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Estrogen deficiency: Education for all!

In July 2011, the Royal College of Obstetricians and Gynaecologists published the Expert Advisory Group Report High Quality Women’s Health Care: A Proposal for Change. This landmark publication highlighted a new concept – the continuum of important aspects of women’s health through puberty, the reproductive years, menstruation, pregnancy, contraception and fertility, through to the menopause and postreproductive health. We feel the concept of a life-course approach to healthcare should be widely adopted with an emphasis on the fluid and changing challenges in women’s health. Healthcare providers need to be reminded that many conditions and disease processes evolve during the process of aging. This means that the same condition may have different manifestations depending upon her age and consequently her endocrinological status. For example, a history of polycystic ovarian syndrome increases the risk of endometrial cancer and so would influence the threshold for investigation of increased perimenopausal bleeding or postmenopausal bleeding; pregnancy-related problems such as pre-eclampsia increase the risk of cardiovascular disease in later life; the use of hormonal contraceptives may influence a woman’s views, and those of her doctor, on the use of hormone replacement therapy (HRT); diabetes influences the use of contraception, pregnancy and management of the menopause as clearly outlined in this issue in the review paper by Morling. So has this concept been applied to the care of women experiencing the menopause, and to the management of postmenopausal health? There has certainly been a broadening of interest in postmenopausal health and focus has moved away simply from ‘the menopause’ and the pros and cons of HRT, but it appears that the concept of changing health as life progresses after the point of the menopause has not been widely adapted. When women attend gynaecology clinics with postmenopausal bleeding, is full assessment taken of the number of years since the menopause, i.e. since she became estrogen deficient, whether or not she is still experiencing vasomotor symptoms, what has been the effect of estrogen deficiency on her vagina and bladder, how healthy are her bones and what is her cardiovascular risk? The same can be applied to women attending with prolapse, continence problems, and even when asymptomatic and attending for cervical or breast screening after the age of 50. If these assessments of the effects of estrogen deficiency are not being made, then surely opportunities are being lost? While cognisance has to be made of time limitations and what is realistically achievable, surely at least gynaecologists should take on the broader, life-course view of women’s health and of the continuum of estrogen deficiency in particular and address the possible effects in any woman attending their clinics who is in an estrogen-deficient state. How can this message be adapted? It is time that primary care doctors and nurses, gynaecologists, physiotherapists, physicians, indeed all healthcare professionals caring for estrogen-deficient women had a broad understanding of the consequences of estrogen deficiency not only in the short term but throughout the years after periods stop and understood the life-course of women’s health. How? Education, education, education!