Menopause Perspectives Around the World

President: Dr Francisco Gago; Secretary: Dra Marta Murga

The Argentine Association for the Study of Climacteric (AAPEC) was founded in 1987 at the Hospital de Clínicas Gral. José de San Martín (Clinic Residents Hospital Gral José de San Martin) of the University of Buenos Aires. The foundations for a non-profit association were set in order to promote the scientific research of climacteric in Argentina. Today, with more than 500 members in different medical specialties, basically from areas such as medicine, gynecology, endocrinology, sociology, nutrition and anthropology, we feel that AAPEC is the leading scientific association that provides a consensus and guidelines on the use and side-effects of hormonal therapy in our country.
About 3–5% of menopausal women in Argentina use hormonal and other therapies to treat the menopausal syndrome. Osteoporosis without fracture is treated by our members but also by endocrinologists and rheumatologists.
We work within the conceptual framework of Total/Entire Health (World Health Organization) including diagnosis and therapy of the prevailing pathologies of this age group.
Our Society has a school for the training of new professionals in this discipline. We have 10 years of experience in this field and receive the support of the country’s top academic university centers. By means of the credits obtained during the course, knowledge updating through scientific events and attendance in the gynecology hospital service for a period of not less than 5 years, the professional is able to obtain a specialist degree, which must be subsequently re-certified.
AAPEC has organized seven National Congresses in its extensive scientific trajectory, as well as many Updating Workshops and Conferences to introduce topics such as Osteoporosis, Use of hormone therapy post-WHI, and Cardiovascular disease. In 2005, we realized our long-held dream to organize the 11th International Menopause Society World Congress on Menopause in Buenos Aires. The Congress had the distinguished presence of a prestigious member of AAPEC, as local chairman, Professor Nestor Siseles. We were very grateful for the participation and support of colleagues from all over the world, who helped us to overcome many obstacles in the process of organizing this event.
Last, and as the final scientific event in 2006, we published our guidebook Tratado de Climaterio, AAPEC, which deals with the problems of menopausal women, both in an interdisciplinary and multidisciplinary way.

President: Dr Elizabeth Farrell, Australia

The Asia Pacific Menopause Federation (APMF) was established in 1998 when the representatives of member countries met in San Francisco. Currently, APMF consists of 14 member countries, which are Australia, China, Hong Kong, Japan, Korea, India, Indonesia, Malaysia, Pakistan, Philippines, Singapore, Taiwan, Thailand and Vietnam. A Council was created, by one representative from each member country, to be the policy making and executive organization.
The APMF Scientific Meeting has been carried out triennially along with the election of the new president of the Federation. The 3rd Scientific Meeting was held on March 1–4, 2007 at Taipei International Convention Center in Taipei, Taiwan.
It has long seemed obvious that the perception, symptoms, and modes of diseases of postmenopausal women in the Asia Pacific are different from those of western women. A panel of 14 experts (the ‘Panel’) from 11 of the Asia Pacific Menopause Federation member countries agreed that these differences are likely to exist. When the panel met on September 4–5, 2005 to create APMF guidelines for menopause management, the experts also discussed the need for future menopause research in Asia. The Panel recommended that, ideally, the studies that have been done with western women should be repeated with Asian women. However, this seems impossible due to several factors including financial limitations. Therefore, epidemiological or observational studies on Asian women should be performed. The panel further recommended that the areas of research should include: (1) the relationship between hormone therapy (HT) and breast cancer, (2) cardiovascular diseases, (3) osteoporosis, and (4) alternative medicine, particularly the use of traditional Chinese medicine (TCM).
The APMF, which consists of the most populated area and the largest number of menopausal women in the world, would like to have a more intimate relationship with the IMS. In order to fulfill the role of maintenance and improvement of health and quality of life of Asian menopausal women, APMF hopes that Asians will have more chance to participate than currently in the activities as well as decision-making of the IMS for world-wide health care of menopausal women.

President: Dr Beverley Lawton

The Australasian Menopause Society (AMS), founded in 1988, is a multidisciplinary society of 660 members ranging from primary-care physicians, gynecologists, physicians including endocrinologists, psychiatrists, psychologists and nurses from Australia and New Zealand. The AMS holds an annual scientific meeting. The mission of the Australasian Menopause Society is ‘to improve the quality of life of women during and after the menopause’.
In 2004, at the instigation of the Australasian Menopause Society and under the auspices of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, a Consensus meeting was held regarding the use of postmenopausal hormone therapy (HT). The aim of the meeting was to achieve pragmatic clinical recommendations for clinicians dealing with women with menopausal symptoms, or health-care problems secondary to estrogen lack. The participants were individuals nominated by a variety of professional and government-funded organizations, representing the multiple disciplines involved in the health care of women at mid-life. Importantly, the meeting was not funded by the pharmaceutical industry nor was there pharmaceutical representation at the meeting. All participants were required to submit a statement of dualities of interest. Several members of the Australasian Menopause Society attended this meeting. Presentations were given regarding the available evidence of the effects of HT on the cardiovascular system, bone and association of HT use with any cancer risk. Emphasis was on critical appraisal of data quality, with substantial input from experts on biostatistics and epidemiology. The significance of the available evidence was debated extensively. There was full agreement that HT use is effective and indicated for the treatment of menopausal symptoms.
A major limitation to the provision of specific recommendations was that evidence to answer the most pressing questions is lacking: adequately powered studies evaluating the benefits and risks of HT use in symptomatic women in their fifties have not been undertaken. The most controversial issue was whether HT may be used as a first-line therapy in the prevention of osteoporotic fracture, or whether it should be limited to second-line use. This remains a grey area for clinical practice.
The AMS has endorsed these recommendations as a guide to HT use, with the understanding that they are not prescriptive, but rather provide a broad framework for delivery of clinical care.
The AMS particularly recognizes the importance of counseling in the care of menopausal women, and, to support members in delivery of accurate information, has prepared 14 papers to be given to women at the time of consultation, on the following topics: Contraception for women approaching menopause; Early menopause (spontaneous & unexpected ovarian failure); Early menopause due to chemotherapy; Coping with menopause depression; Treating menopause – the concept of risk and benefit; Menopause – combined hormone therapy; Menopause – estrogen-only therapy; Menopausal treatments and the risk of blood clots; Tibolone for postmenopausal women; The role of SERMS after menopause; Low libido and testosterone therapy; Healthy aging & lifestyle; Sleep disturbance and menopause; Menopause and body changes.

President: Professor Shahla Khatun, FRCOG, Head of Department of Obstetrics & Gynecology, Bangladesh Medical College, Dhaka.

The Bangladesh Menopause Society was founded in 2005; its first scientific seminar was held in December 2005. Membership is open to specialist and non-specialist doctors, paramedics, teachers and social workers who are directly or indirectly involved with the management of menopausal problems, e.g. physical medicine experts, orthopedic surgeons, cardiac physicians, psychiatrists, rheumatologists, representatives of the pharmaceutical industries, and members of social organizations like Innerwheel, Zonta and Rotary. Gynecologists treating menopausal problems are not known as menopause specialists. Most endocrinologists are not gynecologists.
In Bangladesh, menopause is not a topic much talked about except among a few educated and affluent urban people. Considered to be a biological phenomenon, it is accepted without much complaint among the majority of the elderly rural population. The social custom of respect and care for the old does not cause much problem in general. The global increase in women’s life span with the added problems of old age has impacted on Bangladeshi women. There are 28–30 million women (49% of the total population) and elderly women are increasing in number (3–5% aged ≥ 46). The average age of menopause is 51 years and the average life span of women is now 62 years. Under such circumstances, it was thought mandatory that a society be formed for the care of a population that was increasing in such numbers. Bangladesh is a unique country where the Prime Minister and the leader of opposition are both women.
Oral HRT is used to relieve acute climacteric/menopausal problems. Patches are expensive but available on demand. Other used medications are calcium with Vitamin D, calcitriol, calcitonin, bisphosphonates, SERMS, natural/herbal products. Diet, lifestyle and yoga are widely publicized in recent times through awareness programs and the media. Very few women used to come for consultation and help, but the numbers are increasing with education and awareness in recent years.
The problems that clinicians experience in treating these women are lack of compliance and follow-up due to ignorance and lack of facilities; fear of cancer; and the cost of treatment. Bone problems like osteoporosis are treated mainly by the members of our society. Rheumatologists are rare in our country.
The Society’s objectives and activities are: to act as a platform for all aiming to face this important transition with a positive attitude; to promote information, education and communication on understanding of the menopause; to promote knowledge, study and research on all aspects of aging in women; to encourage multidisciplinary approaches; to organize and participate in national and international meetings and congresses; to liaise with government health agencies and relevant organizations; to form clinical programs for the community; to encourage the interchange of plans and experience between individual members.

President: Ulysse Gaspard; Secretary: Serge Rozenberg

The Belgian Menopause Society (BMS) was founded in 1990. This leading, non-profit, scientific organization is devoted to promoting the understanding of menopause and thereby improving women’s health through mid-life and beyond. The BMS has 150 members, mostly, but not exclusively, physicians (gynecologists) who have an interest in the menopause and related topics. The BMS provides general information regarding the menopause. There is no official title of ‘menopause specialist’ in Belgium, but, in the curriculum of graduates in gynecology, courses are organized and often provided by our members.
Following the publication of the estrogen–progestin WHI study (WHI-EP) and of the Million Women Study (MWS), there has been a tremendous need for communication with gynecologists, physicians and patients. The BMS organizes two or three meetings per year. It also hosted a workshop that was organized by EMAS. In addition, the BMS organizes press conferences and publishes press reports. Consensus conferences and statements about menopause management are organized and reported in the medical press and on the BMS’ website. Finally, most of its Board members are repeatedly invited to present seminars or conferences at national or international meetings.
As in many other European countries, a decrease in use (by about 40%) of hormone therapy (HT) has been observed after the publication of the WHI-EP and the MWS. This decrease has been greatest for regimens which included conjugated equine estrogens (CEE) or medroxyprogesterone acetate (MPA).
Belgian gynecologists modified their prescription attitude in two ways: first, they restricted treatments preferentially to postmenopausal women who presented menopausal symptoms; second, they shifted towards regimens which involved either a lower dose of estrogens, the use of natural progestins, percutaneous or transdermal estrogens, or products such as tibolone.
Using a survey among Belgian practitioners, following the publication of the WHI-EP study, we observed, with the aid of a single case of an asymptomatic 55-year-old woman with no particular medical history, that about 80% of the physicians would either have stopped prescribing the CEE + MPA regimen or prescribed another HT type, while about 25% would have done so if the regimen included tibolone. On the other hand, general practitioners prefer to prescribe herbal or complementary products, such as isoflavones [1].
In another survey, we observed that less than 25% of Belgian gynecologists would prescribe HT to a 65-year-old asymptomatic woman even if she suffered from osteoporosis. They would, however, continue to screen for osteoporosis and, if necessary, prescribe specific drugs for osteoporosis prevention and treatment such as calcium, vitamin D and bisphosphonates [2].
From crude sales data extrapolations (228,000 monthly treatments sold in September 2006), we hypothesize that approximately 13% of women above the age of 50 use HT currently. Since most of these women are between the ages of 50 and 65, we may hypothesize that + 28% of women in that age class currently use HT in Belgium.

