27 January, 2020

A comment on Climacteric Editor’s Choice "Sexual quality of life in men and women after cancer" by L. R. Schover

Summary

There is a global agreement about the fact that cancers and cancer therapies have a negative impact on the sexual health of men and women with prevalence rates on average of 50-60%. There is also global agreement that patients are very often left alone with their sexual problems and that there is not adequate care. In this review [1], the physical and psychosocial consequences of cancers and cancer treatment on the sexual life of male and female patients are summarized. The barriers and gaps are described. Lack of information and counseling during oncological care, reluctance of patients to bring up sexual issues in a medical environment, lack of training of oncological professionals, lack of time, lack of education material, non-familiarity with the variety of sexual orientations and preferences, focusing on heterosexual penetrative intercourse, etc.. The review [1] describes the short history of initiatives in the US to respond to these barriers and gaps. The National Comprehensive Cancer Network (NCCN) issued guidelines (2019 (https://www.nccn.org/professionals/physician_gls/default.aspx#supportive)), ASCO also issued a guideline in 2017 (https://www.asco.org/research-guidelines/quality-guidelines/guidelines/patient-and-survivor-care#/28976) with some agreement on the basic requirements. The cancer team should initiate discussion about sexuality and provide follow-up visits with the possibility to refer to multidisciplinary treatment.

Ren and colleagues have undertaken a cross-sectional study of 8191 women (median age 56 years, interquartile range 47–65 years) recruited in rural China to determine the association between menopause and the likelihood of developing type 2 diabetes (T2D) [1]. The diagnosis of T2D in women was established by a fasting plasma glucose of 7.0 mmol/l or greater, and/or the use of insulin or an oral hypoglycemic agent and/or a self-reported history of diabetes (excluding type 1 diabetes, gestational diabetes mellitus, or diabetes due to other causes).

Of note, 38% of the women in the study were overweight, 22% were obese and 30% had hypertension. Only 7.8% reported a family history of T2D.

The study reported an overall prevalence of T2D of 13% amongst the included women. After adjusting for age, smoking, alcohol drinking, body mass index (BMI), age at menarche, systolic and diastolic blood pressures, and family history of diabetes, the risk of T2D was greater for women who were postmenopausal versus premenopausal women (adjusted odds ratio (AOR) 1.90, 95% CI 1.51–2.37). The strongest association between T2D and menopause in the adjusted model was for normal weight women (a BMI < 24 kg/m2), such that postmenopausal normal-weight women had a more than three-fold risk of having T2D versus premenopausal women (AOR 3.35, 95% CI 1.98–5.32). Age was a mediating factor in the apparent effect of menopause, but an effect of menopause persisted despite adjustment for age.

Review of North American Menopause Society ‘Guidelines for the Evaluation and Treatment of Perimenopausal Depression: Summary and Recommendations’

Endorsement by the IMS

Professor Wendy Wolfman

IMS Education Committee and Education Committee Members, Department of Obstetrics and Gynaecology, University of Toronto, Canada

The North American Menopause Society has developed an important guideline for the evaluation and treatment of perimenopausal depression [1]. This document, co-authored by an 11-member panel of experts and opinion leaders, who systematically reviewed the literature between 1980 and 2015 on depression and depressive symptoms, focuses on issues related specifically to perimenopause and postmenopausal women. The document reviews five relevant areas: epidemiology, clinical presentation, therapeutic effects of antidepressants and hormonal therapies as well as the efficacy of other therapies including psychotherapy, exercise and natural health products.

The IMS endorses this well-written comprehensive document that provides a summary and recommendations for improving the mental health of perimenopausal and menopausal women. Depressive symptoms are highly prevalent in at least 45% of perimenopausal women around the world. The paper confirms that the perimenopause is a time of vulnerability for the development of depression in women, particularly those who have had a prior episode of depression. The presentation may be complicated by perimenopausal symptomatology such as hot flushes, night sweats, sleep and sexual disturbances, weight changes and cognitive shifts. Evaluation involves identifying the menopausal stage and assessing psychiatric symptoms via validated screening tools. Proven therapeutic options include antidepressants such as SSRI and SNRI antidepressants, cognitive behavior therapy and other psychotherapies. For perimenopausal women, there is some evidence that estrogen therapy has antidepressant effects similar to antidepressant agents. However, estrogen alone is ineffective for depressive disorders in postmenopausal women. Estrogen may enhance the clinical response to antidepressants. This synergy needs to be evaluated in further research trials.

