Menopause is a natural biological process that marks the end of a woman’s reproductive years, typically between 45 and 55. As women approach or experience menopause, common “change of life” concerns include hot flushes, sweats and mood swings, brain fog and fatigue.

But many women may not be aware of the long-term effects of menopause on the heart and blood vessels that make up the cardiovascular system. Heart disease accounts for 35% of deaths in women each year – more than all cancers combined.

What should women – and their doctors – know about these risks?

Hormones protect hearts – until they don’t

As early as 1976, the Framingham Heart Study reported more than twice the rates of cardiovascular events in postmenopausal than pre-menopausal women of the same age. Early menopause (younger than age 40) also increases heart risk.

Before menopause, women tend to be protected by their circulating hormones: oestrogen, to a lesser extent progesterone and low levels of testosterone.

These sex hormones help to relax and dilate blood vessels, reduce inflammation and improve lipid (cholesterol) levels. From the mid-40s, a decline in these hormone levels can contribute to unfavourable changes in cholesterol levels, blood pressure and weight gain – all risk factors for heart disease.

4 ways hormone changes impact heart risk

1. Dyslipidaemia– Menopause often involves atherogenic changes – an unhealthy imbalance of lipids in the blood, with higher levels of total cholesterol, triglycerides, and low-density lipoprotein (LDL-C), dubbed the “bad” cholesterol. There are also reduced levels of high-density lipoprotein (HDL-C) – the “good” cholesterol that helps remove LDL-C from blood. These changes are a major risk factor for heart attack or stroke.

2. Hypertension – Declines in oestrogen and progesterone levels during menopause contribute to narrowing of the large blood vessels on the heart’s surface, arterial stiffness and raise blood pressure.

3. Weight gain – Females are born with one to two million eggs, which develop in follicles. By the time they stop ovulating in midlife, fewer than 1,000 remain. This depletion progressively changes fat distribution and storage, from the hips to the waist and abdomen. Increased waist circumference (greater than 80–88 cm) has been reported to contribute to heart risk – though it is not the only factor to consider.

4. Comorbidities – Changes in body composition, sex hormone decline, increased food consumption, weight gain and sedentary lifestyles impair the body’s ability to effectively use insulin. This increases the risk of developing metabolic syndromes such as type 2 diabetes.

While risk factors apply to both genders, hypertension, smoking, obesity and type 2 diabetes confer a greater relative risk for heart disease in women.

So, what can women do?

Every woman has a different level of baseline cardiovascular and metabolic risk pre-menopause. This is based on their genetics and family history, diet, and lifestyle. But all women can reduce their post-menopause heart risk with:

• regular moderate intensity exercise such as brisk walking, pushing a lawn mower, riding a bike or water aerobics for 30 minutes, four or five times every week
• a healthy heart diet with smaller portion sizes (try using a smaller plate or bowl) and more low-calorie, nutrient-rich foods such as vegetables, fruit and whole grains
• plant sterols (unrefined vegetable oil spreads, nuts, seeds and grains) each day. A review of 14 clinical trials found plant sterols, at doses of at least 2 grams a day, produced an average reduction in serum LDL-C (bad cholesterol) of about 9–14%. This could reduce the risk of heart disease by 25% in two years
• less unhealthy (saturated or trans) fats and more low-fat protein sources (lean meat, poultry, fish – especially oily fish high in omega-3 fatty acids), legumes and low-fat dairy
• less high-calorie, high-sodium foods such as processed or fast foods
• a reduction or cessation of smoking (nicotine or cannabis) and alcohol
• weight-gain management or prevention.

What about hormone therapy medications?

Hormone therapy remains the most effective means of managing hot flushes and night sweats and is beneficial for slowing the loss of bone mineral density.

The decision to recommend oestrogen alone or a combination of oestrogen plus progesterone hormone therapy depends on whether a woman has had a hysterectomy or not. The choice also depends on whether the hormone therapy benefit outweighs the woman’s disease risks. Where symptoms are bothersome, hormone therapy has favourable or neutral effects on coronary heart disease risk and medication risks are low for healthy women younger than 60 or within ten years of menopause.

Depending on the level of stroke or heart risk and the response to lifestyle strategies, some women may also require medication management to control high blood pressure or elevated cholesterol levels. Up until the early 2000s, women were underrepresented in most outcome trials with lipid-lowering medicines.

The Cholesterol Treatment Trialists’ Collaboration analysed 27 clinical trials of statins (medications commonly prescribed to lower cholesterol) with a total of 174,000 participants, of whom 27% were women. Statins were about as effective in women and men who had similar risk of heart disease in preventing events such as stroke and heart attack.

Every woman approaching menopause should ask their GP for a 20-minute Heart Health Check to help better understand their risk of a heart attack or stroke and get tailored strategies to reduce it.