References
1. Ena G, et al. Hum Reprod 2003;18:2245–8
2. Rozenberg S, et al. Maturitas 2006;53:483–8

President: Luis Alvarez Navia

Since its inception, the Bolivian Climacteric Society had particular peculiar difficulties as some gynecologists linked to the Bolivian Society of Gynecology and Obstetrics considered the climacteric to be an area of exclusive interest and research for gynecologists (Group of Menopause) and they fiercely opposed the inclusion of other health professionals.
The Society was founded in 1998 and is a non-profit organization within the meaning of the Bolivian Civil Code. It is open to any health professional and other professionals working in the area of menopause.
Dra Sonia Ocampo de Ruiz was the first president and later was appointed as honorary past president. The founding members were eight gynecologists, two endocrinologists, one internal medicine physician, one cardiologist, one dermatologist and one psychologist; there are now about 80 members. In April 1999, the Bolivian Climacteric Society was officially affiliated as a member of the IMS. In Bolivia, gynecologists do not need to be called menopause specialists.
In the latest census in 2002, there were 3,908,310 Bolivian women, 62% of whom lived in urban areas and 38% in rural areas. Women over 45 years old numbered 797,029.
Bolivia is a developing country with many restrictions in all areas of human development; the priority focus is on women’s reproductive life (maternal mortality is one of the highest in the American continent). Interest in women’s health after the age of 50 is limited. Bolivia has the largest native population in Latin America; ancestral cultures remain and traditional medicine is used. The large ethnic groups have poor access to health-care providers. The majority do not know of hormone therapy (HT) and most women use alternative therapies. Furthermore, 38% are not aware of the benefit of plant estrogens for menopausal treatment and, due to very low incomes, have no access to modern HT. Menopausal native women in rural areas do not have access to information about menopause and do not know that menopause is associated with an increased risk of disease and, due to economic and cultural factors, do not demand menopausal HT.
In Bolivia, almost all sales of drugs or medicaments are dispensed by pharmacies without physician prescription. This could indicate that an individual woman’s attitudes towards HT are the primary decisive factor concerning hormonal therapy use. Existing reports show that, after the WHI study, there were observed changes in the preference of alternatives to hormone prescription such as tibolone.
Despite the negative findings of the WHI study, physicians in Bolivia tended to continue prescribing HT, although other regimens than equine estrogens and medroxyprogesterone acetate. Other regimens containing different estrogen/progestin formulations are acceptable options. Currently, a particular problem in menopause management is the absence of guidelines and protocols. Treatment of osteoporosis is given by different specialized physicians and not only by rheumatologists.
The future challenge of our society is to improve access to information and educational opportunities, particularly for women with poor resources, through the design of educational projects funded by different sources.

President: Professor João Sabino Pinho Neto, Chairman of Department of Gynecology of Federal University of Pernambuco, Brazil

SOBRAC was founded on September 24th, 1986 and now has around 2500–3000 members. More than 90% of our members are gynecologists, but our society is open to non-gynecologists too, especially geriatricians, endocrinologists and rheumatologists. We also have a small number of non-MDs (paramedics) as members, such as psychologists and nurses.
To be called a ‘menopausal specialist’ in our country, a gynecologist does not need any other qualification. Currently, we are working to organize a menopause specialist examination that is open only to medical doctors who have already completed their medical residence (Board) in Gynecology and Obstetrics. In Brazil, not only rheumatologists and endocrinologists treat osteoporosis, but gynecologists, in general, prevent and treat osteoporosis too.
According to the Brazilian Institute of Geography and Statistics, almost 25% of the Brazilian female population is 45 years old or older, corresponding to more than 11% of the total population.
The major problem of HRT use in Brazil is the fear of some doctors and the patients of its side-effects, mainly after the publicity of the results of the WHI 2002 study. Besides HRT, bisphosphonates and raloxifene are frequently used in the prevention and treatment of osteoporosis. Other medicines are used in agreement with the needs of each patient.
Difficulties in compliance with treatment (fear of cancer, bleeding and other reasons) as well as the high cost of medicines are the major problems experienced in menopause management.
SOBRAC has one delegate in each of the 27 States of the Brazil Federation. Frequently, various symposia are held in several regions of the country. Recently, an advisory board was created involving other medical specialties (cardiologists, rheumatologists, endocrinologists, neurologists and others), with the objective of integrating the knowledge in a multidisciplinary consensus that will be compiled by experts and published for the Brazilian medical community.

Our society organizes a national congress every 3 years (the next event will be held in 2009) and edits an indexed journal together with the Brazilian Societies of Human Reproduction and Endocrine Gynecology. In addition, a newspaper is published quarterly with news of the society. SOBRAC is always represented in the events and statements of FLASCYM.

President: Doz. Ellian Ratchev

The Bulgarian Menopause and Andropause Society was founded in 1996; we have almost 400 members. The Society is registered according to a special law for non-profit organizations and has one employee on fixed income. The membership is open to any physician who has an interest in menopausal medicine; companies cannot be members. The financial support of interested parties from the industry, however, is granted according to a memorandum, signed between the Society and the management of leading pharma companies. Menopausal specialists are almost exclusively gynecologists; some other specialties also treat menopausal women.
We have almost 1.4 million women above the age of 45 years; the use of hormone replacement therapy is very low – less than 1%.
Osteoporosis therapy is prescribed by gynecologists, endocrinologists and rheumatologists. However, the reimbursement of anti-resorptive therapy is not satisfactory. HRT is not reimbursed at all.
The Bulgarian Menopause and Andropause Society publishes a medical journal, which is issued three to four times a year. The Society organizes Congresses on menopausal medicine every third year; we participate with workshops in all major gynecological events. We support an educational campaign among women aged above 45. We have a strong influence on the development of a National Osteoporosis program.

President: Dr Juan Enrique Blümel Méndez
Vice President: Dr Sergio Brantes Glavic

The Chilean Menopause Society was founded in 1991 by a group of gynecologists and endocrinologists interested in the subject, who carried out update meetings in a social environment. The Society now has seven branches distributed throughout the country, with a total of 131 active members.
Since beginning as a Scientific Society, it has organized seven International Courses, five National Congresses, many Regional Courses, innumerable symposiums and many other meetings of discussion and update. Also it has held several Press meetings.
Chile has a subsidiary Medical Care system in which the Government sets a program of priorities with specific goals on health issues; some of these focus on fetomaternal health, cardiovascular and oncological diseases, but there is no programme for the health of women in the post-reproductive phase.
Our Society has issued a document that emphasizes our concern for quality of life as well as specific problems such as cardiovascular, mental, sexual and bone health and others in women at this stage of life.
At present there are also marked differences in the ability to access suitable treatments depending on a woman’s socioeconomic status. This difference has diverse explanations that go beyond the mere availability of material resources; while better income groups are able to consult well-informed private specialists, women from the lower income groups attend the Public Health service in which individual postmenopausal care is not a high priority.
The aftermath of the WHI study has severely limited the proper development of this area of medical care. The initial publicity for the adverse effects of the WHI findings has not been effectively counteracted by the later less adverse interpretations, and a large number of doctors and patients still see hormonal therapy as a problematic subject.
Our Society considers that the results of the WHI study were not properly communicated to the Public and Scientific Communities, resulting in changes in prescribing right from the very beginning, without there being appropriate scientific debate. Also, it produced arbitrary statements on the risk/benefit ratio that ignored the effects on the prevention of fracture and premature cardiovascular disease.
In late 2004, we issued a guide on menopause management. We have since modified the recommendations for the duration of therapy and suggest an unlimited period while contraindications do not arise, always with the minimum condition of an annual evaluation made by an expert, which must include suitable investigations for the early diagnosis of cardiovascular and malignant disease.
This change of paradigm is influenced in particular by the publication of Chen WY et al. [1], which we believe is extremely important as it demonstrates that unopposed estrogen can be given for up to 15 years before there is a significant increased risk of breast cancer.

Reference
1. Chen WY, et al. Arch Intern Med 2006;166:1027–32

President: Professor German Baron, specialist in Gynecological Endocrinology (Universidad del Rosario); Distinguished Professor of the Universidad del Rosario; Professor of the School of Medicine, Universidad El Bosque; Medical Director of Centro Medico para la Mujer, all in Bogotá.

The Association was founded in 1994 and now has 350 active members. Membership of the society is not exclusive to gynecologists. It is open to all kinds of physicians, including specialists in internal medicine, physical therapists, cardiologists, psychiatrists and general practitioners. Non-medical professionals, such as nutritionists, nurses and psychologists, can be affiliates.
In Colombia, any gynecologist can work with menopausal women and the title of ‘menopause specialist’ is gained only on the basis of study and experience; titles are not required. Gynecological endocrinologists are scarce and most of them are working in reproductive medicine.
In Colombia there are about 3,700,000 women who are considered to be postmenopausal. Before the WHI publication, around 5% had access to menopause clinics and HRT. Now, not more than 1% of women start HRT and, of them, 90% have abandoned it 1 year later. Although some gynecologists are still using HRT, therapies considered by women to be more ‘natural’, like phytoestrogens, are gaining place in the menopause market.
Several problems are experienced in the management of menopause in Colombia. First of all, it is important to recognize that, after the WHI publication, women are afraid of the risks, especially related to breast cancer. This issue has a very strong impact because each day there are fewer women wanting to take HRT. It has become common practice that, after starting HRT in any woman, general practitioners or specialists in other areas withdraw the treatment due to possible risks, like cardiovascular disease, even in young women without risk factors. After the WHI study was published, most of the social security agencies decided to abolish the menopause clinics, so women seeking advice must do it on a private practice basis. Finally, the cost of medications related to HRT has been rising, so not all women are able to pay for them.
At this moment, most of the members of our society are qualified to treat postmenopausal osteoporosis. Gynecologists start most treatments and the role of the rheumatologist is to treat secondary osteoporosis, osteoporosis in men and glucocorticoid-induced osteoporosis. Gynecologists treat most women with osteopenia or osteoporosis.
The activities and objectives of our society are focused on continued medical education, patient teaching and prevention programs. Meetings, a biennial national congress and the publication of a journal achieve the first objective. The other two are met with meetings, newspapers, radio and TV shows.