Some of the limitations of the document identified by the IMS reviewers included little mention of effects of other hormones on depression such as thyroid and adrenal hormones, and only a small mention of testosterone [2,3]. A section on directions for future research would have been useful in the document. For instance, comment could have been made about very important recent genetic research and its impact on depression, as noted in the recent review on gene polymorphisms and the risk of depression in menopausal women [4]. Also, there is currently a deficiency in the literature comparing doses, types, vehicles and timing of hormone therapies with regard to outcomes of depression. More research is needed to address the etiology and management of premature ovarian insufficiency-related depression as well as the synergistic effects of psychoactive medication with hormone therapies. These areas may prove to be relevant to address in future research recommendations.

In conclusion, we endorse this excellent guideline. We believe it validates the alterations in mental well-being that occur during the menopause transition, with the goal of improving the health of women around the globe.

As the world-wide population ages, it is projected that the number of persons living with osteoporosis will also increase. Osteoporosis is usually asymptomatic until a fracture occurs, and preventing osteoporotic fractures is the main goal of an osteoporosis screening strategy. Osteoporosis justifies a screening program because it is an important public health problem and effective treatments are available.

The objectives of bone mineral density (BMD) measurements are to provide diagnostic criteria, prognostic information on the probability of future fractures, and a baseline status to follow the evolution of the disease. Dual-energy X-ray absorptiometry (DXA) is the most widely used bone densitometric technique for this purpose.

All the major societies recommend the evaluation of risk factors for osteoporosis in women after the age of 50 years. There is also agreement that DXA-based screening is indicated after the age of 65 in all women not tested previously, and for all men 70 years and older. In the younger population, women less than 65 and men less than 70 years old, BMD assessment is only recommended when risk factors for low bone mass are present. These recommendations are included in the guidelines and consensus for women by the International Menopause Society and the North American Menopause Society and for both genders in the guidelines from the National Osteoporosis Foundation [2], the American College of Obstetrics and Gynecology, the International Society for Clinical Densitometry, the International Osteoporosis Foundation, the Endocrine Society [3] and the American Academy of Family Physicians. The American Association of Clinical Endocrinologists also recommends evaluating all women 50 years and older for osteoporosis risk and considering DXA testing based on clinical fracture risk profile.

The US Preventive Services Task Force (USPSTF) has recently published recommendations on screening for osteoporosis, to prevent bone fractures in adults, based on the revision of evidence on screening and treatment of osteoporotic fractures in men and women [1]. The screening population was postmenopausal women and older men with no known previous osteoporotic fracture and no known co-morbid conditions or medication use associated with secondary osteoporosis.

Professor Rod Baber is Clinical Professor of Obstetrics and Gynaecology, Faculty of Medicine and Health, The University of Sydney, Australia, the Editor-in-Chief of the Society’s journal, Climacteric, and Past President of the International Menopause Society.

I’ve been reading

I’ve been reading The Immortal Life of Henrietta Lacks by Rebecca Skloot. This book describes the sad tale of an African American woman who died of cervical cancer but whose donation of cells (unbeknown to her) prior to her death established the HeLa cell line, the oldest and still most commonly used immortal human cell line. Scientists are estimated to have grown over 20 tonnes of cells from HeLa for multiple scientific purposes, the first of which was the development of the Salk Polio vaccine. This prize-winning book is notable for its reflections on ethics as well as its ability to explain scientific processes to non-scientific readers.

I’m researching

We are about to start a mixed-methods multi-ethnic study on women’s experience of menopause and aging, in collaboration with The University of Tasmania.

My team

My team is small but busy, comprising three consultant gynecologists with a particular interest in menopause, menstrual disorders, reproductive endocrinology and infertility, and psychosocial issues. We also have two research fellows and, most importantly, our Nurse coordinator without whom nothing would happen.

An anecdote

When I was a young research fellow, I presented a free communication at an international meeting on research that I had done with my boss. In the audience was one of my boss’s mortal enemies who, in question time, did his best to discredit everything I had said. After the session, as I sat shell-shocked in the auditorium, the chair of the session reminded me that ‘if you swim with sharks you must expect to get bitten’. It taught me not to take these things too personally or too seriously. It’s sometimes just part of a game.

