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Healthcare
Women's health issues in haemodialysis patientsChristina Jang, Robin J Bell, Vikki S White, Petrova S Lee, Karen M Dwyer, Peter G Kerr and Susan R Davis
MJA 2001; 175: 298-301
For editorial comment, see Hawley
Abstract -
Methods -
Results -
Discussion -
References -
Authors' details
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More articles on Obstetrics & gynaecology and women's health
Abstract |
Objectives: To describe reproductive health issues
in women with end-stage renal disease (ESRD) treated with
haemodialysis. Study design: Cross-sectional survey based on structured interviews. Setting: Nephrology units of two major metropolitan tertiary referral hospitals in Victoria and their satellite dialysis centres between 1 November 1998 to 30 June 1999. Methods: Outcome measures: Menstrual status; prevalence of menstrual and climacteric symptoms; use of gynaecological screening; and prevalence of comorbidities that may benefit from hormone replacment therapy. Results: 48 women completed the survey. They were similar to the 485 women undergoing haemodialysis in Victoria in age (mean age, 55.5 years; range, 20-84 years), years on dialysis (mean age, 3.9 years; range, 1 month-17 years) and primary diagnosis. Eleven of the 15 premenopausal women reported menstrual cycles of 22-35 days, 13 reported common premenstrual symptoms, and six reported dysmenorrhoea that interfered with daily activities. Average age at menopause was 47.7 years (95% CI, 45.6-49.9 years), and six of the 31 postmenopausal women underwent menopause before 45 years. Eight had ever been prescribed hormone replacement therapy (oral in all cases). Over half the women (26) had not had a Pap smear in the last two years, and 12 of those aged over 50 (38%) had not had a mammogram in the same period. Conclusion:Despite their risk of early menopause, cardiovascular disease and bone fracture, few women undergoing haemodialysis were offered hormone replacement therapy. Nor were they adequately screened for gynaecological cancers. Women's health issues seem to be neglected among haemodialysis patients.
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Chronic renal failure is associated with neuroendocrine disturbances, menstrual disorders and sexual dysfunction,1 and it has been generally accepted that most women undergoing long-term haemodialysis are amenorrhoeic.2,3 However, a North American study noted that the development of strategies to address women's health issues among haemodialysis patients is limited by lack of information about their menstrual patterns, menopausal symptoms, sexual function and use of preventive screening.4 The situation is similar in Australia. As nephrologists increasingly assume the role of primary healthcare providers for haemodialysis patients, with the role of general practitioners less well defined, routine health matters may be overlooked. The problem is increasing as more people enter dialysis programs for end-stage renal disease (ESRD),5 and as their survival improves. Issues unique to women undergoing haemodialysis deserve greater attention. Our aim was to describe the menstrual status, prevalence of menstrual and climacteric symptoms, comorbidities that may benefit from hormone replacement therapy and use of gynaecological cancer screening among women undergoing haemodialysis for ESRD in Victoria.
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Methods |
The study was a cross-sectional survey based on structured interviews. Ethics approval was obtained from the research and ethics committees of both Monash Medical Centre and St Vincent's Hospital, Melbourne. | ||
| Women were eligible if they were aged 20 years or over and were undergoing haemodialysis for ESRD at two tertiary care hospitals (Monash Medical Centre and St Vincent's Hospital, Melbourne) or their associated satellite dialysis centres in Victoria during the survey period, 1 November 1998 to 30 June 1999. Participants were identified from haemodialysis schedules provided by each centre. Exclusion criteria included inadequate spoken English, acute illness and inability to give written informed consent. | |||
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Participants were interviewed by a psychologist (V S W) at the
centre where they underwent haemodialysis (43 women), or, for those
undergoing home haemodialysis, by telephone (4) or at home (1).
The survey asked about demographic details, history of renal disease, menstrual history, menstrual or menopausal symptoms, pregnancies, gynaecological surgery, sexual function, use of Pap smears and mammograms, medications and comorbidities (eg, diabetes mellitus, cardiovascular disease and osteoporosis). | |||
Frequencies were compared using the  2 test (Yates corrected where
appropriate) or Fisher's exact test, if the expected cell frequency
was less than 5.
