Systeemiset sidekudossairaudet, hedelmällisyys ja raskaus

Systeemisissä sidekudossairauksissa hedelmällisyyteen, sikiöön ja raskauteen vaikuttavat sairauden ­aiheuttamat elinmuutokset, taudin aktiivisuus sekä hoitoon käytetyt lääkitykset. Systeemiset sidekudossairaudet voivat lisätä keskenmenon, sikiön pienipainoisuuden ja ennenaikaisen ­synnytyksen riskiä. Tyypillisesti Sjögrenin oireyhtymään liittyviä sikiön sydämen johtumishäiriöitä aiheuttavia vasta-aineita voi esiintyä myös muissa sidekudossairauksissa. Systeemisiin sidekudossairauksiin voi liittyä myös tukoksille altistavia fosfolipidivasta-aineita. Systeemistä sidekudossairautta sairastavan naisen raskauden suunnittelu ja seuranta tulee keskittää keskus- tai yliopistosairaaloihin.Peer reviewe

Vaihdevuosien hikoiluoire, verisuoniterveys ja hormonihoito

Vasomotor hot flushes are complained of by approximately 75% of postmenopausal women, but their frequency and severity show great individual variation. Hot flushes have been present in women attending observational studies showing cardiovascular benefit associated with hormone therapy use, whereas they have been absent or very mild in randomized hormone therapy trials showing cardiovascular harm. Therefore, if hot flushes are a factor connected with vascular health, they could perhaps be one explanation for the divergence of cardiovascular data in observational versus randomized studies. For the present study 150 healthy, recently postmenopausal women showing a large variation in hot flushes were studied in regard to cardiovascular health by way of pulse wave analysis, ambulatory blood pressure and several biochemical vascular markers. In addition, the possible impact of hot flushes on outcomes of hormone therapy was studied. This study shows that women with severe hot flushes exhibit a greater vasodilatory reactivity as assessed by pulse wave analysis than do women without vasomotor symptoms. This can be seen as a hot flush-related vascular benefit. Although severe night-time hot flushes seem to be accompanied by transient increases in blood pressure and heart rate, the diurnal blood pressure and heart rate profiles show no significant differences between women without and with mild, moderate or severe hot flushes. The levels of vascular markers, such as lipids, lipoproteins, C-reactive protein and sex hormone-binding globulin show no association with hot flush status. In the 6-month hormone therapy trial the women were classified as having either tolerable or intolerable hot flushes. These groups were treated in a randomized order with transdermal estradiol gel, oral estradiol alone or in combination with medroxyprogesterone acetate, or with placebo. In women with only tolerable hot flushes, oral estradiol leads to a reduced vasodilatory response and increases in 24-hour and daytime blood pressures as compared to women with intolerable hot flushes receiving the same therapy. No such effects were observed with the other treatment regimes or in women with intolerable hot flushes. The responses of vascular biomarkers to hormone therapy are unaffected by hot flush status. In conclusion, hot flush status contributes to cardiovascular health before and during hormone therapy. Severe hot flushes are associated with an increased vasodilatory, and thus, a beneficial vascular status. Oral estradiol leads to vasoconstrictive changes and increases in blood pressure, and thus to possible vascular harm, but only in women whose hot flushes are so mild that they would probably not lead to the initiation of hormone therapy in clinical practice. Healthy, recently postmenopausal women with moderate to severe hot flushes should be given the opportunity to use hormone therapy alleviate hot flushes, and if estrogen is prescribed for indications other than for the control of hot flushes, transdermal route of administration should be favored.Keskimäärin kolme neljäsosaa vaihdevuosi-ikäisistä naisista