President: Arturo Esquivel Grillo, MD
Website: www.menopausiacostarica.com

ACCYM was founded in 1997, having an Executive Board consisting of specialized doctors in Gynecology and Obstetrics, General Medicine, Cardiologists, Neurologists, Endocrinologist, Psychologists and Pharmacists. We have a common interest in offering information and support to women about medical and emotional aspects during the climacteric and menopause. ACCYM has also taken the responsibility of keeping doctors and other professionals in the health sciences up-to-date in this topic. We are also the specialized reference center in this topic for all the professionals in our country. Our values are humanism, support, quality of life and emotional integrity.
The association offers support and information to Costa Rican women with the primary objective of education about the climacteric and menopause, but also to inform about the merits of HRT, and to dispel the many myths that exist concerning HRT. In Costa Rica, it is the specialists in Gynecology and Obstetrics who manage and treat osteoporosis.
Our association has been given the task of organizing five annual national meetings and four courses for up-dating knowledge on menopause with the participation of excellent Costa Rican as well as international experts. ACCYM also wishes to be involved in other important activities such as the International Osteoporosis Day and World Menopause Day. It provides educational radio programs and discussions to keep doctors and other professionals in health sciences informed about appropriate management of menopausal patients, embracing their physical and emotional aspects, with the objective of establishing guidelines that can be applicable in our country.  
The association has also tried to identify the reality of menopause management and knowledge in Costa Rica. Sonia Cerdas, MD, a member of the Executive Board of ACCYM, carried out a study in 1998, in which 1126 Costa Rican patients were interviewed, and found that 7% of that population used HRT.
One of the problems that Costa Rica has had in relation to the climacteric and menopause started with the publication of the WHI study in 2002. HRT was discredited and it has been very difficult to re-establish public confidence about its many benefits and limited risks. This situation requires time, effort and expensive campaigns that are sometimes beyond our capabilities.

President: Professor Srećko Ciglar, Obstetrics & Gynecology
Secretary General: Dr Ivan Fistonic

The Croatian Menopause Society (CMS) was founded in 2000. With 113 members in good standing, there is a strong basis for educational and promotional efforts that we continuously provide through scientific regional meetings and the media in order to promote the health of women over the age of 50 years.
As an applicant member of IMS/CAMS and a member of EMAS, CMS is keen to collaborate closely and spread the ideas of a healthy lifestyle and appropriate medication for postmenopausal women.
Almost all of the conventional medication used in menopausal medicine is available in Croatia and gynecologists are the first line in prescribing menopausal hormonal therapy. Although gynecologists are the majority, CMS also has as members other specialists in the field of menopause (endocrinologists, rheumatologists, internists, etc.).
CMS acts in a complementary way with the Croatian Society for Osteoporosis (member of IOF) and the Croatian Society for Gynecological Endocrinology and Reproduction. Most consensus conferences are the result of collaboration between these three societies.  
Today, Croatia has 693,540 inhabitants older than 65 years, or 15.6% of the total population. Women are in the majority (18.6% vs. 12.4% of men). There are 1455 people older than 100 years (1132 women vs. 323 men). On average, women live 7.5 years longer than men and every year their life span increases by 3 months.
Approximately 850,000 women ³ 50 years constitute about 33% of all the female population, with 480,000 in the 50–64-year age group. There are still a low number of women using hormone therapy in Croatia (target group 50–64 years, prevalence 10%). CMS estimates that this number will increase very slowly in the next 5 years. There is a problem in the management of alternative therapy. The standards of quality control and control of over-the-counter distribution are poor. More than 50% of pharmacy sales for the relief of menopausal symptoms are herbal mixtures and alternative therapies. Unfortunately, among products with any scientific background, the vast majority have little or no evidence of benefit. These products are registered as ‘food supplements’, as is common globally, but, in the opinion of the CMS, there is inadequate quality control and poor regulation of advertising and product labeling.
Osteopenic perimenopausal women are treated by gynecologists and, in the field of osteoporosis, prescribing of therapy is shared with rheumatologists.   
Our further interests are in the promotion of quality of life, with advice on lifestyle aspects such as sexuality, maintaining  physical and other activities after retiring, mental training (adjusting to new skills and knowledge), avoiding obesity, reducing nicotine and caffeine, independence and compliance with medications, and an optimistic lifestyle with the accent on leisure and quality rest. The merits of hormone therapy as complementary to quality of life should be advocated.

President: Dr Miguel Sarduy Nápoles, Professor of Gynecology and Obstetrics, Medical Sciences Institute, Havana

This multipurpose group was created in 1993 and is interested in women’s health problems. It was accepted by FLASCYM during its First Congress in Buenos Aires, Argentina in 1995.
There are no menopause specialists in Cuba, but we are a group of medical and paramedical colleagues who study and research on menopause. The group has 113 members, including a number of medical disciplines such as gynecology, endocrinology, biology, anthropology, sociology, psychology, sexology, family medicine, orthopedics, rheumatology, physical and rehabilitation medicine, nourishment, nursery and social work.
The aim of our group is to deal with the problem in both a general and an individualized way at the same time, taking into account the social and medical diagnosis and leaving the use of hormonal therapy (type of medicine, administration and duration of the treatment) for those women who really need it. We also have experience in the use of non-hormonal treatments like herbal therapy, phytoestrogens and acupuncture.
The majority of investigations show that the mean age of menopause in Cuba is between 47 and 48 years. The main problems are vasomotor symptoms, sexual dysfunction, heart disease and osteoporosis. Treatment for osteoporosis is by a multidisciplinary team. The medical treatment could be prescribed by a rheumatologist, orthopedic, endocrinology or gynecology specialist but always in consultation with other medical specialists.
Our group has held two National Congresses and seven International Symposia based on the climacteric and menopause. In 1999, the first Cuban consensus about climacteric and menopause was published and this was updated at a national multidisciplinary meeting in December 2006.
In 2007, we will commence Diploma and Mastership courses in climacteric and menopause.
Our group has participated in two research projects of the Research Latin-American Net on the Climacteric. We have seven Latin-American experts in climacteric and menopause.
Our objectives are related to the four essential elements of good medical provision: good health care, medical studies, research and continuing medical education; our aims are to: identify the clinical and epidemiological characteristics (menopause age, climacteric syndrome, hidden morbidity and related health effects, among others) and also the impact of gender roles and gender conditions associated with the clinical expression of the climacteric; strengthen all the pre- and postgraduate studies of health professionals and teach the specialists and those in primary and secondary medical care, the topics related to climacteric and menopause and to understand how best to communicate with individuals and groups about diagnosis, benefits of therapeutic management and risk factors; utilize social science methodology to evaluate social and biological factors.

President: Dr Pedro Pérez Cos
Vice President: Dr. Manuel Peña

The Sociedad Dominicana de Menopausia was founded in 2000; it is open to all medical and paramedical fields and has 237 members. Society members are gynecologists as well as endocrinologists, cardiologists, orthopedic surgeons, rheumatologists, and general practitioners. In our country, there is still no formal certification, and this is not needed to be dedicated in this field. All the society’s members can treat osteoporosis, not just rheumatologists.
In Dominica, the total female population is 4,657,000; there are 790,000 women over 45 years and 330,000 between 45 and 60 years old. Life expectancy for women is 76 years. Women taking hormone replacement therapy (HRT) and other therapies number 9000.
The principal problem in Dominica is that there is little awareness in the population about climacteric problems. In addition, there is poor access to services dedicated to menopausal women.
The main objective of our society is to promote knowledge about menopause in the Dominican medical class in particular and in Dominican women in general. We have been very active in courses, conferences, patient activities, TV programs, and participation with the international community. We are planning to establish a National Foundation for Dominican climacteric women to achieve the next level of action.

Secretary-General: Professor Emad Darwish, Professor of Obstetrics & Gynecology, Alexandria University

The Egyptian Post Fertility Society was established in 2003 as the first NGO dealing with problems of menopause in Egypt. The initial number of members was 60; it now reaches 155. However, the size of membership is still below our expectations. In 2007, the Society was renamed as the Egyptian Menopause Society.
In Egypt, there are about 7–8 million women above the age of 50 years. This number is expected to rise with an increasing population, which rose from 65.1 million in 1996 to 71.5 million in 2001.
The main objectives of our society are: to study menopausal problems in Egyptian females; to set up a database of studies about menopausal problems, e.g. incidence of menopausal osteoporosis; to spread knowledge about the management of menopausal problems and guidelines about hormone replacement therapy (HRT) among physicians, gynecologists and health workers; to help the public to know more about menopausal problems, HRT, alternatives to HRT and how to deal with these problems.
Awareness about menopausal problems increased in the last few years among both the public and physicians. During 2006, about 25% of females attending the consultant clinic in the main insurance health hospital in Alexandria complained of menopausal problems and sought treatment.
Data about the size of menopausal problems in Egypt are limited. The mean age of the menopause is 46.7 years, but this age has been rising recently. The incidence of menopause-associated symptoms is higher than in the West, probably because of the different ‘socio-cultural attitudes’ towards the menopause in different communities. Bone mineral density charts have been constructed for Egyptian women and show that, in general, they have a lower bone mineral density compared to their Western counterparts. Egyptian women do not know much about the menopause, except that the incidence of osteoporosis is increased [1].
The National Institute of Nutrition in Cairo has conducted a cross-sectional study to assess status of bone density among adolescents and adults in Egypt; 1500 families were included. They found that the prevalence of osteoporosis and osteopenia is higher among females compared to males in the age group 40–50 years, osteoporosis and asymptomatic low BMD present at an earlier age than that reported in literature.
We can conclude that awareness of menopausal problems among both health workers and the public needs to be improved. More community-based studies are needed to have a solid database about the prevalence of the short- and long-term problems among menopausal women. The Society should work more to spread knowledge among both health workers and the public. We are expecting more collaboration with the IMS to help our new Society to reach its objectives.

Reference
1. Sallam H, Galal AF, Rashed A. Menopause in Egypt: past and present perspectives. Climacteric 2006;9:421–9

President: Professor Henri Rozenbaum

The Association was founded in 1979. Membership is open to all those who work in the field of menopause, whether doctors or not. To be called a ‘menopausal specialist’, a gynecologist does not need any other qualification. Members of the society treat osteoporosis and osteopenia.
The Association conducts a survey every year dealing with the menopause. In 2005, the survey showed that, as the result of the WHI and the Million Women studies, 50% of women withdrew from treatment and 70% complained about troubles. In 2006, the survey examined the sexuality of women after natural or surgical menopause.
AFEM publishes brochures for patients and doctors and organizes an annual congress with about 1700 participants.
The particular problem in menopause management that AFEM’s members experience is the difficulty of explaining to doctors and women that French women are not the same as US women and that hormone therapies are different.

President: Professor Ludwig Kiesel, Chairman of Department of Obstetrics and Gynecology, University Hospital of Muenster, Muenster

The German Menopause Society was founded on July 14, 1995 and now has 288 members. Most members are gynecologists, but the Society is basically open to non-gynecologists and non-MDs (at the moment less than 10 members). To be called a menopausal specialist, no further qualification is necessary. Osteoporosis is treated by gynecologists and orthopedics.
The Society organizes nationwide workshops on hormone therapy for private practitioners and nationwide workshops on hormone therapy for patients. It holds an annual conference of the German Menopause Society and funds young researchers (Christian-Lauritzen-Award).

