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A pragmatic approach to the management of menopause

Author/s: 
Lega, I. C., Fine, A., Antoniades, M. L., Jacobson, M.

Menopause is defined as 1 year of amenorrhea caused by
declining ovarian reserve or as the onset of vasomotor
symptoms in people with iatrogenic amenorrhea. It is preceded
by perimenopause or the menopause transition, which can last
for as long as 10 years. Although many treatments exist for
menopausal symptoms, fears around the risks of menopausal
hormone therapy and lack of knowledge regarding treatment
options often impede patients from receiving treatment. In this
review, we summarize the evidence for treating menopausal
symptoms and discuss their risks and benefits to help guide
clinicians to evaluate and treat patients during the menopausal
transition (Box 1).
• Menopausal symptoms can occur for as long as 10 years before
the last menstrual period and are associated with substantial
morbidity and negative impacts on quality of life.
• Menopausal hormone therapy is indicated as first-line
treatment of vasomotor symptoms, and is a safe treatment
option for patients with no contraindications.
• Though less effective, nonhormonal treatments also exist to
treat vasomotor symptoms and sleep disturbances.
• It is critical that clinicians inquire about symptoms during the
menopause transition and discuss treatment options with
their patients.

Keywords 
quality of life menopause risk assessment fear Morbidity

A challenging diagnosis: hereditary angioedema presenting during pregnancy

Author/s: 
Chair, I., Lacuesta, G., Nash, C. M., Cook, V.

• Hereditary angioedema (HAE) is a rare autosomal dominant
disorder characterized by recurrent episodes of painful (and
usually asymmetric) swelling without urticaria that leads to
substantial morbidity and even mortality (in the case of
laryngeal involvement) if left untreated.
• Delayed diagnosis and misdiagnosis of HAE are common,
particularly during pregnancy and the postpartum period.
• Hereditary angioedema should be considered in the differential
diagnosis of any patient presenting with unexplained
abdominal pain and recurrent episodes of angioedema
(particularly if asymmetric in nature) without urticaria.
• Tests to confirm the diagnosis of HAE include measurement of
C4 and C1 inhibitor (INH) antigen and function.
• Successful pregnancy and delivery are possible in HAE with
proper medical management, which includes plasma-derived
C1-INH and collaboration with HAE specialists.

Keywords 
abdominal pain Morbidity diagnosis, differential Hereditary angioedema (HAE) female

Mortality and Morbidity in Mild Primary Hyperparathyroidism: Results From a 10-Year Prospective Randomized Controlled Trial of Parathyroidectomy Versus Observation

Author/s: 
Pretorius, M., Lundstam, K., Heck, A., Fagerland, M. W., Godang, K., Mollerup, C., Fougner, S. L., Pernow, Y., Aas, T., Hessman, O., Rosen, T., Nordestrom, J., Jansson, S., Hellstrom, M., Bollerslev, J.

Background: Primary hyperparathyroidism (PHPT) is a common endocrine disorder associated with increased risk for fractures, cardiovascular disease, kidney disease, and cancer and increased mortality. In mild PHPT with modest hypercalcemia and without known morbidities, parathyroidectomy (PTX) is debated because no long-term randomized trials have been performed.

Objective: To examine the effect of PTX on mild PHPT with regard to mortality (primary end point) and key morbidities (secondary end point).

Design: Prospective randomized controlled trial. (ClinicalTrials.gov: NCT00522028).

Setting: Eight Scandinavian referral centers.

Patients: From 1998 to 2005, 191 patients with mild PHPT were included.

Intervention: Ninety-five patients were randomly assigned to PTX, and 96 were assigned to observation without intervention (OBS).

Measurements: Date and causes of death were obtained from the Swedish and Norwegian Cause of Death Registries 10 years after randomization and after an extended observation period lasting until 2018. Morbidity events were prospectively registered annually.

Results: After 10 years, 15 patients had died (8 in the PTX group and 7 in the OBS group). Within the extended observation period, 44 deaths occurred, which were evenly distributed between groups (24 in the PTX group and 20 in the OBS group). A total of 101 morbidity events (cardiovascular events, cerebrovascular events, cancer, peripheral fractures, and renal stones) were also similarly distributed between groups (52 in the PTX group and 49 in the OBS group). During the study, a total of 16 vertebral fractures occurred in 14 patients (7 in each group).

Limitation: During the study period, 23 patients in the PTX group and 27 in the OBS group withdrew.

Conclusion: Parathyroidectomy does not appear to reduce morbidity or mortality in mild PHPT. Thus, no evidence of adverse effects of observation was seen for at least a decade with respect to mortality, fractures, cancer, cardiovascular and cerebrovascular events, or renal morbidities.

Keywords 
Hyperparathyroidism mortality Morbidity trial
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