New studies give greater understanding on menopause

One year of hormone replacement therapy may be able to prevent development of depressive symptoms in women who are in the menopause transition, a study published online in JAMA Psychiatry has shown.

The double-blind, randomised controlled trial, conducted by University of North Carolina (UNC) School of Medicine found certain women would be more likely to experience the greatest mood benefit of hormone replacement therapy during the menopause transition, which are women early in the transition and women with a greater number of recent stressful life events.

Women are two to four times more likely to develop clinically significant depressive symptoms during the menopause transition, according to the study.

“We know that midlife for women, particularly in the transition to menopause, is a time of substantial elevations in risk for depression,” said Professor Susan Girdler, who helped lead the research.

“During the menopause transition, our risk for depression actually increases two to four times. And that’s true even for women who haven’t had a history of depression early in life.”

The participants were randomly selected and put into two separate groups. Over the course of a year, one group received transdermal estradiol on a daily basis, the other a placebo.

The study found more than 30 percent of the placebo group developed clinically significant depression. However, only 17 percent of women who received estradiol developed the same depression symptoms.

Other research published by The University of Illinois (UI) in the journal Sleep Medicine suggests addressing menopausal symptoms of hot flushes and depression may also address sleep disruptions.

The UI study also gives women hope that their sleep symptoms may not last past the menopausal transition, said Professor Rebecca Smith, from the Pathobiology Department at the University of Illinois. Professor Smith conducted the study with Professors Jodi Flaws and Megan Mahoney.

“Poor sleep is one of the major issues that menopausal women seek treatment for from their doctors,” Professor Mahoney said.

“It’s a huge health care burden, and it’s a huge burden on the women’s quality of life. Investigating what’s underlying this is very important.”

The study used data from the Midlife Women’s Health Study, which followed 776 women aged 45-54 in the greater Baltimore area for up to seven years.

The study found no correlation between the likelihood of reporting poor sleep before menopause, during menopause and after menopause. Meaning, for many women in the study, their reported sleep problems changed as they transitioned to different stages of menopause. For example, women who had insomnia during menopause were not more likely to have insomnia after menopause.

“That’s a hopeful thing for women who feel like their sleep has gone downhill since they hit the menopause transition: It might not be bad forever,” Professor Smith said.

“Your sleep does change, but the change may not be permanent.”

The researchers found that hot flushes and depression were strongly correlated with poor sleep across all stages of menopause.

Those two risk factors vary in reported frequency across menopausal stages, which might help explain why poor sleep also varies across the stages, the researchers said.

Professor Smith believes that the study has shown sleep disturbances in menopause are part of a bigger picture that doctors should be looking at.

“It indicates that when dealing with sleep problems, physicians should be asking about other symptoms related to menopause, especially looking for signs of depression and asking about hot flushes,” Professor Smith said.

MEREDITH HORNE

[Correspondence] Women’s health in Israel

We congratulate The Lancet for its Health in Israel Series, which takes a broad and unprecedented look at Israeli health and health care, and applaud the effort to focus on women’s health. We read with interest the Viewpoint by Leeat Granek and colleagues (June 24, 2017, p 2575),1 in which the authors state that the health of women in Israel is affected by the political situation in Israel. Although it might be true, this statement needs more support.

Why heart disease is so often missed in women

Heart disease is the No. 1 cause of death for women throughout the world. Approximately seven times more women will die from heart disease than breast cancer. Even in women with breast cancer, dying from heart disease is a leading cause of death.

Yet when I ask undergraduate students in my chronic disease class (most of whom are female) which disease causes the most deaths in women, only about half give the answer heart disease; a third say it is breast cancer.

This mirrors a 2012 survey from the United States, which found that only 56 per cent of female respondents identified heart disease as the leading cause of death.

Such a lack of awareness has very real consequences. Women who experience a heart attack in the U.S. are more likely to misunderstand the symptoms and delay seeking treatment. In Canada, early heart attack signs were missed in 78 per cent of women, according to the 2018 Heart Report from the Canadian Heart and Stroke Foundation.

Upon arrival in hospital, women’s symptoms can be dismissed by medical professionals as something else. They are also referred less for in-hospital treatments such as angioplasty (the clearing of a blockage in a heart artery) than men in the U.S., experiencing greater risk for death. Research has found a similar gender bias among general physicians in the United Kingdom and Germany as well as the U.S., resulting in less accurate diagnosis and treatment for women.

