When health issues hit the news headlines, it is important pharmacy teams are able to separate fact from fiction and provide women with accurate, up-to-date advice.

 

One topic frequently raised by women is whether the benefits of hormone replacement therapy (HRT) outweigh the risks. According to a recently published study, HRT significantly increases the risk of ovarian cancer in women over 50 years of age, even if it is only taken for short periods of time. Results from a meta-analysis of 52 separate studies found that taking HRT for five years was linked to one additional case of ovarian cancer per 1,000 women.¹

To put this risk into context, for every 1,700 HRT users, there will be one extra ovarian cancer death. Confirmation of the increased ovarian cancer risk with HRT is likely to reinforce health concerns among the UK’s one million HRT users – particularly given that HRT already has well-documented links to breast cancer, endometrial cancer and blood clots.²

Pharmacy teams can help to reassure anxious female patients by pointing out that the increased risk is modest in clinical terms and that ovarian cancer itself remains a relatively uncommon cancer.

Women in general have only a one-in-50 chance of developing ovarian cancer over their lifetime. While recognising the real risks associated with HRT, it also important to balance these against the proven benefits of treatment. HRT has been shown to reduce the risk of both bowel cancer and osteoporosis, and the relief provided from often unbearable menopause symptoms is, for many women, life-changing.

“For the treatment of menopausal symptoms, the benefits of short-term HRT outweigh the risks in the majority of women, especially in those aged under 60 years,” notes the BNF.² Current advice is that the minimum effective dose of HRT should be used for the shortest duration, with treatment reviewed at least annually.²

In women where osteoporosis is the chief concern, other effective treatment options are available and should be considered. Pharmacists can also provide important lifestyle advice to help women adjust to menopause onset and manage optimally the signs and symptoms produced by falling levels of female hormones. 

Obesity and cancer risk

Another high profile research study, this time on the link between obesity and cancer, saw women singled out as being twice as likely to suffer cancer linked to their weight.³

According to the study by the Internal Agency for Research on Cancer (IARC), an estimated 4.4 per cent of cancer cases in UK men and 8.2 per cent of all cancer diagnoses in UK women, are directly attributable to obesity.³ Worryingly, the UK also ranked joint second highest in the global estimates for the proportion of cancers linked to body weight.

High BMI was associated with a raised risk of nine different malignancies, several of them (postmenopausal breast, ovarian and endometrial cancer) specific to women. Overweight or obese women can be reassured that losing weight through positive, proactive lifestyle and diet changes is proven to reduce this excess cancer risk, and will also help improve general health and well-being.

In one study, women who shed 20lb or more lowered their overall cancer risk by more than 10 per cent compared to women who did not undergo any significant weight loss.⁴

Other research has shown that, by losing 22lbs and keeping the weight off, post-menopausal women can halve their risk of breast cancer.⁴ Although weight loss and food can be complex and emotive issues, pharmacy staff are well placed to provide valuable lifestyle advice and guidance on exercise and healthy diet, as well as signposting female customers to a range of supportive interventions.

Cancer Research UK and Weight Concern have recently joined forces to develop a specific programme to help people maintain a healthy weight. Known as the ‘Top Ten Tips’, the guidance is based on the very latest scientific evidence (see Cancer Research- Top Ten Tips). Although any suggestion of raised cancer risk will always prove worrying for pharmacy customers, evidence shows that making small, simple changes can develop into healthy habits, which carry over into a long-term impact on behaviour and health.

Dementia and death

Statistics released by the Office for National Statistics in February this year show that dementia and Alzheimer’s disease now rank as the leading causes of death in women over 80 years of age in the UK.⁵ Two-thirds of people affected by dementia in the UK are women. So what factors have triggered this apparent increase in dementia prevalence and mortality?

“As people live longer – women more commonly than men – there has been an increase in the number of people living and dying with dementia,” says George McNamara, head of policy at the Alzheimer’s Society. “The increase also reflects a more accurate recording of dementia as a cause of death, increased awareness of the condition and dispels the myth that dementia is a natural part of ageing.”

Current evidence suggests that dementia risk can be reduced by:

• Regular exercise
• Adhering to NHS guidelines on alcohol intake
• Keeping blood pressure well-controlled
• Stopping smoking
• Adopting a Mediterranean-style diet
• Maintaining cholesterol levels at target (especially during mid-life)
• Managing any underlying diabetes and depression effectively.

