Approaches to taking a sexual history.

Advances in modern medicine have extended the lives of many people, in both quantity and quality. One of the emerging quality of life factors for many women as they approach and pass the menopause is sexuality. Sexuality is a very important part of physical and emotional health, underscoring the importance of incorporating the sexual history as part of the overall patient history. Although health professionals may experience a degree of anxiety and discomfort in discussing sexual issues, it is nonetheless essential to learn to be comfortable in asking questions about sexuality and in responding to issues that arise from such questioning. Most patients also show some discomfort when discussing their sexual problems. A sensitive, nonjudgmental approach on the part of the physician is essential and may create an atmosphere of security for both patient and physician. It is sometimes helpful to begin the sexual history with basic, open-ended questions, thereby allowing for expansion according to the responses received. Dispelling the myth that all older people should have a declining interest in sex may help patients feel less reticent about talking to physicians about sexual matters.

What's new in preventing and treating osteoporosis?

Women should be encouraged to maintain an adequate calcium intake throughout their life so they have good BMD when they reach menopause. The most effective choice for prevention and treatment of osteoporosis after menopause is estrogen or combined estrogen-progestin. The addition of progestin to estrogen therapy to prevent endometrial cancer does not impair effectiveness of estrogen in increasing BMD. In women who have contraindications to or do not wish to take estrogen, alendronate is the most effective alternative. Raloxifene has been found to protect BMD but not to the extent of estrogen or alendronate, and it does not provide the other benefits offered by estrogen. Calcitonin-salmon has an excellent long-term safety record, but its effectiveness in preventing fracture remains to be fully demonstrated. Adequate calcium intake and exercise are important adjuncts to other therapies but alone do not prevent osteoporosis in most women.

Continuous combined estrogen/progestin hormone replacement therapy.

Women entering menopause should be informed of the benefits and risks of hormone replacement therapy and of the variety of regimens available. One option, a continuous combined regimen of conjugated equine estrogen 0.625 mg and medroxyprogesterone acetate 2.5 mg, maintains the beneficial effects of estrogen on cardiovascular risk factors, although its effects on high-density lipoprotein cholesterol levels are less pronounced than with estrogen alone. The addition of progestin does not affect carbohydrate metabolism except for a slight decline in glucose tolerance. Blood coagulation factors and blood pressure showed no clinically significant changes different from those resulting from unopposed estrogen. Bone mineral density is increased more with the continuous combined regimen than with the continuous combined regimen than with a cyclical regimen of the same hormones. The incidence of endometrial hyperplasia is substantially less than that observed with unopposed estrogen. The overall frequency of irregular bleeding is lower than with estrogen alone and diminishes with continuation of therapy, whereas the incidence of amenorrhea increases from 52.1% to 75.1% between cycles 2 and 11. Epidemiologic evidence linking any hormonal therapy with breast cancer remains inconsistent, possibly because the risk, if any, is small. The relative risk of breast cancer for the continuous regimen has not been extensively studied in large-scale studies.

Hormonal management of fibrocystic disease of the breast.

Fibrocystic breast disease is a source of considerable discomfort in a sizeable percentage of women between 35 and 50 years of age. Earlier treatments designed to reduce the pain, tenderness and nodularity associated with this condition met with little success. It was not until 1971, when Danocrine (danazol) was introduced for the treatment of endometriosis, that the potential usefulness of this synthetic steroid in the management of benign breast disorders was recognized. Numerous studies have substantiated the efficacy and safety of danazol for this application. At one center involved in a multicenter study of danazol, the drug was administered in dosages of 400 mg/d for two months, followed by 200 mg/d for an additional four months, to 25 women with fibrocystic breast disease. Eighteen (79%) of the women demonstrated a marked improvement in or elimination of their symptoms. The majority remained asymptomatic for at least one year after treatment. The side effects were mild and of the "nuisance" variety. These findings are consistent with the overall data reported by the other centers participating in the study.

Medical versus surgical treatment of endometriosis.

I believe that surgery is the treatment of choice for patients with endometriosis desiring pregnancy. An exception to this, in my opinion, is the patient with early endometriosis without significant ovarian enlargement or adhesions limiting tubal or ovarian mobility. In these cases, danazol therapy (discussed elsewhere in this symposium) appears to offer very good results. A report by Garcia and David that 65% of a group of 17 patients with minimal endometriosis conceived within 2 years without treatment questions the need for therapy in this group of patients. I believe therapy is indicated because of concern that the disease may progress in this period of watchful waiting and because of evidence that fertility rates decline both with duration of infertility and duration of disease. I believe a place remains for the use of progestin--estrogen pseudopregnancy in the treatment of early endometriosis without ovarian enlargement when the patient is single or does not desire to become pregnant in the near future. It is particularly indicated if the expense of danazol is prohibitive to the patient. It is not known as yet whether danazol over the long term will or will not provide a lower incidence of recurrence.

Oral contraception.

PIP: Although oral contraception (OC) offers reliable and esthetic contraception for 40-50 million women in the world today, serious complications do occur with its use and must be considered in a basic risk-benefit equation. Thorough knowledge of these complications and their predisposing factors may guide the selection of patients for OC use and management of its use. The following complications are reviewed: Vascular thrombosis (cerebrovascular disease, coronary artery disease), hypertension, carbohydrate metabolism, lipid metabolism, neoplasms (cervical tumors, breast tumors, endometrial carcinoma, benign tumors of the uterus and ovary, liver tumors), subsequent reproductive function (outcome of pregnancy), subjective effects (emotional state), gallbladder disease, liver function, and other effects. The incidence of complications may be decreased by proper prescribing and selection of patients. OC use in hypertensive or diabetic patients is not recommended. They should be used with caution in the younger obese patient and not used in the obese patient over age 35. OC may be prescribed for women over age 35 who do not smoke or have any other risk factor and who are apprised of the possible but uncertain degree of increased risk of coronary occlusion from pill use alone. Women with headaches developing or increasing with OC use should discontinue this method of contraception. It is recommended that women with any of these risk factors who have completed their desired families should be offered surgical sterilization.^ieng