President: Dr Vassilios Tziggounis
Vice President: Dr George Creatsas
e-mail: geocre@aretaieio.uoa.gr

The Hellenic Society was founded in 1982 and now has 86 members. Membership is open to gynecologists and endocrinologists as well as non-MDs. The Society does not require its members to have received special training. Its members are characterized by a particular motivation towards menopause-associated symptoms and diseases.
In Greece, gynecologists or endocrinologists are not accredited as menopause specialists, nor is any official training required in evaluating and treating menopausal women. The specialty is acquired by those having a sincere interest in menopause through prolonged work in menopause clinics. Menopause clinics in Greece function within the framework of the university obstetrics & gynecology units or the state hospitals. Gynecologists as well as endocrinologists treat osteoporosis in Greece.
The mean age of menopause in Greece is 52.4 years. The mean age of menopause recorded in menopause clinics is 46.9 years. The low age of menopause, compared to that of the general Greek population (51 years) is probably attributed to cases of premature ovarian failure (13%) and cases with surgical menopause (18%).
Approximately 80% of women are symptomatic. Of these, approximately 10% either refuse treatment or have contraindications to treatment. Combined estrogen/progestin regimens, either continuous or sequential, are prescribed to the majority of women. Approximately 25% of women are under tibolone treatment. Raloxifene or bisphosphonates are prescribed to symptom-free menopausal women with osteopenia or osteoporosis.
The media tend to be hostile on matters regarding hormone therapy and the quality of information provided by them is quite unacceptable. As a result, menopausal women are extremely sceptical in initiating and continuing hormone therapy.
The Society aims to disseminate information to the public concerning menopause, to inform the media on menopause-related health and economic issues, and to defend hormone therapy.

President: Dra Judith Ochoa de Pacheco

AGCYM was founded in March 1993 and has 83 members. AGCYM is open to all doctors who treat menopausal women (gynecologists, rheumatologists, psychiatrists, orthopedic surgeons, endocrinologists). A gynecologist who dedicates time in his/her practice to treat and attend menopausal women can be called a ‘menopausal specialist’. AGCYM’s members treat osteoporosis.
The particular problem in menopause management experienced by our members is the refusal of cardiologists and oncologists to give hormonal treatment when necessary. Guatemalan women use hormones and other therapies according to each individual case.
The activities of AGCYM include an annual national congress on menopause, symposia and lectures. In 2001, AGCYM organized a successful Latin American congress on menopause.
AGCYM aims, first, to study and publish work on the prevention and the effects of the physical and emotional diseases related to menopause and, second, to enable health personnel to bring an integral attention with quality and kindness to all menopausal women.

President: Professor Grace W. K. Tang, Department of Obstetrics & Gynaecology, The University of Hong Kong

The Hong Kong Menopause Society (HKMS) was founded in 2002 with the primary objective to promote and assist the study of all aspects of the menopause and its consequences for the sake of public interest. Any medical practitioner, nurse, scientist or other health professional with an interest in the menopause and aging is welcome to join the Society. The HKMS is closely associated with the Hong Kong Obstetrical & Gynaecological Society and memberships overlap. Currently, there are 32 members, all of whom are gynecologists active in the field of menopause. In the past 4 years, the Society has organized scientific meetings, public exhibitions and seminars.
The first systematic study on menopause in Hong Kong began in 1989 when the International Health Foundation launched a study on menopause in East and South-East Asia including Hong Kong. Data showed that Hong Kong Chinese women, though leading a relatively Westernized lifestyle, did not experience the same symptoms as their western counterparts. They had much less hot flushes and relatively higher psychological complaints. A majority of women felt that the climacteric and menopause are a natural process, which caused them no concern.
Longitudinal studies have been carried out subsequently in a cohort of about 500 women. The incidence of hot flushes had increased from 15% to 30% over 5 years. However, the use of hormonal treatment had not increased in the same fashion. In those who had started on hormonal treatment in the public health sector, the 1-year continuation rate was only 68%. The low uptake and continuation rate of hormone use have been attributed, at least in part, to the use of Chinese herbal medicine to alleviate menopausal symptoms. According to a survey conducted by the Census and Statistics Department, 15% of the population had consumed Chinese medicinal products 1 month before the survey. Given the high acceptability of Chinese medicinal products in the local population, it could be inferred that some of these products were used for menopause. A pilot study has shown that the menopausal symptom score in healthy Chinese women improved markedly after 3 months of treatment with a specific Chinese herbal medicine preparation. Further study is warranted to explore the effectiveness of different preparations.
The profile of hormonal treatment changed again after the publication of the WHI trial in July 2002. The decline in the number of hormone users in the public sector was modest in the second half of 2002, but reached 32% in early 2003. There has been no further decline since. Relative to the first half of 2002, prescriptions in the first half of 2003 declined by 70% for combined conjugated equine estrogens (CEE)/progestogen and 47% for CEE-alone products. A territory-wide survey is currently underway to involve all gynecologists and family physicians in both the private and public sectors in order to appraise the complete profile of hormone use in the local population.

President: Professor Karoly S. Toth, St. Margaret’s Hospital, Budapest
President elect: Professor Karoly Pap, Josa Andras’s Hospital, Nyiregyhaza

The Hungarian Menopause Society was founded on 25 November 1995; it now has 330 members. The Society has a multidisciplinary structure: MDs, physiotherapists, nurses, midwives, assistants in the menopause clinics. Most of the doctors are gynecologists, but we have endocrinologists, urologists, rheumatologists, neurologists, psychologists, oncologists, internists, and cardiologists. We have a small, not very active, group of ten people dealing with complementary medicine (phytoestrogens, herbal medicine, soy) inside the society (Complementary Medicine Forum). We do not have contact with paramedics as they are not very active in the field of the menopause.
Menopause specialists are those doctors (independent of their speciality) who are actively working in a menopause clinic, attending regularly the society’s quarterly organized postgraduate course, and having passed the qualified Doctor of Menopause medical exam (oral and multiple-choice test every 5 years). Scientific activity is not obligatory, but it is highly valued in the score system. This postgraduate education system was accepted by the College of Obstetrical and Gynaecological Speciality in 2000.
There are about 1.5 million postmenopausal women with half a million in the perimenopause. About 40,000 packs of menopausal hormone therapy are sold per month to 3–4% of this age group. This proportion has decreased from 6% before 2002. During the same period, the use of phytoestrogens increased and of the cimicifuga extract by about 3%.
The most important problem is the increasing fear of breast cancer and cardiovascular side-effects. The disproportionate fear of side-effects is fuelled by both professional literature and the mass media. Doctors from other specialties, particularly GPs, are hostile towards menopausal hormone therapy.
Gynecologists are allowed to treat osteoporosis, and can prescribe for it, with reimbursement. Rheumatologists do not use menopausal hormone therapy.
The Hungarian Menopause Society is a popular and well-known society, and a member of the Alliance of Hungarian Medical Societies. We organize national congresses biannually since 1995 in early June. In every meeting, one or more opinion leaders in the field of menopause participated. We organize a quarterly postgraduate course (MAKO, menopause clinic’s club in Óbuda), accredited by the Continued Medical Education system of Semmelweiss University. Participants come from all parts of the country. We support the scientific research and publication activity of our members.
We opened a website www.mmt.hu in the late 1990s, which is popular with 500 registered visitors. We regularly publish News Letters on our website and e-mail them to members. Society life is quite active. We arrange ad hoc meetings, organized as the opportunity arises, to hear famous speakers who are visiting our country (e.g. Wulf Utian, Henry Burger, Hermann G. Schneider, Martin Birkhäuser, David Purdie), or press conferences (e.g. after publication of the WHI results).

President: Dr Sunila Khandelwal MS, FICOG, FICMCH, FICS

The Indian Menopause Society is a fast growing society with 34 chapters and 2000 members at present. Membership is open to all those interested in the well-being of the mature woman. The society has both doctors and non-doctor members. Amongst the doctors, one-third of the members are non-gynecologists. To be called a ‘menopausal specialist’, a gynecologist does not need any other qualification. Members of our society treat osteoporosis.
The Indian subcontinent is a mix of many ethnic groups and cultures where perception of menopause varies. The age of menopause varies from 47 to 51 years in various studies from different regions. The symptoms too are different from region to region. In studies from the western region, joint pain is the most distressing symptom, while in the north the majority does not complain of symptoms. Largely, women accept this transition as a part of the process of aging and do not seek help. Alternative medicine is better accepted and used because of its supposed safety. The WHI study has affected HRT usage adversely.
Spreading awareness about menopause is difficult. Women do not wish to attend such programmes in hospitals: the society has to organize camps and lectures at their doorstep. Most patients also want such activities to be free and hence funding is required. The gynecologist members also find it difficult to convince patients to use HRT.
The Indian Menopause Society is committed to fostering the comprehensive well-being of mature and elderly Indian women. The society provides a common forum for medical, other interested health professionals and people from all walks of life to work towards the goals of the society. The goals are: to increase awareness regarding menopause and aging through public health and education activities; to promote a multidisciplinary multifactorial comprehensive approach to the care of these women – medical and non-medical; to regularly update doctors and health professionals in the field of menopausal medicine; to facilitate the exchange of ideas and experiences of different disciplines since the physical, mental and emotional health of women in the years after menopause is truly multidimensional; to collect information and data and encourage research with particular reference to Indian women; and to help provide awareness and services to the less-privileged groups of women in our society.

Chair: President Dr Muharam Natadisastra
Dr M. Sjarief Darmasetiawan

Indonesia is an archipelago of more than 13,500 islands, consisting of 35 provinces. In 1990, we established an organization for menopausal women called PPKW (Organization for Elderly Women’s Welfare). The organization has since been changed to the PERMI (Indonesian Society of Menopause) and was chaired by Professor R. S. Samil as the first President on 19th February 1997. The organization has 18 branches throughout the country. Currently, it is located in government universities only.
PERMI’s membership represents Indonesian physicians, intellectuals (non-medical), and scientists, and is not limited to physicians or gynecologists. There are approximately 25–30 members in each branch. Our system has a consultant of reproductive endocrinology & fertility (KFER) instead of a gynecological endocrinologist, who could be categorized as a menopause specialist. To achieve this qualification, a gynecologist needs two more additional years of education. This position is primarily responsible for the educational aspect of endocrinology (including menopause) rather than as a clinician, since family doctors also have authority to treat women with menopausal problems.
The geriatric population increased from 9.4 million to 16.2 million people by the year 2000. This 72% increase over a period of 15 years was simultaneously accompanied by a population increase from 164.6 million people to 216.1 million people (a 32% increase). This phenomenon shows that the growth rate of geriatric people is approximately double than that of the total population. Approximately 78% of geriatric people live in villages. Indonesia will have serious geriatric-related health problems in the future. Based on a study conducted by 191 GPs in Jakarta, the use of hormonal therapy was only 2.9%, whilst 52.6% preferred non-hormonal therapies. The remaining 44.5% inconsistently used a combination of hormonal and non-hormonal therapies. The main reasons why they were not choosing HRT was because they did not have confidence and the fear of cancer (42%).
Climacteric symptoms have less prevalence compared to those of Western countries. The patterns of complaints and climacteric symptoms identified are the same as those found in Western countries except that the symptoms are more mildly perceived, or not expressed at all. The consumption of soybean and rice (besides traditional herbs) may contribute to the low prevalence of climacteric symptom in our population. This issue still needs to be determined and investigated further.
The objectives of PERMI are: to enhance the quality of life of premenopausal, menopausal, and postmenopausal women through the development of health and medical science and technology, particularly those which relate to these problems; to enhance the service quality of menopausal problems and to provide help and support for its members. PERMI has been able to include the study of menopause in the medical curriculum as pre-service training as well as in the training for family doctors as an in-service training. PERMI is also doing its utmost to develop an Indonesian densitometer machine, and to determine the normative value of normal bone mass density of elderly menopausal women in Indonesia.

