Newsletter: HRT and Heart Disease, Obesity, PCOS, Alternative Medicine

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June 2009 Newsletter

Question

"Pelvic Pain and PCOS"

I am 17 years of age.

A years ago i was diagnosed with "PCOS" the only thing is i'm not over weight in fact in under weight. I've been in and out of hospital were the cysts have popped but the only thing the hospital gives me is co-dydromal and mefenamic acid but i feel it doesn't help me, i still get the awful pain. I haven't had a period for over a year and i'm not being funny but its changed my life and not in a good way. I find it hard to go to college some days were Im in so much pain, I have lost my appetite. its very frustrating and it makes me very upset that no-one is doing anything about this.
is there anything you think i should do?
Is there any other way i can go?

"Thank you for your interesting question.
I am saddened to hear of the problems you have been experiencing.
The relationship between PCOS and pelvic pain is discussed on my website -
http://www.2womenshealth.com/PCOS-Polycystic-Ovary-Syndrome.htm
There is a difference between PCOS and ovarian cysts and I just wonder if you have cysts rather than PCOS or perhaps a combination of the two.
As you will see from the above link (half way down the page), I would question if your pain is really due to PCOS.

There are many causes of pelvic pain - some gynaecological and some non-gynaecological.
PCOS could be the cause for you not seeing your periods.
I hope this is helpful.
Kind Regards

Statement from the Royal College of Obstetricians and Gynaecologists on Women Delaying Motherhood.- June 2009

Reproductive ageing in women is caused by declining number and quality of oocytes. There is little immediate prospect of reversing the underlying biological phenomena and determinants of reproductive ageing.

There is a steady continuing rise in age at childbirth. Women may face personal, social or economic constraints to earlier childbearing and these may also vary cross-culturally.

Sexually transmitted infections are rising in older women.

Early ovarian ageing affects around 10% of women in the general population. There is no evidence to support the use of screening for early ovarian ageing or ovarian response tests.

Infertility is a time of great emotional and social stress for women and couples.

Reproductive outcome in fertility treatment depends mainly on the woman’s age.

Assisted reproductive technologies, including in vitro fertilisation (IVF) with the woman’s own fresh oocytes, cannot compensate for the effect of reproductive ageing.

The purported benefits of oocyte banking either by cryopreservation or by vitrification for postponing pregnancy to a later age are unproven.

Delay in childbirth is associated with worsening reproductive outcomes: more infertility and medical co-morbidity, and an increase in maternal and fetal morbidity and mortality.

Women who start their family in their 20s or complete it by age 35 years face significantly reduced risks.

PMS and Excercise

J Womens Health (Larchmt). 2009

Premenstrual syndrome (PMS) refers to a constellation of regular, recurring, psychological or somatic complaints, or both, that occur specifically during the luteal phase of the ovulatory menstrual cycle and that resolve by the onset of or during menstruation. Many women of reproductive age experience PMS.

Exercise has been proposed as a potential treatment in this regard, and several observational studies have reported a reduction in PMS and associated symptomatology in physically active women relative to their less active counterparts.Studies were identified by systematically searching relevant databases. RESULTS: Four eligible intervention studies were identified; all of these reported a reduction in PMS and related symptomatology after participation in exercise interventions. However, studies to date have recruited small samples and have been of low methodological quality. There is a paucity of research on the effects of exercise on PMS. Although the American College of Obstetricians and Gynecologists (ACOG) has advised that regular aerobic exercise may help relieve PMS, to make any evidence-based policy recommendations regarding the effectiveness of exercise, more high-quality research is required.⁰⁹⁰¹

PCOS associated infertility - The role of metformin

Fertil Steril. 2009 ⁰⁹⁰¹

Although the exact causation of PCOS is not yet fully known, insulin resistance is believed to be a major contributory factor. From the late 1990's, metformin has become popular treatment of PCOS related anovulatory infertility because it increases insulin sensitivity and therefore reverses the underlying problem. Many of us who have used metformin for this purpose have been impressed by its clinical benefits. It takes large randomised controlled studies to provide scientific evaluation of treatments. PCOS Infertility Metformin

Based on recent data available in the literature, the routine use of this drug in ovulation induction is not recommended. However, those administering Metformin continue to find favourable outcomes. In the latest study, Palomba S, et al⁰⁹⁰¹ found that insulin-resistant PCOS patients with low BMI are more likely to respond to metformin whereas CC treatment is more effective in less hyperandrogenic and insulin-resistant PCOS patients with low BMI.

