparation is recommended for systematic use in surgical abortions (professional consensus). Misoprostol is a first-line agent for cervical preparation at a dose of 400 µg (grade A). Vacuum aspiration is preferable to curettage (grade B). A uterus perforated during surgical aspiration should not routinely be considered to be scarred (professional consensus). An elective abortion is not associated with a higher risk of subsequent infertility or ectopic pregnancy (LE 2). The medical consultation before an elective abortion generally does not affect the decision to end or continue the pregnancy, and most women are sufficiently certain about their choice at this time. Women appear to find the method used most acceptable and to be most satisfied when they were able to choose the method (grade B). Elective abortions are not associated with an increased rate of psychiatric disorders (LE 2). However, women with psychiatric histories are at a higher risk of psychological disorders after the occurrence of an unplanned pregnancy than women with such a history (LE 2). For surgical abortions, combined hormonal contraceptives - oral or transdermal - should be started on the day of the abortion, while the vaginal ring should be inserted 5 days afterwards (grade B). For medical abortions, the vaginal ring should be inserted in the week after mifepristone administration, while the combined contraceptives should begin the same day as the misoprostol or the day after (grade C). Contraceptive implants should be inserted on the same day as a surgical abortion, and may be inserted the day the mifepristone is administered for medical abortions (grade B and C respectively). In case of medical abortion, the implant can be inserted the same day the mifepristone is administered (grade C). Both the copper IUDs and levonorgestrel intrauterine system should be inserted on the day of the surgical abortion (grade A). After medical abortions, an IUD can be inserted in 10 days after mifepristone administration, after ultrasound scan verification of the absence of an intrauterine pregnancy (grade C).

The CORALIE study: improving patient education to help new users better understand their oral contraceptive.

OBJECTIVES: Combined oral contraceptives (COCs) are the most widely used contraceptive method in Europe. Paradoxically, rates of unintended pregnancy and abortion are still remarkably high. A lack of knowledge about COCs is often reported to lead to poor adherence, suggesting an unmet need for adequate contraceptive counselling. Our objective was to investigate the impact on the knowledge level of users of a structured approach to deliver contraceptive information for a first COC prescription. METHODS: The Oral Contraception Project to Optimise Patient Information (CORALIE) is a multicentre, prospective, randomised study conducted in France between March 2009 and January 2013. The intervention involved providing either an 'essential information' checklist or unstructured counselling to new COC users. The outcome measure was a questionnaire that assessed whether the information provided to the new user by the gynaecologist had been correctly understood. RESULTS: One hundred gynaecologists and an expert committee used the Delphi method to develop an 'essential information' checklist, after which 161 gynaecologists were randomised to two groups. Group I (n = 81) used the checklist with 324 new COC users and group II (n = 80) delivered unstructured information to 307 new COC users. The average score for understanding the information delivered during the visit was significantly higher in women in group I than in the women in group II, even after adjustment for age and previous history of pregnancy: 16.48/20 vs 14.27/20 (p < 0.0001). CONCLUSION: Delivering structured information for a first COC prescription is beneficial for understanding contraception. Our tool could ultimately contribute to increased adherence and should be investigated in a prospective study of long-term outcomes.

Usefulness of bone density measurement in fallers.

The objective of this systematic literature review is to discuss the latest French recommendation issued in 2012 that a fall within the past year should lead to bone mineral density (BMD) measurement using dual-energy X-ray absorptiometry (DXA). This recommendation rests on four facts. First, osteoporosis and fall risk are the two leading risk factors for nonvertebral fractures in postmenopausal women. Second, BMD measurement using DXA supplies significant information on the fracture risk independently from the fall risk. Thus, when a fall occurs, the fracture risk increases as BMD decreases. Third, osteoporosis drugs have been proven effective in preventing fractures only in populations with osteoporosis defined based on BMD criteria. Finally, the prevalence of osteoporosis is high in patients who fall and increases in the presence of markers for frailty (e.g., recurrent falls, sarcopenia [low muscle mass and strength], limited mobility, and weight loss), which are risk factors for both osteoporosis and falls. Nevertheless, life expectancy should be taken into account when assessing the appropriateness of DXA in fallers, as osteoporosis treatments require at least 12months to decrease the fracture risk. Another relevant factor is the availability of DXA, which may be limited due to geographic factors, patient dependency, or severe cognitive impairments, for instance. Studies are needed to better determine how the fall risk and frailty should be incorporated into the fracture risk evaluation based on BMD and the FRAX® tool.