So, why this dismal knowledge of heart disease in women?

Not just a “widowmaker”

One reason is that research has historically been conducted in middle-aged and older men. This is, in part, because men had heart attacks during their working years, potentially limiting their economic productivity.

Women — who tended to suffer heart disease at a later age — received less attention.

There was also a fear of involving pregnant women in research, which led to all women of child-bearing age being restricted from participating in most research in the U.S. until the 1990s.

As a result, people both within and outside the medical profession had the impression that heart disease is for men.

This bias is easily recognized by the term “widowmaker” to describe the left main artery: One of the key arteries of the heart in which a blockage may lead to early death.

Smaller hearts and arteries

The second reason for our general lack of understanding of heart disease in women is due to differences in biology. We now know that the findings from research in men don’t fully apply to women — given differences in risk for heart disease and in anatomy.

As women get heart disease later in life than men, they also have more age-related risk factors than men — such as diabetes, which makes treatment more complex.

Women with diabetes have a 44 per cent greater risk for heart disease than men. In addition, gestational diabetes (which occurs during pregnancy and impacts approximately 5.5 per cent of births in Canada), is associated with a higher risk for heart disease compared to women who haven’t had gestational diabetes.

Early age of puberty and menopause have also been associated with greater heart disease risk.

And differences extend to anatomy. Given their smaller body size, women tend to have smaller hearts and arteries than men. This has been associated with higher mortality during bypass surgery.

Smaller arteries also make diagnostic techniques like the electrocardiogram (ECG) and coronary angiography (X-ray imaging of heart arteries) more challenging.

Women have different symptoms

One of the more perplexing facts about heart disease in women is that a heart attack can occur even without any heart arteries being blocked. This can happen with a “coronary artery spasm,” in which an artery of the heart suddenly closes upon itself. And it can happen with “spontaneous coronary artery dissection,” in which the inside of the heart artery tears, leading to a blood clot.

When there is no blockage, diagnosis by traditional methods is difficult.

Symptoms of a heart attack can differ in men and women.
(Shutterstock)

While women having a heart attack can feel severe pain in their chest, many also experience more subtle symptoms such as shortness of breath, discomfort in their arms, neck and jaw, sweating or nausea.

Despite these symptoms being fairly common in women, they are still referred to as “atypical,” indirectly suggesting that a woman’s experience is not normal. Yet they are normal for women.

A review of studies from nine countries found that women are also less likely to be referred to, and attend, cardiac rehabilitation programs.

And recent research from Sweden shows that failure to adhere to treatment guidelines results in greater premature death for women within five years after a heart attack compared to men. This confirms earlier findings in many other countries as well.

Female-only cardiac rehabilitation

While there is much work to be done, each year this gap in knowledge and treatment closes in North America thanks in part to Health Canada and the US Food and Drug Administration implementing guidelines to ensure the inclusion of women in research.

Continued advocacy by the Heart and Stroke Foundation and the American Heart Association is also important for increasing awareness both within and outside of the health care systems.

Additionally, more research in tailoring treatments to women, like female-only cardiac rehabilitation, will help in the design and application of treatments.

As individuals, the capacity to recognize and understand the signs and symptoms of heart disease could be life-saving — for our loved ones, friends, bystanders and even ourselves.

Scott Lear writes the weekly blog Feel Healthy with Dr. Scott Lear.

Scott Lear, Professor of Health Sciences, Simon Fraser University

This article was originally published on The Conversation. Read the original article.

[Editorial] Year of reckoning for women in science

Gender equity in science is both a moral and necessary imperative. Although women make up more than half of graduates in the medical and life sciences and 70% of the global health workforce, they are vastly under-represented at senior levels: in the USA, for example, women comprise 45% of assistant professors in academic clinical sciences but only 35% of associate professors and just 22% of full professors. Numbers are similarly unbalanced for the basic medical sciences, demonstrating the “leaky pipeline” that wastes women’s education and potential, prevents needed diversity in workplaces, and restricts women’s goals and rights.

