- Email: [email protected]
S28 Urogenital ageing-a hidden problem
S27
S28
INTRODUCTION TO DISCUSSION OF UROGENITAL AGEING AND ITS TREATMENT
UROGENITAL
AGEING
- A HIDDEN
PROBLEM
Samsioe Giiran
Lila E Nachtigall, M.D.
Department of Obstetrics Hospital, Lund, Sweden.
251 East 33rd Street, 5th Floor, New York, NY 100 16.
and
Gynecology,
Lund
University
As our female population ages, the atrophy in the urogenital system, particularly the vagina, becomes a major health problem. Even if we ignore the quality of life issues i.e. dyspareunia and vaginal itching and burning, we cannot ignore the increasing urinary tract infections. It is sometimes difficult to separate the tirogenital problems caused by ageing from those that are strictly from estrogen deprivation. However, it is worth treating the estrogen deficiency because of the many reversible features of urogenital atrophy. For example: the cornified vaginal layer returns, as do the rugal folds, pelvic blood flow and the acid pH. Oral, transdermal or local estrogen will accomplish this, but if no other reason for systemic estrogen is indicated a low dose local delivery would be superior. The following discussions will address the quality of life issues, suggestions for higher awareness on the part of health care providers and patients and the results of a completed multi-centre study on a vaginal ring low dose delivery system.
World population is currently both growing and preying. Today our elderly population is healthier than a generation ago. Hence a good quality of life inclusive of urogenital integrity becomes increasingly important also after 70. Oestrogen deficiency commonly leads to discomforting urogenital symptoms, such as itching, smarting dyspareunia, urge incontinence and recurrent urinary tract infection. Some of these symptoms may commence at menopause, but commonly become overt about a decade later. As a consequence, lower doses of oestrogens are required to combat these problems in comparison with doses used for the treatment of sweats and hot flushes. Indeed, oestrogen influence to maintain urogenital integrity is lower than the dose required for endometrial stimulation. Local oestrogen therapy could consequently be given continuously without progestogen comedication. A large bulk of clinical data support these notions, even if randomised controlled clinical trials are less frequent. Incontinence and recurrent urinary tract infections are the symptoms most often studied with subsequent positive effects by ERT. Incontinence alone accounts for 2 % of total health costs and ERT may substantially reduce these costs. The mechanisms of action by oestrogens are not fully understood. Oestrogen receptors have been identified in several structures of the female urogenital tract but at rather low concentrations. The profound effects of low dose oestrogens are di&ult to explain by a classical receptor mediated effect. However, the recent understanding of the interactions between oestrogen receptors and the local cytokine environment opens new and tantalazing possibilities to explain the local response by urogenital tissues. Oestrogens are well known to stimulate epidermal growth factor in urogenital tissue. Several other cytokines may also be involved in this context.
S29
s30
THE FEMALE PERSPECTIVE: WOMEN’S ATTITUDES TOWARDS UROGENITAL AGEING
EDUCATIONAL RECOGNITION
H J Wrkht, Burson-Marsteller. UK
EFFORTS TOWARDS BETTER OF UROGENITAL AGEING
MD&m, 24-28 Bloomsbury
Way, London
WCIA
2PX,
University of Mtinster, Department of Obstetrics & Gynecology, Albert-Schweitzer-St 33, D-48129 Mtinster, Germany.
Estimates of the prevalence of symptoms of urogenital ageing (UGA) are becoming more available, and there is considerable variation between countries. It is likely that lack of recognition of UGA by doctors is partly responsible, but this variation may also arise from different perspectives among postmenopausal women, resulting from an interplay of many social and cultural factors. Focus groups in Sweden and Denmark, countries thought of as very ‘open’, have shown that postmenopausal women rarely feel able to discuss urogenital problems freely - with their doctors, their husbands, or their- friends. European women over the age of 55 tend to have been brought up to prize ‘modesty’ and to consider urogenital symptoms as private, intimate matters. Urogenital symptoms are often seen as an inevitable result of the menopause; they may be regarded as irritants that must be put up with, or problems which the woman must solve herself. Many women suffer in silence for years, despite the fact that a European study in 6 countries showed up to 30% of women perceiving their urogenital problems as affecting their daily lives. While sexuality in older age groups is increasingly being recognised as important, many European postmenopausal women are reluctant to complain of deteriorating sex lives, perhaps especially so if their doctor is from a younger generation. In contrast, in the USA there is an increasing willingness among postmenopausal women to discuss their sexuality and their urogenital problems, and to seek treatment.
Urogenital ageing is given a low priority not only in the medical community but in the general public as well. Many women do not complain of these estrogen-deficiency related symptoms in comparison to i. e. vasomotor complaints. This may be because they regard changes in the urogenital system as a “normal” part of the ageing process, or because they are too ashamed to ask their physicians. Women do not have sufficient access to the information that many forms of the so-called urogenital dysfunction respond to hormonal replacement therapy. In addition, physicians hesitate to address the issue of urogenital symptoms and the field of sexual activity for fear of causing embarrassment. Educational efforts in the medical and non-medical community that might help to remove the taboo attached to the complex of urogenital ageing may include involvement of patient (osteoporosis) self help groups familiar with the potential of hormonal replacement therapy. Promotion of information using various media could increase public awareness of urogenital ageing and may support women to acquire information upon specific forms of estrogen replacement, in particular local administration of estradiol, to avoid many consequences of urogenital ageing.