An interesting case

All of our referrals are tertiary and all are ‘interesting’, but I think those which challenge me most are the women who need ongoing care after surviving hormone-dependent cancers. These women need a ‘conductor of the orchestra’ to balance the views, wishes and priorities of all the different health-care professionals involved in their ongoing care.

Dear friends, colleagues, contributors, reviewers and readers

With the advent of a new IMS Board under the leadership of Professor Susan Davis, I thought it timely to bring you all up to date with the progress of our journal.

At the recent 16th IMS World Congress on the Menopause in Vancouver, Canada, our Editorial Board, Editors and publisher met to discuss progress and future plans. We will continue to publish six issues per year and, within those issues, we will from time to time have special themed issues with high-level reviews on topics of importance to us all. The first of these was on screening for women at midlife and was published in June. Our August issue will focus on Progesterone in its many guises. More special issues are planned as well, including one focusing on papers presented at the recent World Congress. We will continue to publish occasional issues of Climacteric in Chinese, including, from 2019, abstracts in Chinese available on line. I am hopeful that we may be able to establish a Spanish-language equivalent in the near future.

I am pleased to advise that Taylor & Francis will remain the publisher of Climacteric under a new 5-year contract signed in Vancouver.

I am also delighted to inform you that the most recent Impact Factor for Climacteric is 2.807, an increase of over 23% and the highest in the journal’s history. This is a testimony to our authors and to the standard of scientific papers published in our journal.

The Impact Factor is also a testimony to the hard work of our peer reviewers, our management team and our Editors, most particularly Nick Panay and Anna Fenton who were Joint Editors-in-Chief of Climacteric until September 2016. I wish to thank them and to congratulate all involved.

11 June 2018

When any food is served, we examine it by its esthetics, color, smell and taste, and the end evaluation is summarized by a simple question that echoes in our mind: did we like it? So food is not just nourishment. It may have psychic effects of all sorts. We enjoy food, we speak about food, eating together may be a social event.

The relationships between dietary glycemic index, glycemic load, and other carbohydrate measures (added sugars, total sugars, glucose, sucrose, lactose, fructose, starch, carbohydrate) and depression in the women who participated in the Women's Health Initiative Observational Study at baseline (n = 87,618) and at the 3-year follow-up (n = 69,954) were investigated [1]. The results suggested that high glycemic index diets could be a risk factor for depression in postmenopausal women. What we eat is usually categorized as healthy or unhealthy, depending on its contents. Studies are still being published to demonstrate the advantage of raw, plant-based foods over processed foods. As an example, a recent study in young adults showed that raw fruit and vegetable intake predicted reduced depressive symptoms and higher positive mood, life satisfaction, and flourishing [2]. A cross-sectional study in China among 906 postmenopausal participants identified three dietary patterns: processed foods (refined grains, preserved foods, fat meat, fried foods, and sweets), whole plant foods (whole grains, vegetables, and fruits), and animal foods (fish, lean meat, and milk products) [3]. The conclusion was that dietary patterns featuring a low intake of processed foods and/or a high intake of whole plant foods were associated with a reduced risk of depression and perceived stress. Contrarily, the highest tertile score for processed foods was associated with a 79% increased risk of depression. It appears that various electrolytes and minerals may also play an important role in regard to mood and cognition. Adequate physiologic status of iron and zinc may enhance cognitive and emotional functioning [4]. Several studies found improvements in aspects of mood and cognition after iron supplementation, regardless of whether the participant was initially iron-insufficient or iron-deficient.

21 May, 2018

A famous saying goes: It is better to be rich and healthy than poor and sick. A side-saying broadens this simple fact by clarifying that you would better be rich if you are sick. There have been numerous studies on the association of socioeconomic status with health and disease, and there is no need to enlarge on that. However, a new study from the United States, where money really talks, has found alarming data that must be discussed by the citizens and their administration [1]. The study analyzed data on a cohort of 51–61-year-old people at baseline, who were followed long-term. The participants of the Health and Retirement Study gave detailed information on their wealth (housing, businesses, individual retirement accounts, cash and savings accounts, investment holdings, loans, debts, etc.), and accordingly were grouped into wealthy or poor. Furthermore, they were divided into subgroups that considered changes in wealth during the study period, i.e. those who maintained or increased their wealth, those who lost wealth, and those who experienced ‘wealth shock’, defined as loss of at least 75% of their wealth during a period of 2 years. All-cause mortality data were obtained as well, which allowed examination of associations between mortality risk and economic status. The sample size was 8714 participants with a mean follow-up of 17.7 years, totaling 80,683 person-years; 26.2% experienced a negative wealth shock and 6.9% had long-term asset poverty. A total of 2823 participants died during follow-up. In the positive-wealth-without-shock reference group, the crude mortality rate was 30.6 deaths per 1000 person-years. By contrast, the crude mortality rates were 64.9 per 1000 person-years for those who experienced a negative wealth shock and 73.4 per 1000 person-years for those who had asset poverty.