Mental activities that stimulate the brain such as reading and puzzles can also reduce dementia risk by boosting the brain’s capacity to cope with, and compensate for, physical damage. For women with established dementia, supportive memory aids and strategies can prove particularly useful.

The Memory Handbook, available from the Alzheimer’s Society (Alzheimers Memory Handbook), suggests practical approaches and tools to help people living with mild memory problems. Anyone concerned or worried about their memory should be advised to consult their GP for access to formal testing and treatment.

Women are twice as likely to suffer from cancer linked to their weight as men

 

Type 1 diabetes

Type 1 diabetes is more dangerous for women than men, according to the results of a systematic review of 26 studies. The review showed a higher risk of death from any cause and cardiovascularspecific mortality over a given period in female versus male type 1 diabetics.⁶ Researchers have proposed that this gender inequality could be due to underlying hormonal factors.

It is important to reassure female pharmacy customers with type 1 diabetes that their risk of experiencing any diabetes-related complication, including CV disease and death, can be reduced by effective glycaemic control.

The best way to keep glucose levels within recommended targets is to carry out regular blood sugar testing (up to four times a day), administer insulin therapy as prescribed and follow a healthy balanced diet. Female customers should additionally be aware that fluctuating hormone levels during menstruation can affect blood glucose levels.

It is also important to bear in mind that, although this study indicates that the relative risk of type 1 diabetes-driven mortality is increased in female sufferers, this may not necessarily equate to a higher absolute risk of death – given that women typically outlive men anyway. The results also have no correlation or relevance for women with type 2 diabetes as the study was carried out exclusively in patients with type 1 disease.

Menstruation and smoking

An intriguing insight into why stopping smoking tends to be harder for women than men has been offered by researchers at the University of Montreal, whose study also reveals the impact of the monthly menstrual cycle on both ability and desire to quit.⁷

It has already been established that female smokers become dependent on smoking more quickly than their male counterparts and that addiction to nicotine is established more rapidly. This latest research looked at functional MRI brain scans and found that patterns of craving-related brain activity fluctuated across the female menstrual cycle, with urges to smoke appearing strongest during the follicular phase of the reproductive cycle, which beings immediately after a woman’s period.⁷

The overall conclusion was that women might find it easier to overcome nicotine cravings during the second half of their menstrual cycle when oestrogen and progesterone levels are highest. Giving greater consideration to factors like these, which reflect the underlying biology of addiction, and incorporating them into smoking cessation advice for female customers could prove a valuable refinement to existing pharmacy stop smoking services.

 

Hormones can affect quitting?

 

Aspirin and the link to age

Taking aspirin daily as prophylaxis against cardiovascular disease remains a contentious and confusing issue for many pharmacy customers. Findings from a recent large-scale study involving nearly 28,000 women suggest stronger benefits for low-dose aspirin in women aged 65 and over than their younger female counterparts.⁸ In females under 65 years, the slight reductions in cancer and heart disease risk linked to aspirin use were offset in the study by higher rates of serious bleeding requiring hospitalisation.⁸

In women over 65 years, however, the risk:benefit balance shifted so that overall outcomes were found to be better for those who took aspirin compared to those who did not.⁸ Although the risk of bleeding was still increased, it was counterbalanced by more significant reductions in the risk of colon cancer, heart disease and the commonest type of stroke.

Overall, researchers concluded that for every 32 women aged 65 years and over taking low-dose aspirin for 15 years, there would be one less case of cancer or heart disease than expected without medication.⁸

So does this new research mean that pharmacy staff should now be advocating low-dose aspirin to all their older female customers? At the moment, the overall body of evidence on aspirin is not robust enough for it to be recommended for either the primary prevention of CV disease or cancer risk reduction. It is, however, recommended as secondary prevention in women with established CV disease at a dose of 75mg daily.

It is important to remember that aspirin carries important contraindications and cautions that must always be considered to ensure the optimal risk:benefit balance is maintained, particularly in older female patients. For patients at high risk of GI bleeding, concomitant therapy with a proton pump inhibitor is advised. All female customers over the age of 40 years are eligible for, and should be encouraged to seek, a routine CV risk assessment from their GP.

For women particularly concerned about their cardiovascular health, lifestyle measures such as increasing physical activity, losing weight, stopping smoking, adopting a healthy diet and cutting back on alcohol consumption can be highlighted as key ways of reducing risk. It is also important to encourage adherence to any prescribed medication to control CV risk factors, which may include aspirin or other anticoagulants, as well as antihypertensives and/or statins.