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women, mostly older, have had break-through or irregular bleeding whilst on the medicament;
even so, most of these tended to show some improvement. A few have been
to hospital for curettage with negative findings. A few of those on the cyclical regime
have menstruated once or twice and then either become alarmed or upset by the menstruation
and have withdrawn themselves from the treatment.
Some others in the younger age-group on the cyclical regime have accepted it for
5 or 6 cycles; but it has taken some persuasion to keep them going. There is no doubt
about the improvement in looks and well-being of those who continue. However, we
doubt whether a technique based on recurrent menstruation in older women will succeed.
Once the women are past the menopause and have ceased to menstruate and hence
experienced the relief of not having to bother with it, they are very loath to go back to
the former menstrual regime. What we need is some method of giving oestrogen and
progestogen without the accompanying menstruation. Our experimental dose of 0.05
mg. of E.O. and 4.0 mg. of Meg. was certainly much too high for the older women.
It is quite possible that a maintenance dose of 0.01 mg. E.O. will be sufficient combined
with say 1.0 mg. or 0.05 mg. of Meg. We have eight very old women on these doses
at present with no bleeding and with great benefit. Most authors on this subject advocate
the cyclical menstrual regime for older women, stating that the endometrium needs
to be shed and cleared every so often. But in the child-bearing years some women have
repeated pregnancies and lactation every year, and may thus have ovulated and menstruated
perhaps only once a year, without seeming to do any harm to the reproductive
organs. It is possible to vary the length of the induced menstrual cycle almost at will;
it is only necessary to vary the day in the cycle at which the progestogen is introduced
and the number of days it is continued. The oestrogen can be interrupted, or taken
continuously; we have found the continuous method best. We think it may be possible
to arrive at a correct combination of oestrogen and progestogen for older women which
will avoid menstruation altogether and still confer the benefits of substitution therapy.
Care is necessary when commencing oestrogen therapy in women who have ceased
menstruating. They seem to react violently to high doses; and especially resent the
discomfort, inconvenience, and even misery of the experience. These effects can
counteract the benefits. Women need careful preparation beforehand, and constant
support and encouragement especially in the early stages. It is important to begin
with very small doses and build up slowly.
Summary of trial
Summarizing the results of this trial, we have found that the best diagnostic tests
for deficiency of oestrogen are : absence of menstruation; loss of skin elasticity; recession
of the genital tract and changes in the cytology. The effects produced by replacement
therapy are : restoration of well-being; improvement in appearance; trophic effect on
genital and other tissues; and emotional stability.
Notwithstanding this replacement therapy, nothing we have done has contributed
to delay of the ageing process.
The need for prevention
There are many other aspects of our work I have not covered. We should try to
push on with the setting up of prevention services for the elderly, or more ideally for
the 50s and over, in your own areas. There are various patterns this service can take,
and we need lots of experiments to find out the most useful techniques. We know
there is a great need, which is constantly increasing and ought to be satified. The
maintenance of health in the elderly is as much a challenge to public health as was the
challenge of infant welfare fifty years ago. Let us meet it with determination.
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