 16 April, 2018

Recently, contradictory reports were published concerning the association between the serum concentration of irisin and the physical activity level and fitness status in healthy humans. Irisin is a newly identified myokine that induces the ‘browning’ of white adipose tissue (WAT). Buscemi and colleagues studied a cohort of 858 healthy individuals in Palermo, Sicily, as a part of the ABCD (Alimentazione, Benessere Cardiovascolare e Diabete) study, and found a significant positive correlation between serum irisin concentration and habitual physical activity [1]. However, Binianinov and colleagues showed that serum irisin concentration was not related to any measures of short-term physical activity, habitual physical activity, or physical fitness in a cross-sectional analysis of 300 healthy humans who had participated in the Karlsruhe Metabolomics and Nutrition (KarMeN) study in Germany [2].

Comment

Regular physical activity and fitness are closely related to a positive healthy status in humans [2]. In this context, the muscle becomes more important due to its function as an endocrine organ. Muscle tissue secretes ‘myokines’ in response to physical activity and it is speculated that these myokines are involved in physical activity-induced positive health effects.

20 March, 2018

Member of the IMS Board

The IMS Board works tirelessly to support the aims of the Society and to ensure that the best educational resources and updates on research are available to all the membership. However, do you really know who they are? This new occasional profile series gives you the opportunity to learn more about each Board member, providing a personal perspective and insight into the people who represent the leadership of the Society.

Professor Steven Goldstein

Is Professor of Obstetrics and Gynecology at New York University School of Medicine and Treasurer of the International Menopause Society.

I’ve been reading

Cells are The New Cure by Robin L. Smith, MD and Max Gomez, PhD. This is a cutting-edge look for an intelligent lay-audience by two scientists about the current and future use of stem cells.

I’ve been researching

Making the diagnosis of abnormal uterine bleeding/postmenopausal bleeding truly ‘point of care’. In some cases, this means sonohysterography and, in other cases, these new disposable office hysteroscopes.

My team

Since I am not subspecialty trained, I do not have a ‘division’ but am able to call on very astute colleagues from all major areas of Ob/Gyn in my institution at New York University School of Medicine.

An anecdote

I recently had a total knee replacement. I was signed up to be done by the head orthopedist at the number one-rated orthopedic hospital not only in New York, but in the United States. I subsequently had another opinion with a doctor at my own institution. He performed not only an X-ray of the knee but a scan of my lower extremities. It was clearly obvious (even to my untrained eye) that the polyethylene in my 15-year-old right hip replacement had almost worn through. He informed me that, if this were allowed to totally wear through so that the titanium implants rubbed on each other causing them to loosen, that this would be a major problem. Needless to say, I switched physicians and had my knee fixed and am in the process of planning a revision on my hip as well. The lesson is, we must see the whole patient and not just use such tunnel vision as the first surgeon exercised.

An interesting case

I was once asked to perform a transvaginal ultrasound on a sterile gorilla at The Bronx Zoo when they were moving the animals to a different portion of the facility. Once anesthetized, the animals were brought into the zoo’s hospital where various medical specialists evaluated the gorillas. This one female gorilla had never become pregnant. Dressed in hospital gown and glove, I began to perform a transvaginal ultrasound. The adult female gorilla has a short stubby vagina and axial uterus. This made visualization of the pelvis virtually impossible. They say that necessity is the mother of invention. I put the probe into the rectum, turned it 90 degrees and got beautiful images of the endometrial echo which was thin and there were ‘streaked’ ovaries. If there ever were such a thing as a Turner’s Syndrome in a gorilla, this was it. With the head veterinarian, we wrote a paper that transvaginal ultrasound was of limited value in the species gorilla gorilla gorilla. Since that time, in young virgins and older patients with a stenotic vagina, I have routinely performed transrectal ultrasound with great success.