kärsii hikoiluoireista, ja jopa puolet heistä kokee oireensa sietämättömiksi. Estrogeeni on tehokkain hoito vaihdevuosioireisiin; sitä käytti vuonna 2008 yli 350 000 suomalaista naista. Hormonihoidon vaikutuksia sydän- ja verisuonisairauksiin on tutkittu paljon, mutta tulokset ovat ristiriitaisia. Tutkimuksissa, joissa naiset olivat itse alun perin päättäneet aloittaa hormonihoidon lieventääkseen vaihdevuosioireitaan, hormonihoito selvästi suojasi sydän- ja verisuonisairauksilta. Sen sijaan tutkimuksissa, joihin otettiin mukaan naisia, joilla pääsääntöisesti esiintyi vain vähän tai ei lainkaan hikoiluoireita, hormonihoito ei suojannut sydänterveyttä, vaan saattoi jopa vaarantaa sitä hoidon alkuvaiheessa. Tämä ristiriita voidaan selittää osin sillä, jos hikoiluoire sinänsä vaikuttaa sydämen ja verisuonten toimintaan ja hormonihoidon käyttäjät edellä mainituissa tutkimuksissa ovat tässä suhteessa erilaiset; tätä asiaa ei ole kuitenkaan tutkittu. Asia on hyvin tärkeä, sillä sydän- ja verisuonisairaudet ovat naisten yleisin kuolinsyy. Tässä tutkimuksessa selvitettiin vaihdevuosien hikoiluoireen yhteyttä verisuoniston terveyteen. Tutkimukseen osallistui 150 tervettä, vastikään vaihdevuosiin tullutta naista, joilla oli eriasteisia hikoiluoireita. Naisten verisuonten jäykkyys ja laajenemiskyky sekä koko vuorokaudenaikainen keskimääräinen verenpaine mitattiin ja lisäksi määritettiin verinäytteistä useita sydän- ja verisuonisairauksien riskiä kuvaavia merkkiaineita, kuten kolesteroli ja muita rasva-aineita. Tämän jälkeen naisia hoidettiin estrogeenilla kuuden kuukauden ajan ja tutkittiin, vaikuttaako hormonihoito eri lailla oireellisilla ja oireettomilla naisilla edellä mainittuihin sydänterveyttä mittaaviin tekijöihin. Niillä naisilla, joilla esiintyi voimakkaita hikoiluoireita, verisuonten laajentumiskyky oli suurempi kuin täysin oireettomilla naisilla. Tätä voidaan pitää sydänterveyden kannalta edullisena ominaisuutena. Yölliset voimakkaat hikoiluoireet nostivat hetkellisesti verenpainetta ja pulssia, mutta koko vuorokauden ajalta mitattuna ei verenpaineessa tai pulssitasossa ollut eroa oireettomien naisten ja niiden naisten välillä, joilla esiintyi lieviä, keskivaikeita tai voimakkaita hikoiluoireita. Hikoiluoire ei vaikuttanut veren kolesterolipitoisuuksiin tai muihin merkkiaineisiin. Hormonihoitotutkimuksessa naiset jaettiin kahteen ryhmään: niihin joilla oli siedettäviä hikoiluoireita (eivät todennäköisesti aloittaisi hormonihoitoa normaalitilanteessa), ja niihin joilla oireet olivat haittaavia (todennäköisiä hormonihoidon aloittajia). Osallistujat saivat kuuden kuukauden ajan estrogeeniä eri muodoissa (ihogeeli, suun kautta otettava estrogeeni- tai estrogeeni-keltarauhashormonitabletti), tai lumelääkettä. Hikoilemattomilla naisilla suun kautta annettu estrogeeni vähensi verisuonten laajenemiskykyä ja aiheutti verenpaineen nousutaipumuksen verrattuna hikoileviin naisiin. Sen sijaan estrogeenigeeli tai ei aiheuttanut epäedullisia verisuonivaikutuksia. Hikoiluoire ei vaikuttanut estrogeenihoidon aiheuttamiin hyödyllisiin muutoksiin sydän- ja verisuonisairauksien merkkiaineissa. Tutkimuksen kolme päätulosta ovat: 1. Vaihdevuosiin liittyvä hikoilu ei itsessään lisää sydän- ja verisuonisairauksien riskiä vaan päinvastoin, se kertoo hyvin laajenevasta verisuonistosta. 2. Estrogeenitablettihoito vähentää verisuonten laajentumiskykyä ja nostaa verenpainetta, mutta vain niillä naisilla, joiden oireet ovat niin vähäisiä että he todennäköisesti eivät oma-aloitteisesti aloittaisi hormonihoitoa. 3. Estrogeenigeelihoito ei aiheuta verisuonihaittoja niillä, jotka todella tarvitsevat hormonihoitoa hikoilun vuoksi eikä niillä, jotka saattavat käyttää estrogeenia muun syyn, kuten luusuojauksen, vuoksi. Sydän- ja verisuonisairaudet ovat suomalaisten naisten tavallisin kuolinsyy. Nämä tulokset osoittavat, että hikoilevan vaihdevuosi-ikäisen naisen estrogeenihoito sittenkin suojannee sydäntä ja verisuonia