Treasure McGuire, Assistant Director of Pharmacy, Mater Health SEQ in conjoint appointment as Associate Professor of Pharmacology, Bond University and as Associate Professor (Clinical), The University of Queensland

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Spinal cord stimulators are electrical devices that are surgically implanted in the body to treat long-term pain. They have a battery pack and leads that deliver electrical impulses directly to the spinal cord. The devices are thought to work by providing electrical impulses that interfere with how the brain senses pain.

Spinal cord stimulators are mainly used to treat chronic back pain, especially when other less invasive treatments have not worked. They also aim to reduce people’s reliance on risky pain medicines. These include opioids, which research shows are ineffective and harmful for low-back pain.

But research, including our own, shows spinal cord stimulators work no better than a placebo. And they can also carry risks.

Do they work?

In a 2023 Cochrane review, researchers reviewed data from 13 randomised controlled trials on low-back pain and found no benefits in the short and medium term. These international reviews draw together the most robust evidence to provide a detailed summary of what we know on a particular topic.

Only one of the trials in the review tested efficacy in the longer term (six months). That trial found no benefits of spinal cord stimulation.

An earlier Cochrane review looked at the evidence of spinal cord stimulation for chronic pain in general, including for neck pain. Reviewers looked at 15 randomised controlled trials and couldn’t be certain about its benefits, largely due to the quality and reliability of the available trials.

Are there side effects?

Aside from disappointing results for pain relief, there are risks and side effects to consider.

We co-authored an analysis of 520 adverse events reported to Australia’s Therapeutic Goods Administration (TGA). We found 79% of reported events were rated as severe, with 13% life-threatening. The same research found 80% of events required surgery to correct.

Our recent analysis in the Medical Journal of Australia looked at data from private health insurers. These cover 90% of spinal cord stimulation implants in Australia. Five major insurers, which covered 76% of privately insured people, contributed de-identified data.

We found about one-quarter of people who had a spinal cord stimulator implanted needed corrective surgery afterwards. These surgeries occurred within a median of about 17 months. This indicates these surgeries are not routine or expected interventions, such as to replace batteries, which are meant to last five to ten years.

Our previous research shows the sorts of reasons for corrective surgery. These include to replace a malfunctioning device, or the person was in more pain, had an infection, or a puncture of the delicate tissues covering the spinal cord.

However, even our latest findings are likely to underestimate the risk of these devices.

Sometimes the lead delivering the electrical current moves away from the spinal cord to elsewhere in the body. This requires surgery to reposition the lead, but does not necessarily require new hardware, such as a brand new lead. So this type of corrective surgery is not counted in the data from the private health insurance companies.

How much does it cost?

We found spinal cord stimulators cost about A$55,000 per patient, including the device, its insertion, and managing any associated additional surgeries.

For people who only had a “trial” – where the leads are implanted temporarily but the battery pack remains outside the body – this cost was about $14,000 per patient.

These figures do not include any out-of-pocket costs.

What do regulators say about the devices?

In 2022 the TGA began a review of spinal cord stimulators on the market because of safety and performance concerns.

As a result, several devices were removed from the Australian Register of Therapeutic Goods – that is, they were banned from use in Australia, but existing stock could still be used.

The rest of the devices had conditions imposed, such as the manufacturers being required to collect and report safety data to the TGA at regular time points.

Should I do my own online research?

Yes, but be careful. Unfortunately not all online information about spinal cord stimulators is correct.

Look for sites independent of those who manufacture or implant these devices.

Government agencies, health departments and universities that have no financial interests in this area may be a better option.

The Cochrane Library is also a reliable and independent source for trustworthy health information.

What shall I ask my doctor?

The Australian health department provides useful advice for consumers about medical implants.

It says medical implants “are considered higher-risk therapeutic goods, and the decision to get one should not be taken lightly”. It recommends asking your health professional these questions:

• do I really need this medical implant?
• what are the risks/benefits?
• is the medical implant approved?
• where can I get more information?
• what happens if I experience an adverse event?

What else could I do for my back pain?

There are other treatment options that are effective and have fewer risks than spinal cord stimulation.

For example, education about how to manage your pain yourself, exercise, cognitive behavioural therapy (a type of psychological therapy), and non-steroidal anti-inflammatory medicines (such as ibuprofen) all have solid evidence to back them. All offer benefits that are not outweighed by their potential risks.

Australian research has shown other types of therapy – such as sensorimotor retraining and cognitive functional therapy – are also effective. You can discuss these and other options with your health professional.

Spinal cord stimulation is a good example of a treatment that got ahead of the evidence. Although the devices have been around since the 1960s, we’ve only had reliable trials to test whether they work in recent years.

Everyone wants to find ways to help people with chronic pain, but we must ensure medical care is grounded in reliable science.

Caitlin Jones, Postdoctoral Research Associate in Musculoskeletal Health, University of Sydney and Christopher Maher, Professor, Sydney School of Public Health, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

On his campaign trail, Prime Minister Anthony Albanese pledged A$200 million to upgrade St John of God Midland Public Hospital in Perth. He promised more beds and operating theatres, and a redesigned obstetrics and neonatal unit.

