Health related information and news from around the world.

While many women are happy to receive treatment for a condition that is bothering them now, far fewer want to take it to prevent something that may (or may not) happen some time in the future. This is a pity, because there are two serious conditions that are directly related to low levels of oestrogen after the menopause: arterial disease, which can lead to heart attack and stroke and is often fatal, and osteoporosis, which isn’t usually directly fatal, but which causes pain, deformity and a considerably reduced quality of life, and can be an indirect cause of death.

Neither of these diseases usually arises until several years after the ovaries have stopped producing oestrogen, but all women are potentially at risk from them the further they get in time from the menopause. The earlier you have the menopause (surgical or natural), the greater the proportion of your life without oestrogen, so the greater your risk of developing arterial disease and osteoporosis, and the more important it is that you are aware of these long-term consequences of low oestrogen and what you can do about it.

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It is unfortunately all too true that the oestrogen replacement therapy widely prescribed in Australia, the US and UK until the late 1970s caused a significant number of cases of endometrial cancer. This form of cancer may develop when oestrogen is used alone without progestogen by women who have an intact uterus.

Medical practitioners know considerably more today than they did then about the role of various reproductive hormones and their relationship with cancer and other diseases. While more is known, we are still on a learning curve with HRT. Here’s just one example. Recent research indicates that the actions of classic hormones like oestrogen and progesterone do not fully explain the way the reproductive system works. A large number of other hormones such as inhibin can apparently fine-tune the way the body responds to the classic hormones. It is only within the past decade that some of these local hormones have been identified, and there may be others as yet undiscovered.

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Psychological factors such as self-confidence, self-esteem and trust are intimately involved in the achievement of satisfying sex for both partners. Men are under greater pressure than women when it comes to sexual performance, and their capacity to have an erection and therefore penetrative sex may be reduced with age. Beyond the age of fifty or so, men generally require more stimulation than in their younger days to get an erection and to maintain it, reaching orgasm takes longer, and ejaculation may be more difficult. Penile sensation also tends to change.

According to Simone de Beauvoir, ‘Whereas a man of a certain age is no longer capable of erection, a woman at no matter what age is endowed with as it were a furnace … all fire and fuel within’. Popular Scottish songs of the eighteenth century make much of this contrast. An elderly woman yearns for the wild embraces of her younger days, now no more than a ghostly memory, since her husband no longer thinks of doing anything in bed except sleep, while she is eaten up with desire.

As with most men, a woman’s attitude to her physical appearance influences the way she relates sexually. Some studies indicate that men are even more concerned than women about the effects of ageing on their sexual desirability. As hair turns grey, with wrinkles becoming more prominent and bodies losing muscle tone, both men and women may see themselves as less attractive and less sexually desirable. If they cannot accept that an elderly person can also be beautiful, they may shy away from sexual intimacy.

It’s worth remembering the personal traits that are independent of age — character, intelligence, expressiveness, warmth and personal style. These form the real basis of deep and lasting sexual attraction.

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Oestrogen therapy is effective in reducing bone loss even if given many years after menopause to women with osteoporosis. There is some evidence that it actually increases bone formation slightly, and that it may also reduce bone pain if this is a problem. Progestogens, testosterone and anabolic steroids (sometimes used to treat osteoporosis that causes debilitating pain in the spine) are also capable of preventing bone loss after menopause, but are not so widely used. The current evidence suggests that treatment with hormones will benefit women up to the age of at least seventy. Follow-up and monitoring, usually at intervals of six to twelve months, are essential to check on side effects and to ensure that the therapy has effectively stopped bone loss.

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You should have a thorough history and examination before beginning HRT. This should include all of the following:

- a full check of your general health, including the occurrence of any symptoms that may be related to menopause (hot flushes, headaches, vaginal dryness, for example), and an assessment of any social and psychological factors that may be contributing to your situation

- an assessment of your present and past menstrual cycle, including any changes to the pattern of your periods, their frequency, and the amount of blood los

- a discussion of your lifestyle, including exercise and nutrition patterns and your use of medications, alcohol and cigarettes

- details of any previous medical, obstetrical, gynaecological or psychological symptoms, and any personal or family history of breast cancer or breast lumps, blood clot formation, heart attack or stroke, fractures or osteoporosis, uterine fibroids, endometriosis, problems experienced with the Pill, liver

disease, any cessation of your menstrual periods for more than six months (unless caused by pregnancy and breastfeeding), and any experience of premenstrual symptoms

- weight and blood pressure measurements, an examination of the breasts and vagina (to check the cervix, uterus and ovaries), and a Pap smear if you have not had one within the past two years

- a mammogram, especially if you have a family or personal history of breast problems

- an assessment of blood fat levels (cholesterol and triglycerides) if this has not been made during the previous twelve months

- a bone density scan if, at any time during the fertile years, menstruation stopped unexpectedly for longer than six months; and also if you have used, or still use, steroids (for example, in asthma or thyroid treatment), have had a recent fracture, have a family history of fractures or osteoporosis, or for any reason regard bone density information as an important part of your decision about HRT

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