[Editorial] Changing culture to end FGM

When Ellen Johnson Sirleaf retired last month after 12 years in office in Liberia, she signed an executive order banning female genital mutilation (FGM) in the country for girls younger than 18 years. Her profile as Africa’s first female president and a recipient of the Nobel Peace Prize for efforts to advance women’s rights and peace ensured her executive order got international media attention, thus shining needed light on a devastating practice. Globally, a staggering 200 million women and girls have undergone FGM, and UNICEF estimates that more than one in three girls between 15 and 19 years of age are currently affected.

[Perspectives] Natalia Kanem: lifelong advocate for women’s health and rights

”My big disappointment is that women’s rights are still not at the centre”, says Natalia Kanem, echoing her lifelong “passion and hope” for women’s health and rights. Her interest in these issues started in 1975 when, as an undergraduate at Harvard University, she attended the first UN World Conference on Women. Appointed as the Executive Director of the United Nations Population Fund (UNFPA) in October, 2017, Kanem hopes she “can really affect the fate of some of the poorest and most vulnerable women and girls in the world”.

[This Year in Medicine] 2017: a year in review

2017 was not only a year marred by conflict-driven humanitarian crises and political quagmires but also a year for biomedical innovation and women’s empowerment. Farhat Yaqub looks back.

[Comment] Women in science, medicine, and global health: call for papers

Women are rising. Recent reports of sexual harassment and assault of women by men in powerful positions have regalvanised solidarity around women’s rights, and remind us that disadvantage, discrimination, and sexism are a regular part of the lived experience of many women. These reflect broader and unjustified inequalities between men and women that have persisted across time, culture, and geography. That disadvantages exist for women in science, medicine, and global health is thus unsurprising—and yet wholly unacceptable.

EU driving e-health

Estonia, which is coming to the end of its presidency of the Council of the European Union, has recently sought to bring together EU countries that would be willing to launch a project concerning the cross-border movement of healthcare data.

The Digital Health Society, initiated by the Estonian Presidency of the Council of the European Union and ECHAlliance, have assembled an e-Health Declaration that includes more than 100 European organisations’ proposals for developing e-health in Europe.

The Declaration describes the bottlenecks that hamper the development of e-health, such as the lack of people’s trust in e-services in Europe, the lack of interoperability between different information systems, the lack of a clear legal framework, inadequate training of health-care professionals. Proposing solutions for overcoming these obstacles, the document emphasizes the need for unified approaches to the development of data exchange infrastructure, raising people’s awareness of the use of e-health solutions and implementing the European Union Data Protection Regulation in a way that it does not create unnecessary obstacles to the free flow of data between member states.

At the recent e-health conference held in Estonia, European Commissioner for Health and Food Safety Vytenis Andriukaitis called for a strong partnership within the EU to move towards simplified public e-services and formalities.

This would make interactions between citizens and public administrations easier.

“Let us all work together with governments, health professionals, businesses, and researchers, but above all with the patients to make digital health in Europe a reality,” he said.

Central to the EU’s agenda on digital innovation in healthcare is: the right of citizens to access, manage and control their health data electronically in a convenient and secure manner; to better use health data, in particular for research and innovation purpose; and the better use of health data, in particular for research and innovation purposes.

Clemens Martin Auer, Director General of the Austrian Federal Ministry of Health and Women’s Affairs, said that using the opportunities of information technology in healthcare, or e-health, is one of the most important innovative drivers in the healthcare sector: “Especially for organizing the continuous care in the fragmented world of healthcare services.”

The EU acknowledges that at that level, although health competence remains the responsibility of each member state, there is a goal for a common understanding to be formed into an agreement that fixes common components and common infrastructure that enables the free flow of health data.

A number of European member states have already designed their healthcare system in order to digitalise data. The remaining member states should implement strategies and policies for the creation of electronic health records across their country in order to stimulate the innovation for health and exchanges data with other EU countries.

MEREDITH HORNE

[Comment] Where is the accountability to adolescents?

Accountability is a loaded concept. For many, the term itself has negative and punitive connotations. When it comes to accountability to adolescents—who number 1·2 billion today1—discourse is rare. Adolescents are the central promise for accelerated, lasting progress on the Global Strategy for Women’s, Children’s and Adolescents’ Health2 and the Sustainable Development Goals (SDGs). But for adolescents, who lack power, vote, and influential voice, the notion of accountability to their health, development, and rights is fragile.