HRT and the prevention of heart disease

There has been increasing criticism of the 2002 WHI trial that had such a disastrous effect on HRT use.^0901,

0902

The reluctance of physicians to use estrogens in women with hormone responsive disorders is a tragic result of the 2002 WHI study. Although their hostility to estrogen therapy antedated these studies, the flawed data is now used as justification for the denial of estrogens for treatment of low bone density and various types of hormone responsive depression in women.⁰⁹⁰¹ Estrogens should be first choice therapy for osteoporosis in women under the age of 60 years, but in practice bisphosphonates, with its increasing number of long-term side-effects, has become first-line therapy for physicians. These side-effects include osteonecrosis of the jaw, mid-shaft femoral fractures and the need for proton pump inhibitors, which further reduce bone density and add to the fracture risk. Pyschiatrists fail to use transdermal estradiol for postnatal depression, premenstrual depression and perimenopausal depression in spite of randomized trials demonstrating their efficacy. Selective serotonin reuptake inhibitor therapy for depression independently decreases bone density and is also responsible for loss of libido, loss of mental acuity and dependence. Thus postmenopausal women with vasomotor symptoms, depression, loss of libido, vaginal dryness or low bone density are frequently denied effective estrogen therapy and given a combination of low-cost generic prozac and fosamax, which is in danger of becoming a post-WHI nightmare drug PROFOX (PROzacFOsamaX). This can only be avoided if advisory bodies review the reassuring evidence concerning estrogen therapy in women under the age of 60 years and advise accordingly.

Subsequent publications of the more complete data from WHI have shown no significant increase in CHD, and a tendency to a reduction in those initiating HRT below age 60 years. This is important because other therapeutic strategies for the primary prevention of CHD, such as aspirin and statins, are not of proven benefit in women, in contrast to men.⁰⁹⁰²

Hormone therapy and cognitive function.

Hum Reprod Update. 2009 ^0901-Review

Clinical trials yield discrepant information about the impact of hormone therapy on verbal memory and executive function. This subject is clinically relevant because declines in verbal memory are the earliest predictor of Alzheimer's disease and declines in executive function are central to some theories of normal, age-related changes in cognition.

In a systematic review of randomized clinical trials of hormone therapy and verbal memory, distinguishing studies in younger (i.e. </=65 years of age; n = 9) versus older (i.e. >65 years; n = 7) women and studies involving estrogen alone versus estrogen plus progestogen. There is some evidence for a beneficial effect of estrogen alone on verbal memory in younger naturally post-menopausal women and more consistent evidence from small studies of surgically post-menopausal women. There is stronger evidence of a detrimental effect of conjugated equine estrogen plus medroxyprogesterone acetate on verbal memory in younger and older post-menopausal women.

Observational studies and pharmacological models of menopause provide initial evidence of improvements in executive function with hormone therapy.

Hormonal management of migraine at menopause.

Menopause Int. 2009

During the perimenopause, it is likely to observe a worsening of migraine, and a tailored hormonal replacement therapy (HRT) to minimize estrogen/progesterone imbalance may be effective. In the natural menopause, women experience a more favourable course of migraine in comparison with those who have surgical menopause. When severe climacteric symptoms are present, postmenopausal women may be treated with continuous HRT. Even tibolone may be useful when analgesic overuse is documented. However, the transdermal route of oestradiol administration in the lowest effective dose should be preferred to avoid potential vascular risk.⁰⁹⁰²

Assessing the Clinical Efficacy of Sildenafil for the Treatment of Female Sexual Dysfunction

Ann Pharmacother. 2009 Jun 9.

Whereas Sildenafil (Viagra) has become popular treatment for male problems, the place of this medication in women with problems remains unproven

In a recent review the clinical data regarding the efficacy and safety of sildenafil for the treatment of female sexual dysfunction has been assessed from a database search from 1950 to February 2009. Clinical trials involving sildenafil treatment of premenopausal and postmenopausal women with FSD and women with FSD due to concomitant medications and/or disease states were reviewed. An increasing number of clinical trials have been published regarding the treatment of FSD with sildenafil. Eight studies demonstrated a possible benefit from treatment for FSD in patients receiving sildenafil, regardless of dose, while 4 trials did not show any significant differences with treatment.

It appears that sildenafil might be beneficial for women with FSD caused by diseases such as multiple sclerosis, type 1 diabetes, spinal cord injury, and use of antidepressant medications. Although data suggest a possible role of sildenafil for the treatment of FSD, the information should be interpreted cautiously, as many of the studies included small sample sizes, used inappropriate statistical tests, and used nonvalidated assessment tools.

Choice and birth method

BJOG. 2009
The prevalent thought in childbirth has become maternal choice.

A study has been performed in Preston, Lancashire to explore whether women view decision-making surrounding vaginal or caesarean birth as their choice. Whilst many women supported the principle of choice, they identified how, in practice their autonomy was limited by individual circumstance and available care provision.

All women felt that concerns about their baby's or their own health should take precedence over personal preference. Moreover, expressing a preference for either vaginal or caesarean birth was inherently problematic as choice until the time of delivery was neither static nor final.

Women did not have autonomous choice over their actual birth method, but neither did they necessarily want it. Conclusions The results of this large exploratory study suggest that choice may not be the best concept through which to approach the current arrangements for birth in the UK. Furthermore, they challenge the notion of choice that currently prevails in international debates about caesarean delivery for maternal request.⁰⁹⁰¹

Women's Health

This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at Whipps Cross University Hospital, London - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.

I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

Newsletter April 2009