Reprint of The nature and utility of the phytoestrogens: a review of the evidence.

Non-prescription remedies are becoming increasingly popular particularly amongst postmenopausal who in this market are the largest consumers. Phytoestrogens are a large family of plant derived molecules possessing various degrees oestrogen like activity. Food or food supplements containing phytoestrogen are often been advocated as an alternative to hormonal replacement therapy (HRT) in women with contraindications to the use of conventional oestrogen replacement, or simply wanting a more 'natural' alternatives. There have been several studies performed with phytoestrogen in various aspects of the postmenopausal women health. Results have been sometimes conflicting and difficult to interpret. The lack of knowledge of what precisely is the active ingredient, its minimally effective doses, the lack of standardisation of the preparations used as well as the large individual variability of metabolism of precursors introduced with the diet may all have played a role in confusing the issue about effectiveness of these compounds. Phytoestrogen fall in the gray area between food and drugs hence in spite of the vast public interest, there are no interests in company producing these supplements in investing in research from which they will not exclusively benefit from. It is difficult for the physician to know how to advise patients on this matter. In this paper we critically review the clinical data available to date in an attempt to answer some of the most commonly asked questions about dose and type of phytoestrogens supplementation most likely to be effective in different aspects of climacteric woman health.

Efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo-controlled trial.

OBJECTIVE: Evaluation of the use of testosterone therapy for hypoactive sexual desire disorder (HSDD) after oophorectomy has mostly involved women treated with oral estrogen preparations. We investigated the efficacy and safety of a testosterone patch in surgically menopausal women receiving concurrent transdermal estrogen. DESIGN: Women with HSDD after oophorectomy, for whom this was a concern, who were using transdermal estrogen, were recruited to a 24-week, randomized, double-blind, placebo-controlled trial in Europe and Australia. Patients were randomly allocated to placebo (n = 40) or testosterone 300 microg/day (n = 37) treatment. Primary endpoints were changes in sexual desire measured by the sexual desire domain of the Profile of Female Sexual Function and the frequency of satisfying sexual activity at 24 weeks. RESULTS: Sixty-one women (79%) completed the trial. All subjects who received at least one application of study medication were included in analysis. The testosterone-treated group experienced a significantly greater change from baseline in the domain sexual desire score compared with placebo (change from baseline, 16.43 versus 5.98; P = 0.02). The domain scores for arousal, orgasm, decreased sexual concerns, responsiveness, and self-image as well as decreased distress were also significantly greater with testosterone therapy than placebo. The frequency of satisfactory sexual events increased but was not statistically different between treatment groups (P = 0.06) Adverse events occurred with similar frequency in both groups, and no serious risks of therapy were observed CONCLUSIONS: In this study, transdermal testosterone therapy via a skin patch improved sexual desire and other sexual function domains. It was well tolerated in these oophorectomized women with HSDD receiving concomitant transdermal estrogen.

A cost-utility analysis of low-dose hormone replacement therapy in postmenopausal women with an intact uterus.

OBJECTIVE: The objective of this study was to evaluate the cost utility of one year's treatment with a low-dose conjugated estrogen/medroxyprogesterone acetate (CE/MPA low dose) preparation (Premique Low Dose [Wyeth Pharmaceuticals, Maidenhead, UK]), compared with a higher-dose preparation (Premique; CE/MPA [Wyeth Pharmaceuticals, Maidenhead, UK]), in postmenopausal women with an intact uterus. The evaluation captured the resource implications associated with the difference in treatment discontinuation and adverse event driven consultations in patients receiving either the low- or higher-dose preparation. This economic evaluation was conducted from the perspective of the NHS. RESEARCH DESIGN AND METHODS: A health economic model was developed to calculate the incremental cost per quality-adjusted life year (QALY) gained from treatment with a lower-dose CE/MPA combination, compared with a higher-dose CE/MPA preparation. Cohorts of 100 patients were assumed to receive either CE/MPA low dose or CE/MPA for one year. A probabilistic sensitivity analysis was used to explore whether the base case model was robust to the assumptions employed. Neither costs nor consequences were discounted because of the one year timeframe. RESULTS: In the base case, CE/MPA low dose dominates, i.e. it showed a greater health gain at a reduced cost, in both mild and severe symptom populations. These results were repeated in the sensitivity analysis, with the cost-effectiveness planes for both mild and severe symptom populations showing a greater utility at a reduced cost. CONCLUSIONS: CE/MPA low dose has been demonstrated to be a cost-effective treatment of estrogen-deficiency symptoms in postmenopausal women with an intact uterus. It has great potential for increasing the number of patients benefiting from relief of menopausal symptoms while also reducing the resource utilisation associated with managing the adverse effects associated with higher-dose HRT.