2012 update of French guidelines for the pharmacological treatment of postmenopausal osteoporosis.

OBJECTIVES: To update the evidence-based position statement published by the French National Authority for Health (HAS) in 2006 regarding the pharmacological treatment of postmenopausal osteoporosis, under the auspices of the French Society for Rheumatology and Groupe de Recherche et d'Information sur les Ostéoporoses (GRIO), and with the participation of several learned societies (Collège National des Gynécologues et Obstétriciens Français, Groupe d'Étude de la Ménopause et du Vieillissement hormonal, Société Française de Chirurgie Orthopédique, Société Française d'Endocrinologie, and Société Française de Gériatrie et de Gérontologie). METHODS: A multidisciplinary panel representing the spectrum of clinical specialties involved in managing patients with postmenopausal osteoporosis developed updated recommendations based on a systematic literature review conducted according to the method advocated by the HAS. RESULTS: The updated recommendations underline the need for osteoporosis pharmacotherapy in women with a history of severe osteoporotic fracture. In these patients, any osteoporosis medication can be used; however, zoledronic acid is the preferred first-line medication after a hip fracture. In patients with non-severe fractures or no fractures, the appropriateness of osteoporosis pharmacotherapy depends on the bone mineral density and FRAX(®) values; any osteoporosis medication can be used, but raloxifene and ibandronate should be reserved for patients at low risk for peripheral fractures. Initially, osteoporosis pharmacotherapy should be prescribed for 5 years. The results of the evaluation done at the end of the 5-year period determine whether further treatment is in order. CONCLUSIONS: These updated recommendations are intended to provide clinicians with clarifications about the pharmacological treatment of osteoporosis.

[Cardiovascular risks differences in women: how can we improve the management?]. / Spécificités du risque cardiovasculaire de la femme : comment améliorer la prise en charge?

Some aspects of cardiovascular risk differ in women; on the whole, this risk is underestimated and insufficiently treated because of lack of knowledge of the problem. According to an INSERM report in 1999, one Frenchwoman in three will die from a cardiovascular disease, while only one in 25 will die of breast cancer. For new generations of women, the protective effect of the estrogen burden may be counterbalanced by the increasing prevalence during the perimenopausal period of metabolic syndrome, particularly harmful in terms of cardiovascular risk. Before oral contraceptives are prescribed, an extremely thorough history must be taken. These should in no case be prescribed for smokers older than 35 years, regardless of how little they smoke. Neither uncomplicated diabetes nor controlled dyslipidemia is a contraindication to hormonal contraception for women. It now seems clear that hormone therapy of menopause does not prevent cardiovascular disease. Nor, however, does it increase the risk if it is administered early, that is, during the first five years of menopause, and accompanied by close monitoring of cardiovascular risk factors and annual reassessment of the benefit-risk balance. The old cliché remains true: the patient at high risk of cardiovascular disease is a man older than 50 years, who smokes and is obese. But men still die more often from cancer than from cardiovascular disease, while the latter is the leading of cause in women, especially after menopause. The symptoms are often misleading and diagnosis is thus frequently delayed. Smoking, lack of exercise, overweight, and stress are all risk factors in women of all ages, and exposure to them can increase as women grow older. These factors should alert the physician and induce earlier screening for cardiovascular disease. In practice, too many women and their physicians underestimate their real risk of cardiovascular accident. It is accordingly essential to develop new campaigns of information and prevention specifically for women.

[Non hormonal contraception]. / Contraceptions non hormonales.

Excluded hormonal contraceptives, there are non hormonal means of contraception. Among them, copper intrauterine devices (IUD) are very efficient. Copper IUD are the most used contraceptives in France and in the world, even then "false ideas", like contraindication to non steroidal anti-inflammatory drugs or higher risk of tubal infertility, have tarnished its reputation. The other non hormonal contraceptives, less effectiveness, include first, the male and female condoms which are the only efficient means to prevent sexually transmitted infections and then the "local" contraceptives like spermicides, diaphragms and cervical caps. The effectiveness of these methods depends primarily on their correct use (which requires a careful training). Then these "local" means are acceptable contraceptive methods only for specific use or for very motivated women.