Vasomotor symptoms and metabolic syndrome

A vast majority of menopausal women suffer from vasomotor symptoms, such as hot flushes and night sweats, the mean duration of which may be up to 7-10 years. In addition to a decreased quality of life, vasomotor symptoms may have an impact on overall health. Vasomotor symptoms are associated with overactivity of the sympathetic nervous system, and sympathetic overdrive in turn is associated with metabolic syndrome, which is a known risk factor for cardiovascular disease. Menopausal hot flushes have a complex relationship to different features of the metabolic syndrome and not all data point towards an association between vasomotor symptoms and metabolic syndrome. Thus, it is still unclear whether vasomotor symptoms are an independent risk factor for metabolic syndrome. Research in this area is constantly evolving and we present here the most recent data on the possible association between menopausal vasomotor symptoms and the metabolic syndrome. (C) 2017 Elsevier B.V. All rights reserved.Peer reviewe

Sex Differences in Age-Related Cardiovascular Mortality

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Decreased mortality risk due to first acute coronary syndrome in women with postmenopausal hormone therapy use

Objectives: The role of postmenopausal hormone therapy (HT) in the incidence of acute coronary syndrome (ACS) has been studied extensively, but less is known of the impact of HT on the mortality risk due to an ACS. Study design and main outcome measures: We extracted from a population-based ACS register, FINAMI, 7258 postmenopausal women with the first ACS. These data were combined with HT use data from the National Drug Reimbursement Register; 625 patients (9%) had used various HT regimens. The death risks due to ACS before admission to hospital, 2-28, or 29-365 days after the incident ACS were compared between HT users and non-users with logistic regression analyses. Results: In all follow-up time points, the ACS death risks in HT ever-users were smaller compared to non-users. Of women with FIT ever use, 42% died within one year as compared with 52% of non-users (OR 0.62, p = 5 year FIT use (OR 0.54, p <0.001) died as compared to 43% of the non-users. Age 60 years at the HT initiation was accompanied with similar reductions in ACS mortality risk. Conclusions: Postmenopausal HT use is accompanied with reduced mortality risk after primary ACS. (C) 2016 Elsevier Ireland Ltd. All rights reserved.Peer reviewe

Current management of pelvic organ prolapse in aging women : EMAS clinical guide

Management of pelvic organ prolapse (POP) is a common and challenging task. Nowadays older women are more active than they were in the past, and the development of POP disrupts quality of life and impairs social and personal activities. The menopausal transition is a time of vulnerability, during which many women start experiencing symptoms and signs of POP. The role of hormonal changes or of hormonal therapies in influencing the development or progression of POP has been explored extensively. The management of POP requires considerable clinical skills. Correct diagnosis and characterization of the prolapse and an identification of the individual woman's most bothersome symptoms are the hallmark of appropriate initial management. Therapy is multimodal and often multidisciplinary, and requires a competence in pelvic medicine and surgery. The integration of hormonal, non-hormonal and surgical strategies is important and needs to be adjusted to changing circumstances on an individualized basis. When surgery is required, optimal management requires clinicians who are familiar with the advantages and disadvantages of all the available strategies and who are able to use these strategies in a tailored manner. Complex cases should be sent to specialist referral centers. Management of POP should be integrated into the practice of healthcare professionals dealing in menopause.Peer reviewe

EMAS position statement : Predictors of premature and early natural menopause

Introduction: While the associations of genetic, reproductive and environmental factors with the timing of natural menopause have been extensively investigated, few epidemiological studies have specifically examined their association with premature (<40 years) or early natural menopause (40-45 years). Aim: The aim of this position statement is to provide evidence on the predictors of premature and early natural menopause, as well as recommendations for the management of premature and early menopause and future research. Materials and methods: Literature review and consensus of expert opinion. Results and conclusions: Strong genetic predictors of premature and early menopause include a family history of premature or early menopause, being a child of a multiple pregnancy and some specific genetic variants. Women with early menarche and nulliparity or low parity are also at a higher risk of experiencing premature or early menopause. Cigarette smoking (with a strong dose-response effect) and being underweight have been consistently associated with premature and early menopause. Current guidelines for the management of premature and early menopause mainly focus on early initiation of hormone therapy (HT) and continued treatment until the woman reaches the average age at menopause (50-52 years). We suggest that clinicians and health professionals consider the age at menopause of the relevant region or ethnic group as part of the assessment for the timing of HT cessation. In addition, there should be early monitoring of women with a family history of early menopause, who are a child of a multiple pregnancy, or who have had early menarche (especially those who have had no children). As part of preventive health strategies, women should be encouraged to quit smoking (preferably before the age of 30 years) and maintain optimal weight in order to reduce their risk of premature or early menopause.Peer reviewe

Menopause and diabetes : EMAS clinical guide

Introduction: Whether menopause increases the risk of type 2 diabetes mellitus (T2DM) independently of ageing has been a matter of debate. Controversy also exists about the benefits and risks of menopausal hormone therapy (MHT) in women with T2DM. Aims: To summarise the evidence on 1) the effect of menopause on metabolic parameters and the risk of T2DM, 2) the effect of T2DM on age at menopause, 3) the effect of MHT on the risk of T2DM, and 4) the management of postmenopausal women with T2DM. Materials and methods: Literature review and consensus of experts' opinions. Results and conclusion: Metabolic changes during the menopausal transition include an increase in and the central redistribution of adipose tissue, as well as a decrease in energy expenditure. In addition, there is impairment of insulin secretion and insulin sensitivity and an increase in the risk of T2DM. MHT has a favourable effect on glucose metabolism, both in women with and in women without T2DM, while it may delay the onset of T2DM. MHT in women with T2DM should be administered according to their risk of cardiovascular disease (CVD). In women with T2DM and low CVD risk, oral oestrogens may be preferred, while transdermal 17 beta-oestradiol is preferred for women with T2DM and coexistent CVD risk factors, such as obesity. In any case, a progestogen with neutral effects on glucose metabolism should be used, such as progesterone, dydrogesterone or transdermal norethisterone. Postmenopausal women with T2DM should be managed primarily with lifestyle intervention, including diet and exercise. Most of them will eventually require pharmacological therapy. The selection of antidiabetic medications should be based on the patient's specific characteristics and comorbidities, as well on the metabolic, cardiovascular and bone effects of the medications.Peer reviewe