Influence of estrogen therapy at conventional and high doses on the degree of mineralization of iliac bone tissue: a quantitative microradiographic analysis in postmenopausal women.

The beneficial skeletal effects of menopausal estrogen replacement therapy (HRT) are well documented. The role of secondary mineralization of bone as a determinant of bone quality is now well established in postmenopausal women treated with bisphosphonates or SERMs. The aim of present study was to investigate the effect of conventional and high doses of estrogen on the main parameters reflecting the degree of mineralization of bone (DMB). Bone biopsies were obtained from 20 women with osteopenia or osteoporosis before and after 24 months (18 to 38 months) of conventional HRT, and from 19 women who had received high doses of estradiol (implant 100 mg every 3-6 months for 1.5-20 years). DMB parameters (mean DMB, DMB Freq. Max. and Heterogeneity Index of the individual distributions of DMB) were measured using quantitative microradiography in cortical, cancellous, and total bone and expressed as g mineral/cm(3) bone. Values obtained in women before HRT were lower than those reported in pre- and postmenopausal control women. After conventional HRT, there was an increase in mean DMB (total bone) of 4.4 +/- 1.9% (mean +/- SEM) versus pre-treatment values (4.1 +/- 2.1% in cortical bone, 4.5 +/- 2.3% in cancellous bone); these differences did not reach statistical significance (P = 0.055). Results were similar for DMB Freq. Max. but Heterogeneity Index was not significantly changed. After high dose estradiol therapy, mean DMB (total bone) was 6.9 +/- 1.9% higher than in untreated women (8.6 +/- 2.1% in cortical bone, 6.5 +/- 2.1% in cancellous bone); this difference was statistically significant (P

Gabapentin for the management of hot flushes: a case series.

OBJECTIVE: To audit the effectiveness of the anticonvulsant gabapentin on hot flushes in postmenopausal women. DESIGN: This was an open case series involving 11 postmenopausal women who were willing to take gabapentin for the relief of their hot flushes and were willing to keep a diary recording the number and intensity of their hot flushes, both before and during treatment. Gabapentin was started at a dose of 300 mg, to be taken at night, and the women were instructed to increase the dose up to 1,200 mg, according to symptom behavior. RESULTS: Eleven women agreed to participate for on average 53.22 days (range, 2-79 days), but two discontinued participation-one before starting treatment and one after 2 days-so there are complete data sets for nine women. Gabapentin was found to be extremely effective in reducing hot flush activity (P < 0.001; Fig. 1). A significant reduction in symptoms was observed with a dose of 300 mg/day (P < 0.001). Scores on the Green Climacteric Scale were significantly improved from a mean of 25.72 (range, 12-42) to 19.25 (range, 13-31; P < 0.001). Palpitations (P = 0.001), panic attacks (P = 0.0001), mood (P = 0.023), muscle and joint pains (P = 0.021), and paresthesias and loss of sensation in the extremities (P = 0.001) were also shown to improve with treatment. CONCLUSIONS: In the present case series, gabapentin was well tolerated and could be a valuable alternative for the treatment of hot flushes in women with contraindications to hormonal replacement therapy. It would be particularly beneficial for women in whom aches and pains and paresthesias are also a significant feature of the climacteric syndrome.

Classical Greek and Roman rhetoric and the modern audience.

The formal structuring of oral discourse or rhetoric was highly developed in antiquity. Both Greek and Roman authorities on the subject codified for orators an arrangement of material and a contextual format which have utility in the present day. The art of public lecturing should encompass relevance of material, structure of presentation and style of delivery in order to render the whole enjoyable and memorable. Teaching does not cause learning, but skilful rhetorical technique can imbue the student with a potent desire for further self-directed study. In this field, the ancient is auxiliary to the modern.

Hyperparathyroidism in elderly osteopenic women.

Raised levels of parathyroid hormones (PTH) predispose to osteoporotic fracture particularly in the elderly. The true prevalence of primary or secondary hyperparathyroidism is unknown, as PTH evaluation is not performed as a screening test in the elderly. We report raised PTH levels in 27 of 190 (14.2%) community living fully mobile postmenopausal women with densitometrically established osteopenia, consuming an average of 645 (+/-191) mg of calcium per day. Twenty-five of the 27 women with raised PTH were normocalcaemic, hypercalcaemia been found only in two. Serum 25 hydroxy vitamin D levels were all within the normal range (above 22 nmol/l). Women with a raised PTH were significantly older and their serum 25 hydroxy vitamin D levels were significantly lower than those women with normal PTH values. These data suggest that in community leaving healthy postmenopausal women, normocalcaemic hyperparathyroidism, in the presence of what are still considered normal vitamin D levels, may be common. This may suggests that widespread supplementation with calcium and vitamin D may be required in postmenopausal women for PTH suppression and preservation of bone mass.