President:Professor Boris (Bari) Kaplan, Schneider Women's Hospital, Rabin Medical Center, Petah Tikva

The Israeli Menopause Society was founded in October 1992. The society, as non-profit, scientific organization, is devoted to promoting the understanding of menopause and thereby improving women’s health through mid-life and beyond. The Israeli Menopause Society is composed of 200 members; both physicians and paramedical professions who have an interest in the menopause and related topics can be full active members in the society. However, the present status shows that most of the members (95%) are gynecologists.
There is no need for special qualification except being a medical or paramedical person for participation as a member of the society, and to be called a ‘menopausal specialist’ in Israel, and there is no official title of ‘menopause specialist’ in Israel.
Prior to the first publication of the WHI study and of the Million Women Study, 92% of Israeli physicians routinely offered HT to their menopausal patients; the treatment was prescribed for 10 years or more by 66% of the Israeli gynecologists. At that time, 24% of Israeli women were using HT, while 70% of female gynecologists use HT. As in many other western countries, a decrease in use of HT has been observed after the publication of the WHI. HT is currently being used by 27% and had been used in the past by another 16% of menopausal women in Israel. There is a positive significant correlation between level of education and both undergoing regular medical screening and engaging in regular sports activity. HT current utilization is negatively associated with age and being a housewife. HT use in Israel has an individualized approach, with careful consideration of both the benefits and risks of treatment.
The Israeli Menopause Society finds a tremendous need for communication with gynecologists, physicians and patients. Thus, it organizes regular three half-day meetings, discussing one issue at a time per year (i.e. imaging during menopause, or esthetics during menopause), and one full-day annual meeting dealing with various issues. In addition, the Israeli Menopause Society organizes consensus conferences and statements about menopause management, in cooperation with the Israeli Obstetrics and Gynecology Society and reported on the Israeli OBGYN web site.
The major problem of HT use in Israel is the fear of patients and physicians, fuelled by the press, regarding the use of HT and the connection with cancer.
HT, bisphosphonates and raloxifene are frequently used by the members of the Israeli Menopause society (gynecologists and general physicians) in the prevention and treatment of osteoporosis. Other medicines such as PTH are used in agreement with the needs of each patient. Only in rare cases after a referral is a treatment given by rheumatologists or endocrinologists.
The Israeli Menopause Society’s objectives are education regarding menopause and related health problems and solutions, promoting good health-care habits and positive attitudes toward menopause and treatment options.

President: Gian Benedetto Melis, Professor of Obstetrics and Gynecology, University of Cagliari

The Italian Menopause Society was founded more than 10 years ago by a group of gynecologists from several Italian universities. Now, SIM has more than 500 members.
Every 2 years, SIM organizes a national Congress with many Italian participants. The speakers and chairmen of the SIM Congress are Italian gynecologists who are known for their original studies on menopause. In the last years, mainly after the publication of the WHI study, SIM has had the necessity to organize local meetings and Round Tables for medical doctors without gynecological specialization, with the aim of giving correct information, both on the results of the WHI study and on the favorable effects of ovarian hormones on women’s health when the woman’s age and her basal conditions satisfy the inclusion criteria for hormonal therapy (HT). HT with low hormonal dosages is supported by SIM because several studies show that low HT doses are capable of improving menopausal symptoms, dependent on lack of ovarian hormonal action on the central nervous system (CNS), mainly hot flushes and psychological symptoms, but also to prevent osteoporosis, cardiovascular diseases and vaginal dystrophy. In the scenario of several kinds of HT, SIM focuses its attention on new progestin compounds, such as drospirenone, capable of counteracting the renin–angiotensinogen–aldosterone system with beneficial effect on the control of blood pressure and water retention. However, the objectives of SIM are also to give more data on personalized hormonal treatments, such as tibolone, or different methods of hormone administration. Therefore, HT can be prescribed after both a complete screening of inclusion and exclusion criteria to HT and a complete examination of a woman’s characteristics.
Although the majority of gynecologists are in agreement with these objectives, many women do not take HT because they are afraid of breast cancer risk with HT use. Therefore, many meetings of SIM are addressed to women in order that they can understand the real overall oncologic role of HT. In women with exclusion factors to HT, SIM focuses on the importance of a correct follow-up and the use of alternative therapies, such as topical estrogen use to counteract vaginal dystrophy, drugs capable of reducing bone resorption and drugs which can antagonize the neurotransmitter changes responsible for CNS symptoms. On the other hand, SIM philosophy indicates that a correct lifestyle oriented to a diet with low caloric intake, but supplemented by adequate doses of calcium and vitamins, together with the association of an equilibrate physical activity, enhance the beneficial effects of HT on the quality of a woman’s life. As for alternative treatments with phytoestrogen compounds, SIM believes that future studies are necessary to better understand their chemical composition, their mechanism of action and whether they are capable of exerting beneficial effects similar to those of HT.

President: Professor Hideki Mizunuma, Department of Obstetrics and Gynecology, Hirosaki University School of Medicine

The Japan Menopause Society (JMS) was founded in October 1992 and has 1600 active members. Its membership is composed of gynecologists (78%), medical doctors other than gynecologists (6%), nurses (7%) and others including basic scientists and community members (9%). To be called a ‘menopausal specialist’, a gynecologist does not need any other qualification.
In the general postmenopause population, 2.5% of women use HRT; of postmenopausal nurses, 12.9% are current users and 5.8% are ever users. Other therapies used are antidepressants, Chinese herb medicine and medical supplements (isoflavone), etc.
The particular problems in menopause management that our members experience are a limited awareness of the importance of preventive menopause management in general and in government, even in medical societies; low acceptance rate of HRT, mainly due to the misunderstanding of hormonal preparations, such as fear of cancer, and low availability of only a few kinds of HRT preparations, due to strict regulation in clinical trials.
Treatment for osteoporosis is given by the members of our society, and not only by rheumatologists.
The mission of the JMS is to serve the community by fostering development and progress of basic science and clinical management on menopausal medicine. The JMS organizes an annual meeting and a workshop that are open to everyone who has interest in the activities. It publishes the official journal The Journal of the Japan Menopause Society biannually and newsletters every 4 months, and maintains an active website (http://www.j-menopause.com/) for dissemination of up-to-date information on menopause to members and the community.
The JMS awards and supports individual members for promoting their achievements. Thus far, no organization awards qualifications as a menopause specialist in Japan; the JMS is planning to establish a qualification system for the menopause health-care specialist in the near future.
In order to collect epidemiological data on women’s health, the JMS has been collaborating with the Japan Nurses’ Health Study (JNHS) since 2001 to investigate prospectively lifestyle, health problems and health care, including potential risks and benefits of hormone therapy for Japanese women. Approximately 50,000 nurses have registered to this study and about 20,000 nurses have agreed to be cohort members and to be followed by mailed questionnaires every 2 years.
The JMS hosted the 9th IMS World Congress on the Menopause in 1999 in Yokohama and the Satellite Symposium in Kyoto.

President: Professor Ki-hyun Park, Department of Obstetrics & Gynecology, Yonsei University Severance Hospital, Seoul
President elect: Professor Jung-gu, Kim, Department of Obstetrics & Gynecology,
Seoul National University Hospital, Seoul

The Korean Menopause Society was founded in January 1992 and now has 1500 members. The Society’s members are gynecologists, internists and general practitioners. Membership is not open to non-MDs or paramedics. A gynecologist does not need any qualification to be a menopausal specialist in our country. The members of our society treat osteoporosis also.
Of 5.74 million women between 45 and 64 years old, 5.1% will be expected to use HT in 2006; 5.5% of postmenopausal women have been estimated to use HT in 2005.
After publication of the WHI study, the HT prescription rate decreased by 16%; approximately half of the Korean physicians who continued prescribing HT changed their prescriptions.
The society’s activities and objectives are to study and to exchange information on menopause, to promote relationships among members and international relationships, to improve awareness of estrogen deficiency for the public. We have education programs for physicians two times a year and an expert meeting once a year. Also we have published a book of peri- and postmenopausal women’s health for public use and a guideline on HT for postmenopausal women.

President: Rolandas Ziobakas, MD, Clinic of Obstetrics and Gynecology, Vilnius University, Vilnius

The Lithuanian Menopause Society was founded very recently, on the 29th of September, 2006, and has 20 members – founders of the Society. Membership is open to all MDs.
The Society’s objectives are: to join together all the medical specialists interested in aged women’s health problems, to improve their knowledge, applying them into clinical practice, to increase the use of evidence-based management of menopausal disorders, to promote scientific activities in the field of menopause issues, to advance the interchange of research and experience between members of the society, to inform and educate the public of the evidence-based health care of aged women, etc.
In Lithuania it is not necessary to have any subspecialty, for example gynecological endocrinology, to be formally called a menopausal specialist. Nevertheless, the Lithuanian Society of Obstetricians and Gynecologists formed a group of menopause experts, which produced practical recommendations for HRT in 2005.
The prevalence of current HRT use among menopausal women in Lithuania is less than 5% (data from IMS).
A great impact on the low prevalence of current HRT use among Lithuanian menopausal women is the fear of HRT-associated risks. Another important cause is that women very often are not advised by their health-care providers to use HRT (especially by general practitioners).
Osteoporosis in Lithuania is mostly treated by non-gynecologists (endocrinologists, rheumatologists, etc.).