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Results | Between 1 November 1998 and 30 June 1999, 73 women aged 20 years and over were listed as undergoing haemodialysis at participating centres. Forty-eight (66%) completed the survey, and 19 were excluded (non-English-speaking [11], too ill [5] or died, changed to peritoneal dialysis or underwent kidney transplantation before interview [1 each]), four were unavailable, and two declined interview. In Victoria as a whole, 485 women aged 20 years or over had haemodialysis in the study period.4 | ||
| The 48 participants were aged 20 to 84 years. Their age distribution and documented cause of ESRD matched closely those of the female haemodialysis population in Victoria5 (Box 1). Average duration of dialysis was 3.9 years (range, 1 month to 17 years), also matching the average duration for female haemodialysis patients in Victoria (mean, 3.9 years; range, 1 month to 25 years).5 Twenty-seven women (56%) were married or in a defacto relationship, 12 (25%) were widowed or divorced, and nine (19%) were single. There are no comparable Victorian data for relationship status. | |||
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Fifteen women (31%) were classified as premenopausal (<
12 months amenorrhoea and no climacteric symptoms), including one
who was taking medroxyprogesterone acetate and had irregular
menses. Thirty-one women (65%) were classified as
postmenopausal (> 12 months amenorrhoea, surgical menopause or
irregular cycles, and persistent vasomotor symptoms), while two
(4%) were classified as perimenopausal as they had
climacteric symptoms but had not been amenorrhoeic for 12 months
(ages, 46 and 47 years). Twenty-four women (50%) reported previous
gynaecological surgery; 11 (23%) had had a hysterectomy.
Premenopausal women: Ten of the 15 premenopausal women reported regular menstrual cycles. For 11 women, length of cycles fell between 22 and 35 days. Duration of bleeding was 3-9 days (12 women), less than 3 days (2, including the woman taking medroxyprogesterone acetate) and longer than 9 days (1). Bleeding was described as moderate or heavy by 14 women. Premenstrual symptoms were reported by 13 of the 15 premenopausal women (Box 2). Seven reported dysmenorrhoea, which interfered with daily activities in six, and for which four took medication. Postmenopausal women: 31 women were postmenopausal, for between 1.5 and 44 years. Two women had had surgically induced menopause (hysterectomy and bilateral oophorectomy). Of the 29 with non-surgical menopause, 27 reported their age at the time. Their average age at menopause was 47.7 years (95% CI, 45.6-49.9 years). Six women experienced early menopause (< 45 years), including one woman with premature menopause at 35 years. Three women experienced menopause after begining haemodialysis (at ages 49 [2 women] and 53 years [1]). Oestrogen-deficiency symptoms are shown in Box 2. Twelve postmenopausal women and one perimenopausal woman reported that their doctors had ever suggested hormone replacement therapy (HRT), and eight (all postmenopausal) had been prescribed this therapy — oral HRT in all cases. | |||
| Thirty-seven of the 48 participants (77%) reported having been pregnant, and all but two of these had given birth to at least one child. We did not explore the relationship between pregnancy and dialysis. | |||
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Twenty-five women reported being in a sexual relationship (20 of the
24 who were married or in a defacto relationship and five of the 23 who
were single, divorced or widowed). Among postmenopausal women,
those who had been prescribed HRT were more likely to be in a sexual
relationship (7 of 8 versus 9 of 22 not prescribed HRT; P =
0.04). Eight premenopausal women reported being in a sexual
relationship; three of these were not using contraception and had not
had a tubal ligation or hysterectomy (ages, 34, 41 and 51 years).
Of 42 women who responded to the question "Are you experiencing diminished sexual interest?", 14 answered that they were (33%). Three of 15 premenopausal women reported diminished sexual interest, compared with 10 of 25 postmenopausal women, a difference which was not statistically significant (P = 0.30). Four women reported that this was problematic in their relationships (one premenopausal, one perimenopausal and two postmenopausal women). | |||
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Most recent screening for breast or cervical cancer is shown in Box 3.
Twenty-two women (45%) reported that they had had a Pap smear within
the previous two years. This was more likely among premenopausal than
postmenopausal women (11 of 15 versus 10 of 31; P = 0.02). Three
of the 15 women on the current renal transplant list had not had a Pap
smear within the previous two years and did not report having a
hysterectomy (ages, 20, 38 and 57 years). Ten women (21%)
reported never having a Pap smear.
Breast self-examination was performed regularly by 24 of the 36 women
who had been shown how to do this by a medical practitioner, and by none
of the 12 women who had never been shown ( | |||
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All women were taking some form of medication. Forty-six of the 48 were
taking caltrate or calcitriol, and 37 were taking erythropoietin.
Fourteen women were being treated for hyperlipidaemia, and 26 for
hypertension. Seven women were current cigarette smokers.
Ten women (21%) had diabetes mellitus, and 18 (38%) had
cardiovascular disease. Prevalence of cardiovascular
disease was greater in those with a family history (14 of 24 versus 4 of
24 with no family history; Fourteen women had a history of bone fracture, 11 of whom were postmenopausal. Only one postmenopausal woman with past fracture was taking HRT at the time of the fracture, and two had previously taken HRT. None had been prescribed a bisphosphonate. Risk of fracture was higher in women with a family history of osteoporosis (6 of 8 versus 8 of 40 with no family history; P = 0.005). | |||
Discussion |
We found that the average age of menopause among women undergoing
haemodialysis in our study was 47.7 years. About a third of the women
were premenopausal, and most of these had menstrual cycles which
appeared ovulatory on the basis of cycle length and regularity and
presence of premenstrual symptoms.6 A third of women who
answered a question about sexual interest reported that it was
diminished. More than half the women had not had a Pap smear in the
previous two years, and more than a third of those aged over 50 years had
not had a mammogram in this period. Although our sample was small, it
was representative of the adult female haemodialysis population of
Victoria in terms of age, cause of ESRD and time on dialysis.
