Practice Guidelines
AHRQ Releases Evidence Report on Managing Menopause-Related Symptoms
The Agency for Healthcare Research and Quality (AHRQ) has released the results of a systematic review on managing menopause-related symptoms. The full report, Evidence Report/Technology Assessment No. 120, "Management of Menopause-Related Symptoms," is available online at http://www.ahrq.gov/clinic/epcsums/menosum.htm.
By definition, menopause is the permanent cessation of menses caused by reduced ovarian hormone secretion. Menopause usually occurs in women 40 to 58 years of age, and it may take several years to fully transition from onset to completion. During this time, many women experience symptoms that can cause reduced quality of life. Common menopause-related symptoms include:
• Hot flashes
• Vaginal dryness
• Sleep disturbance
• Mood symptoms
• Cognitive disturbances
• Somatic complaints
• Urinary complaints
• Uterine bleeding
Many therapies exist to manage these symptoms, including hormone therapy, antidepressants and other drugs, behavioral interventions, and complementary and alternative medicine.
The AHRQ evidence report evaluates the benefits and harms of common interventions to relieve menopause-related symptoms. The review included American women who were going through menopause and who presented with at least one of the above symptoms. A technical expert panel, which was made up of experts and clinicians in the field, and expert reviewers provided input for this review.
Managing Menopausal Symptoms
estrogen
Estrogen was the most consistently effective intervention for vasomotor symptoms. The therapy also helped manage urogenital symptoms, along with sleep, mood, sexual, and quality-of-life outcomes compared with placebo. The most common adverse effects of estrogen therapy were breast tenderness and uterine bleeding.
testosterone and estrogen
The reviewers found few trials evaluating testosterone therapy. However, one trial showed no difference between combination testosterone and estrogen therapy and estrogen therapy alone for hot flashes, vaginal dryness, or sleep problems. The results of two trials showed that testosterone and estrogen therapy improved sexual symptoms better than estrogen alone or placebo. However, women receiving combination therapy had significantly more incidences of acne and hirsutism compared with those in the estrogen-only group.
progestin
Trials showed varying results regarding progestin in the management of vasomotor symptoms.
tibolone
A few trials of fair to good quality showed that tibolone (Livial) helped manage vasomotor symptoms, sleep, and somatic complaints compared with placebo. Tibolone was similar to estrogen in the management of some symptoms. Patients treated with tibolone experienced more uterine bleeding, body pain, weight gain, and headaches compared with patients who were treated with placebo.
soy isoflavones and other alternative therapies
Although results varied and more research is needed, alternative therapies were beneficial in managing some nonvasomotor symptoms.
Conclusion
Trials evaluating therapies for the management of menopause-related symptoms were conclusive only for estrogen in the management of vasomotor and urogenital symptoms. After further research, other therapies may demonstrate beneficial results.
limitations
The trials included in this evidence review had the following limitations:
• Highly selected, small sample groups
• Short duration
• Inadequate reporting of loss to follow-up, maintenance of comparable groups, contamination, methods of analysis, and adverse events
• Some nonstandardized and nonvalidated measures and outcomes
• Unclear inclusion and exclusion criteria
• Industry sponsorship
further research
Research is needed to fill in the gaps of this evidence review. Researchers should focus on determining optimal effective dosing, combination regimens, duration of use, and timing of therapy. Trials also should include head-to-head and placebo comparisons of estrogen alone and combined with other therapies, including nondrug interventions, as well as the best way to discontinue estrogen therapy after the symptoms subside.
Practice Guideline Briefs
CDC Recommendations on Lead Poisoning in Refugee Children
The Centers for Disease Control and Prevention (CDC) has released recommendations on identifying and treating lead exposure in refugee children. The full report, "Recommendations for Lead Poisoning Prevention in Newly Arrived Refugee Children," is available online at http://www.cdc.gov/nceh/lead.
Although blood lead levels in children one to five years of age are decreasing in the United States, the prevalence of elevated blood lead levels among newly resettled refugee children is substantially higher than in children born in the United States.
The CDC recommends that physicians test blood lead levels for all refugee children six months to 16 years of age upon entering the United States. After children six months to six years of age are placed in permanent residences, testing should be repeated in three to six months. In older children, testing should be repeated if a child has a sibling with elevated blood lead levels, regardless of his or her initial test results.
The CDC guidelines recommend performing nutritional evaluations for all refugee children upon their arrival in the United States, and providing appropriate nutritional and vitamin supplements when needed. Physicians also should evaluate the value of iron supplementation in refugee children.
AAP Policy on Caring for Immigrant, Migrant, and Homeless Children
The Committee on Community Health Services of the American Academy of Pediatrics (AAP) has developed a new policy statement on providing health care for immigrant, homeless, and migrant children. The policy statement, which appears in the April 2005 issue of Pediatrics, supports a community-based approach to ensure that underserved children get the care they need. Persons in medically underserved communities face many obstacles to health care-such as poverty, lack of insurance, low level of English language proficiency, and the more urgent need for food and accommodation-and often seek health care on a crisis-oriented rather than preventive basis. The AAP urges physicians to provide compassionate and effective health care services to all children living in the United States, regardless of status. Physicians should be aware of alternative sources of funding or medical provision, and of supportive resources in their local area (a list of resources is provided in the statement). In addition, the AAP committee recommends that physicians develop and maintain cultural and linguistic knowledge and skills, and advocate on behalf of underserved children.
According to the AAP committee, physicians fill a unique role in medically underserved communities and should therefore understand the particular health issues common to these communities. Many of these issues are listed in the statement. For migrant families (e.g., farm workers), potential issues include overcrowded housing, poor sanitation, and cultural isolation. Migrant children are at increased risk for respiratory, skin, and ear infections, as well as gastroenteritis, parasites, tuberculosis, lead exposure, poor nutrition, undiagnosed congenital abnormalities, delayed development, and occupational injuries.
Specific issues faced by homeless children include trauma-related injury, developmental delays, visual or neurologic deficits, sinusitis, anemia, bowel dysfunction, obesity, and hunger. Homeless children also are at increased risk for violence, substance abuse, pregnancy, and sexually transmitted diseases.
Stressors experienced by immigrant families include acculturation-induced depression; separation from support systems; traumatic experiences such as war or persecution; and trouble adapting to the school environment, with consequent depression, posttraumatic stress disorder, or conduct disorders. Physicians also need to be mindful of diseases that are rare in the United States but common to the patient's country of origin (e.g., malaria).
Children may be lacking screening and vaccinations that are routine in the United States, and the AAP recommends that physicians perform these according to standard protocols. Screenings for developmental delays should be part of the initial well-child assessment. Children who do not meet established weight or height measures should be monitored closely. The AAP committee also states that physicians should be aware of traditional medications that may interfere with prescribed therapy, and of medical beliefs that may cause noncompliance.
The AAP committee recommends that physicians caring for homeless, migrant, and immigrant children incorporate screening for social and environmental circumstances into routine assessments. Information about housing, healing practices, and medication use should be obtained respectfully as part of the patient history. The AAP advises the introduction of tracking systems such as portable medical records to ensure that homeless children receive at least basic health care. Physicians need to consider the limitations concomitant with homelessness, such as lack of refrigeration for medications.
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