President: Professor Dr Nik Nasri Ismail, Obstetrics and Gynecology

The Malaysian Menopause Society (MMS) was established in 1997 with the main objective to share and disseminate knowledge and information on climacteric problems. Current membership stands at 1032 members. Membership is open to all Malaysians irrespective of race or sex who subscribe to the objectives of the Society. Non-Malaysians are also considered for associate membership in the society with all benefits except voting rights.
Malaysia is made up of three main ethnic groups, Malays, Chinese and Indians, who live in harmony with other minor ethnic groups. For many Malays who are Muslims, menopause is regarded as a blessing since they are no longer prohibited from participating in religious activities during menstruation. The other two races face menopause with a mixed feeling. The mean menopausal age for Malaysian women was found to be 50.7 years and 70% of the Malaysian women claimed that they did not suffer from symptoms of hot flushes, sweating or palpitations.
A recent survey found 27% of Malaysian women were very much affected by menopause while another 30% claimed the symptoms were mild. The main symptoms were headache, sleeplessness, irritability and reduced sex drive. Unfortunately, only 9% of Malaysian women had advice from doctors about menopause and HRT while 91% did not receive any advice. The survey also found that only 11% had ever used HRT and only 6% were current users, although 39% of them were aware of HRT.
The MMS played a major role in helping the Ministry of Health to draft a statement when the WHI report was released in 1992. A congress on menopause is held every 2 years during which the Executive Council of MMS are elected. It is usually attended by about 300 participants, which also include doctors from Singapore and Indonesia. The next congress will be held on April 6–8, 2007.
The first official menopause clinic was established in 1991. It was a community clinic affordable by many menopausal women. As a result of the dissemination of knowledge and training, many such clinics were opened in government hospitals in various parts of the country. The doctors running these clinics are usually from the discipline of gynecology, although endocrinologists also prescribe HRT.
All kinds of HRT are available in Malaysia. Some common preparations are free at government hospitals, while the rest can be obtained easily at retail pharmacies. Most Muslim women would prefer the no-bleed regimen so that their religious activities are not hindered. This is also in agreement with the religious authorities, which the MMS consulted. The others have no preference except to get the benefits and comfort of the treatment. After the WHI reports, preparations used in the study became less popular even on a short-term basis.
Malaysian women are fortunate as the Government has established a special Ministry of Women and Family Development since 1999. This Ministry also organizes on its own, but with contributions from members of MMS, activities to promote women’s health in general and a special program for women in the golden years.

President: Dr Gilberto Tena Alavez, Obstetrician and Gynecologist

The Association was founded in 1992 and now has 533 members; 437 of them are gynecologists. Membership is open to any physician and professional who works in women’s health. To be called a menopause specialist, a physician must have recognized experience in the diagnosis and treatment of menopause.
In Mexico there are 15,524,742 women between 35 and 65 years of age, 6,755,179 older than 50 years and little more than 7 million in the postmenopause. Life expectancy is 77.8 years. The average age at menopause is 48.5 years, spontaneous in 45% and surgical in 48%; 15.69% of women have premature menopause (40–44 years) and 2.46% have premature ovarian failure (before 40 years).
The main reasons why women consult a physician during menopause are hot flushes and sweating, which are present in 80–85% of women, psycho-emotional symptoms, urogenital discomfort, opportune detection of both cervical and breast cancer, and osteoporosis detection.
The main causes of death in Mexican women between 35 and 64 years are malignant tumors 25%, diabetes 20% and heart diseases 12%. In women of 65 years and older, the main causes of death are heart disease 24%, diabetes 16% and malignant tumors 12%. In Mexican women, breast cancer is the second leading cause of death from malignant disease (2.1% of all deaths). There are 9050 new cases of breast cancer every year. It is estimated that in our country there are 1,080,828 women older than 50 years with osteoporosis.
Approximately 43.7–45.7% of women with spontaneous menopause have used HRT and 53.6% of women with surgical menopause. In Mexico, the main prescriptions are: estrogens 20%, estrogen–progestin 65%, tibolone 10% and SERMs 5%.
In 2003, during a Mexican multidisciplinary consensus about hormone therapy, some important recommendations were made: all patients during menopause must receive individualized attention whether they have symptoms or not; the purpose of individualized management is to improve quality of life during this period; do not start hormone therapy without a control mammogram; hormone therapy must be given according to the clinical situation of the patient and can be modified depending on undesirable effects that present; look for efficiency in management to achieve the maximum benefits with the least resources; in all patients it is required to make an individual diagnosis and provide information about menopause; hormone therapy must be limited to the initial period of menopause.
Almost all members of our association treat osteoporosis.
The association has one course for physicians every 2 months, three meetings each year with patients and a course for nurses, all of them with menopause issues.
The objective of the association is to know, to study, to treat, to prevent and to educate in all issues that are present or have relation to pre- and postmenopause.

President: J.W. (Hans) van der Slikke

The Dutch Menopause Society (DMS) was founded in 1987 and has 187 members. The DMS is open to non-gynecologists and nurses. The menopausal specialist does not exist in The Netherlands. The gynecological endocrinologist mostly treats patients with infertility problems. Climacteric medicine is not a separate speciality in our country.
The number of patients with menopausal complaints is about 1 million. The number of menopausal women using hormone therapy in The Netherlands in 2005 was 59,168. The percentage of women between 45 and 65 treated with hormone therapy in The Netherlands was only 5%, while in Europe the average percentage of women treated with hormone therapy is approximately 25%.
The particular problem is the fear of developing breast cancer when using hormone therapy, and also if it is used only for a short period of time. Especially the general practitioners are very reluctant to prescribe hormone therapy. Unfortunately, menopausal problems are not a hot topic in The Netherlands, for instance the lay press was not at all interested in World Menopause Day. Only a limited number of gynecologists treat osteoporosis.
The society’s activities and objectives are to organize scientific meetings; to promote contacts and collaboration with other national and international menopause societies such as the IMS, EMAS and NAMS; to stimulate and co-ordinate scientific research; to organize postgraduate courses; to advise the Board of the Dutch Society of Obstetricans and Gynecologists of the Netherlands; and to update our website: www.overgang.net, open for professionals and the general public.

President: Dra Marta Montenegro, Gynecologist and Obstetrician

The Association was founded in 1999, with Dra Greta Solís as the Founding President, and now has 45 active members. Our Association is composed of gynecologists, nutritionists, orthopedic surgeons, physicians and internists. It is open to other medical doctors such as radiologists and endocrinologists working with women on menopause or osteoporosis. We are called menopause specialists because we work in this field. A gynecologist does not have to be an endocrinologist.
The mean age of menopause in Nicaragua is 49 years. The use of HT is low (15%) due to economic factors, attitude and lack of education about osteoporosis. Other therapies are not used.
We have a large problem: the women are used to keeping their problems related to sexuality or depression to themselves, for fear of shame. In our country, women give priority to the health of their children or elderly parents and leave their own medical checkups to last. In fact, there are no national health policies for menopausal women. Recently, I was assigned by the Health Ministry of my country to elaborate national guidelines for the management of menopausal women. These guidelines were completed in October 2006 and will be set on Health Unit in 2007. The gynecology medical residents do not have experience of climacteric and menopause because there are no menopause clinics in the public health system. There are specialized clinics on menopause only at the private level and only in the capital city. Another important issue is that most of the doctors (especially internists and cardiologists) are not convinced about HRT and they tend to stop the use of HRT because of the risk of breast cancer.
In Nicaragua, members of our association treat and prevent osteoporosis, especially gynecologists and orthopedic surgeons and physicians. We celebrate the World Day of Osteoporosis with opportunities for bone densitometry testing and we publicise the meaning of osteoporosis, its prevention and all the complications of fractures. We carry out screening in women at risk and teach the importance of a balanced diet, exercise and the avoidance of habits harmful to health (smoke and drink).
The activities of the Nicaraguan Menopause and Climacteric Association, approved by the National Assembly, include the education of patients and medical doctors, a conference for menopausal women, family practitioners and gynecologists, a national congress on menopause every 2 years, meetings with users and non-users of HRT; participation in TV and radio programs, and newspaper articles about menopause, osteoporosis and the risks of estrogen deficiency.
We intend to keep working in the menopause field because we think there is much we can do for our women.

Leadership: NAMS leadership is provided by a Board of Trustees, whose principal officers are President (Steven Goldstein, MD, NCMP; Professor of Obstetrics & Gynecology, New York University) and Executive Director(Margery Gass, MD, NCMP; Consultant, Cleveland Clinic Center for Specialized Women’s Health).

NAMS establishment and mission: NAMS, with central offices in Cleveland, Ohio, is the leading non-profit organization in North America dedicated to promoting the health and quality of life of all women during midlife and beyond through an understanding of menopause and healthy aging. Incorporated on November 29, 1988, the Society was designed to serve North America (Canada, Mexico, and the US). It was launched at a co-sponsored meeting under the auspices of the New York Academy of Sciences on September 21–23, 1989 (Annals of the New York Academy of Sciences, vol. 592, 1990).

NAMS membership: NAMS has over 2,000 members from 51 countries; 90% of the membership is from North America. Membership is open to licensed physicians and other licensed healthcare professionals, scientists holding an advanced degree in one of the biological or social sciences, and others with professional or scientific interests in menopause who subscribe to the principles of professional ethics in their respective disciplines and who support the purposes and objectives of the Society. Members include clinical and basic science experts from medicine, nursing, sociology, psychology, anthropology, pharmacy, epidemiology, nutrition, and education.  About 70% of members are physicians, and of these almost one-half are gynecologists.  Professionals may join NAMS at the website: www.menopause.org

Society activities: NAMS organizes an annual scientific meeting attended each year by registrants from over 41 countries. The Society owns the scientific journal Menopause that ranks 10th out of 70 titles in the obstetrics and gynecology category.  The Society provides original articles every other month to The Female Patient, distributed to 60,000 subscribers and available online with patient handouts in English and Spanish. The NAMS website receives 5 million visits per month. The Society develops position statements on clinical issues of interest to members, produces educational programs (First to Know®  e-newsletter, and Menopause e-Consult), and publishes the textbook Menopause Practice: A Clinician’s Guide, now in its fourth edition with a new digital searchable version. For consumers, NAMS offers the Menopause Guidebook, the Early Menopause Guidebook, and the complimentary web magazine, Menopause Flashes®.  New in 2011 is the online resource Sexual Health and Menopause (www.menopoause.org/sex.aspx).

Women served: Within the US, an estimated 48 million women are postmenopausal; for Canada and Mexico the estimates are 5 and 9 million, respectively. In the US, somewhat over a fourth of women have undergone hysterectomy by age 54, and about half of these women have undergone bilateral oophorectomy as well (surgical menopause).  To raise the level of care for menopausal women, NAMS offers a written competency examination to licensed health-care practitioners for 3-year credentialing as a NAMS Certified Menopause Practitioner (NCMP).