Our finding that most premenopausal women had apparently ovulatory menstrual cycles accords with results of a 1997 study of North American women.3 In contrast, earlier studies suggested a high rate of amenorrhoea among women with ESRD, and this difference has been attributed partly to the introduction of recombinant human erythropoietin to correct the anaemia of chronic renal failure in the late 1980s.1 Erythropoietin reduces prolactin levels7 and may thereby restore ovulation and improve sexual function. Correction of anaemia, and consequent improved well-being, appetite and nutritional status, could also contribute to improved reproductive function.8,9 Greater emphasis over the past decade on delivery of adequate dialysis may have similar effects, although definitive evidence is lacking. Women with ESRD tend to undergo menopause earlier than healthy women, at an average age of 4710 versus 51.5 years.11 Mean age in our participants (47.7 years) is consistent with previous findings.10,4 The hysterectomy rate of 23% in our participants reflects the rate reported for Australian women overall.12 Sexual dysfunction is a feature of chronic renal failure, with many women complaining of decreased libido and inability to achieve orgasm.11 In our study, a third of responding women reported diminished sexual interest. This occurred despite the high rate of erythropoietin use. Clearly, the pathogenesis of sexual dysfunction is complex, involving not only hormonal factors, but also psychological concerns, body image, nutritional status and comorbid medical conditions. It appeared that sexual issues and contraception among these women were not being adequately addressed. Another concern is that a large proportion of women in this group had not been screened for gynaecological cancers according to current guidelines. In Australia, all women are advised to have a Pap smear every two years from the age of 18, or commencement of sexual activity, until the age of 70.13 Screening mammography for breast cancer is recommended two-yearly for women between the ages of 50 and 70 years.14 Although these guidelines are not followed by all women in the general population, women undergoing haemodialysis have increased risk of gynaecological malignancies,10 which may indeed increase further with immunosuppression after transplantation. The failure of three women on the transplant waiting list to have recommended cervical screening suggests poor clinical practice. The leading cause of death among postmenopausal women with ESRD is cardiovascular disease (42% of all deaths).5 Nearly 38% of our study population reported having cardiovascular disease, which was significantly associated with family history, but not diabetes. The extent to which the excessive cardiovascular mortality of ESRD is a consequence of oestrogen deficiency exacerbating the adverse lipoprotein lipid profile of the anephric state requires investigation.15 In addition, a third of postmenopausal women reported a history of fracture and are at considerable risk of recurrent fracture.16 The role of HRT in postmenopausal women undergoing dialysis is uncertain. While benefits would be expected in terms of fracture prevention, they must be weighed against possible complications, especially thrombosis. In particular, patients bearing fistulas made from artificial materials (eg, polytetrafluoroethylene) appear to have a higher risk of thrombosis if their haemoglobin concentration is higher than 12g/dL.17 The risk may be further exacerbated by routine erythropoietin use. Women on maintenance haemodialysis have impaired oestrogen clearance,15 and hence oestrogen therapy should be low dose. Transdermal therapy is preferable to oral therapy, as it is less likely to be procoagulant,18 and circulating levels can be monitored.15 All women treated with HRT in our study were taking it orally. None used local vaginal oestrogen, which, considering the high frequency of sexual problems, is surprising. Dialysis patients have complex health problems requiring specialist care which, combined with their frequent hospital attendance, can result in neglect of the routine health management normally undertaken in general practice. Our findings highlight the need for comprehensive well-woman care programs in dialysis units, incorporating cancer screening, sexual counselling, contraceptive advice, menopausal management and fracture prevention. | ||
References |
(Received 27 Nov 2000, accepted 14 May 2001) | ||
Authors' details | |||
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Jean Hailes Foundation Research Unit, Melbourne, VIC.
Christina Jang, MB BS, Research Registrar; Robin J Bell, PhD, FAFPHM, Consultant Epidemiologist; Vikki S White, Grad Dip Appl Psych, MPH, Research Coordinator; Susan R Davis, PhD, FRACP, Director of Research, and Associate Professor, Department of Preventive Medicine, Monash University, Melbourne, VIC. St Vincent's Hospital, Melbourne, VIC.
Monash Medical Centre, Melbourne, VIC.
Reprints will not be available from the authors. ©MJA 2001
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50 years (n = 31*)