32
S28
INTRODUCTION TO DISCUSSION OF UROGENITAL AGEING AND ITS TREATMENT
UROGENITAL
AGEING
- A HIDDEN
PROBLEM
Samsioe Giiran
Lila E Nachtigall, M.D.
Department of Obstetrics Hospital, Lund, Sweden.
251 East 33rd Street, 5th Floor, New York, NY 100 16.
and
Gynecology,
Lund
University
As our female population ages, the atrophy in the urogenital system, particularly the vagina, becomes a major health problem. Even if we ignore the quality of life issues i.e. dyspareunia and vaginal itching and burning, we cannot ignore the increasing urinary tract infections. It is sometimes difficult to separate the tirogenital problems caused by ageing from those that are strictly from estrogen deprivation. However, it is worth treating the estrogen deficiency because of the many reversible features of urogenital atrophy. For example: the cornified vaginal layer returns, as do the rugal folds, pelvic blood flow and the acid pH. Oral, transdermal or local estrogen will accomplish this, but if no other reason for systemic estrogen is indicated a low dose local delivery would be superior. The following discussions will address the quality of life issues, suggestions for higher awareness on the part of health care providers and patients and the results of a completed multi-centre study on a vaginal ring low dose delivery system.
World population is currently both growing and preying. Today our elderly population is healthier than a generation ago. Hence a good quality of life inclusive of urogenital integrity becomes increasingly important also after 70. Oestrogen deficiency commonly leads to discomforting urogenital symptoms, such as itching, smarting dyspareunia, urge incontinence and recurrent urinary tract infection. Some of these symptoms may commence at menopause, but commonly become overt about a decade later. As a consequence, lower doses of oestrogens are required to combat these problems in comparison with doses used for the treatment of sweats and hot flushes. Indeed, oestrogen influence to maintain urogenital integrity is lower than the dose required for endometrial stimulation. Local oestrogen therapy could consequently be given continuously without progestogen comedication. A large bulk of clinical data support these notions, even if randomised controlled clinical trials are less frequent. Incontinence and recurrent urinary tract infections are the symptoms most often studied with subsequent positive effects by ERT. Incontinence alone accounts for 2 % of total health costs and ERT may substantially reduce these costs. The mechanisms of action by oestrogens are not fully understood. Oestrogen receptors have been identified in several structures of the female urogenital tract but at rather low concentrations. The profound effects of low dose oestrogens are di&ult to explain by a classical receptor mediated effect. However, the recent understanding of the interactions between oestrogen receptors and the local cytokine environment opens new and tantalazing possibilities to explain the local response by urogenital tissues. Oestrogens are well known to stimulate epidermal growth factor in urogenital tissue. Several other cytokines may also be involved in this context.
S29
s30
THE FEMALE PERSPECTIVE: WOMEN’S ATTITUDES TOWARDS UROGENITAL AGEING
EDUCATIONAL RECOGNITION
H J Wrkht, Burson-Marsteller. UK
EFFORTS TOWARDS BETTER OF UROGENITAL AGEING
MD&m, 24-28 Bloomsbury
Way, London
WCIA
2PX,
University of Mtinster, Department of Obstetrics & Gynecology, Albert-Schweitzer-St 33, D-48129 Mtinster, Germany.
Estimates of the prevalence of symptoms of urogenital ageing (UGA) are becoming more available, and there is considerable variation between countries. It is likely that lack of recognition of UGA by doctors is partly responsible, but this variation may also arise from different perspectives among postmenopausal women, resulting from an interplay of many social and cultural factors. Focus groups in Sweden and Denmark, countries thought of as very ‘open’, have shown that postmenopausal women rarely feel able to discuss urogenital problems freely - with their doctors, their husbands, or their- friends. European women over the age of 55 tend to have been brought up to prize ‘modesty’ and to consider urogenital symptoms as private, intimate matters. Urogenital symptoms are often seen as an inevitable result of the menopause; they may be regarded as irritants that must be put up with, or problems which the woman must solve herself. Many women suffer in silence for years, despite the fact that a European study in 6 countries showed up to 30% of women perceiving their urogenital problems as affecting their daily lives. While sexuality in older age groups is increasingly being recognised as important, many European postmenopausal women are reluctant to complain of deteriorating sex lives, perhaps especially so if their doctor is from a younger generation. In contrast, in the USA there is an increasing willingness among postmenopausal women to discuss their sexuality and their urogenital problems, and to seek treatment.
Urogenital ageing is given a low priority not only in the medical community but in the general public as well. Many women do not complain of these estrogen-deficiency related symptoms in comparison to i. e. vasomotor complaints. This may be because they regard changes in the urogenital system as a “normal” part of the ageing process, or because they are too ashamed to ask their physicians. Women do not have sufficient access to the information that many forms of the so-called urogenital dysfunction respond to hormonal replacement therapy. In addition, physicians hesitate to address the issue of urogenital symptoms and the field of sexual activity for fear of causing embarrassment. Educational efforts in the medical and non-medical community that might help to remove the taboo attached to the complex of urogenital ageing may include involvement of patient (osteoporosis) self help groups familiar with the potential of hormonal replacement therapy. Promotion of information using various media could increase public awareness of urogenital ageing and may support women to acquire information upon specific forms of estrogen replacement, in particular local administration of estradiol, to avoid many consequences of urogenital ageing.
32