President: Dr Konstantinos Tserotas, Executive Director, Sección de Climaterio
President, Sociedad Panameña de Obstetricia y Ginecología: Dr Rafael De Gracia

The Climacteric Section was founded in 1991; the Panamanian Society of Obstetrics and Gynecology was founded in November 1947. The Climacteric Section has ten active members of the total 222 that are members of the Panamanian Society of Obstetrics and Gynecology; of the remainder, most join in the activities related to menopause. All members are obstetricians/gynecologists because the Climacteric Section is part of the Panamanian Society of Obstetrics and Gynecology. We have a project, beginning next year, to open the climacteric section to the participation of other health professionals.
We do not have an official title of menopause specialist or established requirements. Gynecologists offer their expertise in the field as part of their daily practice.
Panama has an estimated population (2005) of 3,228,186, of whom 1,599,466 (49.55%) are women and 267,981 (16.75%) are in menopause (> 50 years old). We have a study of 700 women from the Social Security System in 2004 that shows 19.1% are using hormone therapy. Other groups in the capital city and the countryside have not been studied. Other therapies are common and widely used (over-the-counter phytoestrogens, natural products).
The most common problems we face are misinformation of our patients by other health professionals, the press and general public, and the lack of coordination between health authorities, physicians and paramedical health-care professionals to produce appropriate medical care and facilities for menopausal women. We need a national program to address these particular issues in women’s health.
The members of our society treat osteoporosis. Some of our members participate in the activities of the Panamanian Council on Osteoporosis (COPOS), which is a multi-specialist organization whose priority is osteoporosis education for physicians and the general public.
The society’s objectives are to provide continuous education for other health professionals and affiliates, the public and the media, and to have regular communication with government officials on menopause-related issues. The society’s activities include a national congress, local seminars, public education on TV, radio and newspapers, press education, using both seminars for the press and a national contest for the best press reports on menopause; and meetings with government officials.

President: Roberto Sano Ito M.D.

The Sociedad Peruana del Climaterio was founded on November 12th, 1992 in Lima, Peru and now has 320 members. Membership is open to all medical doctors but the principal medical specialties are gynecology, internal medicine, cardiology, rheumatology, endocrinology, urology, psychiatry, and radiology. It is not open to non-MDs or paramedics.
To be called a ‘menopausal specialist’ in Peru, a gynecologist does not need any other qualification. We do not have ‘Menopausal specialist’ as a specialty or as a degree at university or any school of medicine.
In Peru, there are 26,152,265 people, of whom 50.05% are women. For the year 2006, of the total population, 10.76% are women between the ages of 45 and 60 years. The use of HRT was 2% until 2002, but, after the WHI reports, it decreased to 1.6%. We use oral (low dose), transdermal (gel) and tibolone. Complementary and alternative medicines are used when women do not want or reject HRT such as phytoestrogens or Maca (Lepidium meyenii walp or Lepidium Peruvianum), a Peruvian plant known since pre-Inca times and evidence of it being grown 1600 years before Christ. It is cultivated at very high altitudes (4400 meters above sea level). The most useful part of this plant is its roots, which have high nutritious and energy value. There are reports that it improves libido and fertility, as well as diminishing the frequency of hot flushes.
The particular problem in menopause management that our members experience is that there are only a few programs for management and prevention for menopausal women at hospital level and these are only for the people who have some medical insurance. After the WHI and the propaganda of the media, women stopped using hormones, although lately they are accepting their use again but very slowly. In addition, there has always been a high rate of discontinuation. Some older medical doctors and those of certain specialties like oncology, cardiology, or cardiovascular surgery, always speak negatively of the benefits of well-administered HRT and scare the women so that they stop the treatment, although I have to say that this population is aware of the merits of improving their lifestyle (exercise, diet, avoiding harmful habits, etc.).
Members of the society treat osteoporosis, principally gynecologists and endocrinologists as well as rheumatologists.
The society’s activities include: a monthly scientific activity (always with a dinner and with an invited professor who speaks about subjects of much importance); international biennial course and international biennial congress for all the medical and paramedical community; courses on how to interpret bone densitometry; courses about menopause and its management for university residents, mainly of gynecology; diffusion to the population in general through mass media and campaigns. In recent years we have been trying to reach those non-specialist doctors who care for the many peripheral populations of our great cities.

President: Dr Evelyn P. Palaypayon, Associate Professor of Obstetrics and Gynecology, The Far Eastern University, Dr Nicanor Reyes Memorial Foundation Hospital

The Philippine Society of Climacteric Medicine (PSCM) was incorporated on February 12, 1993 with 75 founding members, consisting of obstetrician-gynecologists, cardiologists, orthopedic surgeons, psychiatrists, radiologists, nutritionists and rheumatologists. Currently, there are 530 active members of the society. Although the majority of the members are gynecologists, membership of PSCM has remained open to every licensed physician whose concern is the care of the climacteric woman.
In the Philippines, the gynecological endocrinologist has originally been designated the title of specialist. More recently, however, even general gynecologists who have consistently shown a keen interest and passion for the study and treatment of the menopausal woman have also been referred to as menopausal specialist.
The average age of menopause is 48 years. With the average life expectancy of women placed at 70, women expect to spend about 28–30 years of their lives past the menopause. Common menopausal complaints include hot flushes, headaches, irritability, anxiety, and urogenital atrophy.
The general objective of the PSCM is to promote the art and science of climacteric medicine, with specific objectives including advancement of the current standard of practice in the management of climacteric woman; strengthening ethical standards of practice in the management of climacteric women; increasing public awareness on climacteric medicine/menopause; promoting research in climacteric medicine; and lastly, encouraging the members to undertake community service in the field of climacteric medicine.
With these objectives in mind, the PSCM set out to promote the study of information on all aspects and care of the menopausal woman through conventions, meetings for lay people and out-of-town programs, and to establish menopause clinics throughout the different regions in the country. Annual activities include a mid-year convention in June, and an annual convention in September, both using local and foreign experts as speakers, and a celebration of the menopause months in October.
Prior to the WHI report in July 2002, HRT was widely accepted by both physicians and laymen, not only for treatment of menopausal symptoms but also for prevention of cardiovascular disease and osteoporosis. After July 2002, there was a marked drop in HRT prescriptions as both physicians and patients became fearful of the increased risk of breast cancer and thromboembolic phenomena with HRT use.
In 2005, the PSCM released its own set of guidelines on HRT and management of menopausal problems, including osteoporosis. Gradually, we have seen resurgence in HRT usage among menopausal practitioners. Nevertheless, less than 10% of menopausal patients receive or continue to take HRT, for two reasons – the fear of breast cancer and the high cost of HRT.
Osteoporosis prevention and management are carried out by most Ob/Gyns in the country (presently numbering 3500), and not just by members of the PSCM, the rheumatologist or the orthopedic surgeon. The high cost of such medications such as raloxifene and bisphosphonates remains a great deterrent to continuing care.

President: Professor Decebal Hudiţă, “Carol Davila” University of Medicine and Pharmacy

The Association was founded in May 1997 and has 165 members. The society’s members are gynecologists, endocrinologists, general practitioners, cardiologists, rheumatologists, orthopedic surgeons and geriatric physicians; there are no paramedics.
In Romania a menopause specialists has to complete courses on menopause and gynecological endocrinology. This training and status are recognized by the Romanian Society of Obstetrics and Gynecology.
There are approximately 4 million menopausal women in Romania; 2–2.5% are on hormone HT, and nearly 0.5% on raloxifene, tibolone or herbal supplements and isoflavones.
Most women take HT for a short duration particularly because of fear of HT since the WHI report.
We treat osteoporosis together with endocrinologists and rheumatologists.
The AMMR has organized five national conferences, one national congress on menopause, and the EMAS Congress in Bucharest in May 2003, under EMAS coordination. The second Romanian National Congress on Menopause will be held in June 2007. AMMR was responsible for the consensus on hormone therapy in menopausal women (Sinaia, Romania, February 2004) with different specialists in gynecology, endocrinology, and cardiology. The Association held the National Programme on HT in menopausal women during 2000–2005, and this will be restarted in 2007. AMMR provided national guidelines on menopause therapy (2006/2007).

President: Professor Vera Smetnik, MD, PhD, Head of Gynecological Endocrinology Department, Russian Research Center of Obstetrics, Gynecology and Perinatology, Moscow

The Russian Menopause Society was founded on 16 May 1996. It now has 594 members. Only MDs (gynecologists or non-gynecologists) can be members of the society. To be a menopause specialist, gynecologists in Russia must be certified as an ‘obstetrician-gynecologist’. Gynecologists, endocrinologists and rheumatologists all manage women with osteoporosis.
Epidemiological data in 2005 have shown that there are 77,144,320 women in Russia and 48,652,588 are older than 40 years. The prevalence of HRT use in Russia is about 3%. HRT products are not covered by insurance in Russia, and patients buy medicines themselves.
The main problem in Russia is patients’ traditional negative attitude to and fear of the term “hormone” in any interpretations. This phenomenon exists in current menopausal Russian women because of the association with their negative experience of using first-generation high-dose oral contraceptives in the early 1970s. On the other hand, there is a strong belief among most patients that any hormone has the same side-effects as glucocorticosteroids. That is why most Russian women associate any hormonal therapy with weight gain, hirsutism and oily skin. There is still a lack of knowledge on menopausal problems among women, a negative view of media on HRT, patients’ fear of cancer, thrombosis, stroke and weight gain. We still experience the strong negative effect of the consequences from the WHI reports especially in the media and press.
The main activity of the Russian Menopause Society is education of doctors and patients: the society has a website www.climax.ru and the journal ‘Climacteric’. Residents and clinical fellows can present their own data in the society’s journal. Under the supervision of the Russian Menopause Society, round tables and discussions of clinical cases for doctors are conducted online. The research activity of the society includes statistical analysis of current HRT use among women doctors. The society organizes annual conferences on gynecological endocrinology and menopause and Russian congresses on gynecological endocrinology and menopause every 3 years.
The Special Federal Center, ‘Women’s health after their 40s’, was founded in the Russian Research Center of Obstetrics, Gynecology and Perinatology in 2001. In this Center, there is a ‘Climacteric clinic’, which is an educational center for doctors and patients. Interactive lecture courses are given by PhD gynecologists and cardiologists twice a month. Lecture courses have included issues on menopausal health, cardiovascular system, urinary incontinence, osteoporosis and therapy options in menopause. The Russian Menopause Society is providing a program of educational lectures to stimulate the organization of climacteric clinics in six different regions in Russia.

President: Professor Milka Drezgic, internist-endocrinologist

The Society was founded in 2002, and there are now 400 members. Members include internists, endocrinologists, gynecologists, rheumatologists, general practitioners, oncologists, cardiologists, urologists and non-MDs. It is preferred, but not obligatory, that gynecologists and endocrinologists have a qualification for gynecological endocrinology.
The overall economic situation in Serbia and Montenegro suffers from the lack of long-term political stability and is marked in 2005 by higher then planned inflation (12–13%), currency devaluation, very high unemployment, a certain increase in industrial production, and stronger social pressure (trade unions).
The total number of women in perimenopause and postmenopause age (40+), according to the last census information in 2002, is 1.7 million. The number of women in the age group 40–49 is 0.58 million and in the age group 49–59 years is 0.5 million. The number of women belonging to the urban part of the population is 0.65 million. In Belgrade alone there are 0.25 million women.
Generally, the acceptance rate of HRT among the medical profession and the female population is low (less than 1%). The reasons for the low acceptance are typical for Central-Eastern Europe: fears of hormones as the result of the lack of the information among women and the medical profession; the traditional opinion among women that climacteric disorders are normal and there is no need to treat them; the influence of the results of the WHI reports and the Million Women Study among both doctors and patients.
The particular problems in our country are previous dogmas, and the trustworthiness of false news about ‘alternative therapy’, often without any active substance.
In our country, osteoporosis is treated by rheumatologists, endocrinologists and internists. Twice yearly we organize full-day lectures for doctors in the medical faculty in Belgrade. Celebrating World Menopause Day this year, we gave lectures about perimenopause. The media and pharmaceutical companies were informed, invited and took an active role. We are participating in TV programs explaining the problems of the menopause, complications and implications on quality of life.