It followed other recent election promises from the Labor government, including $120 million for new birthing facilities at Sydney’s planned Rouse Hill Hospital and $150 million to build a health centre in southern Adelaide.

New and expanded health facilities are welcome in fast-growing communities. But are hospital funding pledges in election campaigns based on health-care or political needs?

Does pork-barrelling drive health funding decisions?

Labor and the Coalition have faced allegations of pork-barrelling this election campaign.

Pork-barrelling means using public funds to target specific electorates to win votes, rather than allocating resources based on need. Four in five Australians consider pork-barrelling to be corrupt.

Former New South Wales Premier Gladys Berejiklian suggested pork-barrelling was “business as usual” in her government.

It also seems to occur at the federal level. The Australian National Audit Office found a $1.25 billion Community Health and Hospitals Program implemented by the former Morrison government “fell short of ethical requirements” and deliberately breached Commonwealth grant guidelines.

Of the 63 major projects funded, only two were rated “highly suitable” – the usual benchmark for shortlisting. In fact, most approved projects were picked by the government outside of the established expression of interest processes.

Who funds and manages public hospitals?

The National Health Reform Agreement makes states and territories responsible for managing public hospitals. States and territories contribute around 58% of hospital funding. They also oversee planning and infrastructure.

Local hospital networks help plan and implement capital projects such as new hospitals and facility upgrades.

Under the National Health Reform Agreement, the Commonwealth government also contributes public hospital funding through:

• activity-based funding. This is tied to the number and type of patients treated
• block funding for smaller regional and rural hospitals
• public health funding for initiatives such as vaccination programs.

The reform agreement outlines the Commonwealth’s responsibility for supporting public hospital services. But it doesn’t restrict the Commonwealth from making hospital infrastructure promises.

The Commonwealth often pledges direct hospital funding through supplementary agreements or ad hoc initiatives. Earlier this year, it announced an additional one-off $1.7 billion payment to ease pressure on public hospitals.

State planning vs federal politics: who decides?

States use formal planning frameworks to plan and prioritise health infrastructure projects. NSW Health, for example, applies a structured Facility Planning Process for projects over $10 million. This considers local population needs, health and community benefits, costs and workforce capacity.

These types of frameworks help ensure health capital investment decisions are transparent and evidence-based.

What is less transparent is how the Commonwealth decides which specific hospitals to pledge money to, particularly during election campaigns.

While some federal funding announcements may align with state priorities, picking one hospital over another comes with an “opportunity cost”. For every community that benefits from a new or upgraded hospital, another potentially higher-need community may miss out.

To prevent Commonwealth funding decisions being swayed by political priorities, more transparent processes for setting priorities and making decisions are needed.

What would a better system look like?

The way funds are allocated to medicines listed on the Pharmaceutical Benefits Scheme (PBS) provides the federal government with an exemplary approach to good health-care investment decisions.

The Pharmaceutical Benefits Advisory Committee (PBAC) provides independent advice to the Minister for Health on whether the government should allocate millions to new medicines. The PBAC uses rigorous, transparent processes to make listing recommendations based on patient need and cost-effectiveness.

Federal government hospital infrastructure funding decisions should also follow open, competitive, merit-based processes.

Prioritising evidence and having transparent decision-making guidelines would mean funding is more likely to be allocated based on the greatest population need rather than electoral considerations.

Other ways to improve federal government hospital funding decisions may include:

• incorporating nationally agreed principles for hospital capital funding in future National Health Reform Agreements
• increasing transparency. This could be achieved through a national public register of hospital development proposals, ranked by urgency and need
• strengthening safeguards on election-period pledges. This could improve disclosures and ensure hospital funding decisions align with independent needs assessments.

More hospitals or better prevention?

Former St Vincent’s Health CEO Toby Hall put it bluntly:

If Australia is to make the most of its healthcare future, it will likely need fewer hospitals, not more.

He pointed to Denmark, which cut its number of hospitals by 67% over 1999–2019. This was achieved by shifting as many services as possible from hospitals to other types of health care including primary care, health centres and outpatient clinics.

While more hospitals in Australia may be inevitable as the population ages, health policy should also focus on keeping people out of hospital in the first place. That means investing in prevention, early intervention and technology to support care at home.

Australia lags behind other wealthy nations in this space, ranking 20th out of 33 OECD countries in per capita spending on prevention. It ranks 27th when measured as a share of total health expenditure.

Some local health districts are showing what’s possible. This includes using home monitoring to help people manage chronic conditions. These kinds of innovations can improve health and reduce pressure on hospital infrastructure.

While new hospitals and wards make for compelling election promises, a better health system will come not just from “bricks and mortar”. It will come from smarter investments in prevention, early intervention and innovative care that keeps people healthier and out of hospital.

Anam Bilgrami, Senior Research Fellow, Macquarie University Centre for the Health Economy, Macquarie University and Henry Cutler, Professor and Director, Macquarie University Centre for the Health Economy, Macquarie University

This article is republished from The Conversation under a Creative Commons license. Read the original article.