President: Dr ChuaYang; Past President, Dr Foo-Hoe Loh, Mt Elizabeth Hospital, Singapore

The society was founded in 1998 by Dr Teoh, Eng-Soon. It is a small society and currently has about 50 members. Membership is open to medical professionals. The members are mainly gynecologists, but the membership also includes orthopedic surgeons, rheumatologists, cardiologists, family physicians, etc. Associate membership is open to non-medical professionals.
The ‘menopausal specialist’ is not recognized as a subspecialist in Singapore, but menopause management usually comes under the responsibility of the ‘Reproductive Medicine’ division of an OB/GYN department. Opinion leaders in menopause management in Singapore, therefore, often come from a reproductive medicine background with a body of work in menopause management.
We recently published a nationwide study on the experience of menopause transition amongst women in Singapore [1]. Singapore is a small island republic with a resident population of just over 3 million people, composed primarily of three ethnic groups: Chinese (77%), Malays (14%) and Indians (8%). It is a largely urban population with disease patterns very similar to western populations. The age of menopause amongst the women in the three groups was 49 years, and did not vary significantly between the groups. The main factor influencing the age of menopause was parity, with increasing parity associated with a slight delay in the age of menopause. There is a low prevalence of classical menopausal symptoms such as hot flushes and night sweats (14.6% amongst those in the first year of menopause, declining rapidly to almost zero beyond the fifth year of menopause). The main complaints tend to be somatic in nature such as muscle and joint aches. Amongst the other more prevalent complaints are insomnia, vaginal dryness, and loss of interest in sex.
Amongst the postmenopausal women, some 16% have ever used hormone therapy, with just 5.7% of them being current users (these are pre-WHI data). The main indication of use was relief of menopausal symptoms (85%). Half of these women used hormone therapy for less than 1 year, and only 17.6% used it for more than 5 years.
The universal perception that use of hormone therapy increases the risk of breast cancer must rank as the most important hurdle for women to accept treatment of menopausal symptoms with hormone therapy. Many resort to herbal and traditional alternatives to treat these symptoms.
Gynecologists do manage osteoporosis, but these tend to be more in a preventive mode, or treatment of osteoporosis in its early forms. Severe osteoporosis is generally managed by the orthopedic surgeons and rheumatologists.
The Menopause Research Society, Singapore, organizes continuing medical education for doctors, both generalists and specialists, on varying aspects of menopause management and hormone therapy. We have also participated in an advisory role to governmental bodies advising on the regulation of drugs, and formulation of guidelines on menopause management. In addition, public outreach in the form of public forums is an important component of our activity. Our most recent activity was the 1st Singapore Menopause Congress, which was successfully concluded in July 2006.

Reference
1. Loh FH, Khin LW, Saw SM, Lee JJ, Gu K. The age of menopause and the menopause transition in a multiracial population: a nation-wide Singapore study. Maturitas 2005;52:169–80

Vice-President and Secretary General: Dr Damir Franić

The Slovene Menopause Society was founded in 1996. Our membership currently is 46, consisting mainly of gynecologists, some subspecialized in urogynecology, andrology, or reproductive gynecology, and of medical staff like nurses, social workers, etc. The members of the Executive Board are also cardiologists, oncologists and GPs.
So far, subspecialization in menopause medicine has not been introduced in this country and we do not have postgraduate studies regarding menopause medicine. Thus menopause is being managed by reproductive gynecologists or primary care gynecologists, who are especially interested in menopause medicine.
In Slovenia, with about 2 million inhabitants, there are 1.1 million women, of whom 321,986 are aged 40–65 years and, of those, approximately 5% are HRT users. The highest percentage of HRT users was registered in 2002 (6.5%), before the WHI study results were made public.
The major problems in Slovenia are related to the low interest of our gynecologists in educating perimenopausal women about the consequences of menopause, and a lack of proper counselling for these women. Therefore, our women lack proper information on how to cope with postmenopausal problems, which option to choose to alleviate climacteric symptoms, how to prevent osteoporosis and consequently how to improve quality of life in that particular period of their lives.
Because Slovenia is a small country, we established a consensus conference in collaboration with the Croatian Menopause Society in 2001; every second year either country organizes a 3-day symposium and workshops on menopause. Beside our local experts, we have always invited experts from abroad to help us improve the knowledge of physicians involved in menopause medicine in some way or another.
In our country, osteoporosis is treated by gynecologists, as well as by endocrinologists or GPs utilizing DEXA scanners, and by those related to the problems of osteoporosis (traumatologists, orthopedic surgeons, etc.).
The society’s main activities in the future will be education of and teaching counselling skills to the physicians involved in menopause medicine, as well as education of women in the peri- and postmenopausal periods.

President: Dr Paul Dalmeyer, Port Elizabeth, South Africa

SAMS was established in 1998; presently it has just under 200 members. Although most of our members are gynecologists with a special interest in menopause, membership is open to all registered medical and paramedical persons. Menopausal medicine is not recognized as a subspecialty in South Africa, but falls under the subspecialty of Reproductive Endocrinology (with gynecological endocrinology and infertility). This is a new development and the first students are presently busy with fellowships.
South Africa has a total population of 44.6 million people of which 23.38 million are females; 4.6 million females are older than 45 years. Although the vast majority of females are younger than 20 years (8.1 million), the future projection of the number of menopausal women is complicated by an estimated HIV+ prevalence rate of 20% for women aged 15-49 years. This percentage has increased from 16.1% in 2001. The latest (2006) calculated life expectancy for females is 52.5 years. The management of menopause is further complicated by the rich ethnic diversity of South Africa. Although black Africans are the single largest group (35 million), there are nine different black ethnic groups, each with their own language and different perceptions of menopause. The minority groups (white, colored and Asian) mostly speak English and Afrikaans. The medical needs of about 80% of the population are cared for by the State, while 20% of the population is cared for by the private sector. Menopausal management in the private sector is very little different from American/European standards, with access to the same medications. The use of menopausal hormone therapy has declined after 2002, but not as deeply as in Europe/USA. All forms of alternative non-hormonal preparations are available.
Osteoporosis is treated by gynecologists (largest single group), physicians, rheumatologists and general medical practitioners. A large proportion of the educational activities of SAMS are aimed at osteoporosis.
The next SAMS congress will be in Johannesburg from February 25 to February 28, 2010 and everyone is welcome! SAMS News, a quarterly magazine for members, highlights issues relating to SAMS and features articles relating to menopause. The SAMS website is found at www.menopause.co.za. This website is interactive for the public, with a question-and-answer forum. Articles of relevance to practitioners involved in menopausal medicine are posted on a regular basis.
Our immediate objectives are to determine the perceptions and needs regarding menopause unique to different cultural groups in our rainbow nation.

President: Professor Javier Ferrer, Head of Gynecology and Obstetrics Department of Hospital Central de Asturias, Oviedo

The AEEM was founded on January 5th, 1992 and at present there are 1121 members. The AEEM is a multidisciplinary organization. Most of our members are gynecologists, but we accept other specialties: rheumatologists, traumatologists, general practitioners (GPs), gynecological endocrinologists, etc. The members of our society treat osteoporosis. Gynecologists do not need any other qualification to be called a ‘menopause specialist’ in our country.
There is no study to date with data on menopausal women in our country. But in Spain at present there are 8 million women of menopausal age who are over 50 years old, although we cannot be sure if these women are suffering menopausal symptoms.
The particular problems in menopause management that our members experience are related to hormone replacement therapy (HRT). Patients’ fear of receiving hormone treatment has in turn created doubt among colleagues, and therefore, difficulties with using HRT.
In summary, the main objectives and activities of our society are: to promote the study of all aspects of the climacteric and the postmenopause in women and secondarily the climacteric in men; to organize, prepare, sustain and participate in congresses and meetings which share the same objectives; to promote the interest and knowledge of professionals who are interested in the climacteric and the postmenopause, and the public in general; to promote exchange in the scientific and experimental fields among the members of the Society; to improve the quality of medical support to women in the climacteric and postmenopause; to establish agreements with other societies or associations which have similar objectives to the AEEM; to be a reference community for Spanish menopausal women; to organize training activities such as symposiums, congresses, seminars and scientific meetings; to develop activities in the research field such as clinical trials, post-authorization and epidemiological studies, questionnaires, and other investigation methods; to organize activities in order to promote and disseminate information about the Society among its members and with the members of other Societies.

President: Sabine Steimann
Website: www.meno-pause.ch

The Society was founded in 1994 and has 231 members. It is open to gynecologists interested in the clinics of menopause but also to other specialists such as endocrinologists, cardiologists and general practitioners. Some of our members are also non-physicians.
The subspecialty ‘gynecological endocrinology and reproductive medicine’ emphasizes a 3-year training in all fields of gynecological endocrinology including family planning and contraception, reproductive medicine, andrology, and sexual medicine.
The Swiss Menopause Society is not sponsored by the pharmaceutical industry and is financed entirely by members’ yearly contributions. Consequently, the Society has no data on HRT usage or on the applicability of other treatment modalities in women around menopause.
The aims of the Society were laid down in its Statutes, formulated in 1994. The Society supports interdisciplinary collaboration on all topics surrounding the menopause and scientific research relating to menopause. It aims to further interaction with other international medical societies dealing with the medical problems of menopause. The main task of the Swiss Menopause Society is to organize a yearly national Congress.

President: Dr. Lian-Shung Yeh, M.D., M.S., Director of Gynecological Section, Department of Obstetrician and Gynecology, China Medical University Hospital, Taichung, Taiwan

The Taiwanese Menopause Society was founded in March 1995 with Professor Ko-En Huang serving as the founding president. Currently, there are 250 active members, who are MDs and PhDs, and ten associate members, who are representatives of the industry such as pharmaceutical companies. Those who are Board certified physicians can be a ‘menopause specialist’, although there is no such title officially recognized in Taiwan.
The estimated number of menopausal women in Taiwan is 2.5 million out of the total population of 23 million. Hormone therapy (HT) users increased from less than 5% of all menopausal women in 1995 to 27% in 2001. Of note is that the Taiwanese Menopause Society was established in 1995 and the National Health Insurance of Taiwan, which covers HT, started in the same year. The gradual and significant increase in HT user rates should be credited to the efforts of medical education widely and extensively provided to both the health-care providers and the public by the society. Taiwan has enjoyed the highest rate of HT use among the Asian countries. After the WHI publication, however, the HT user rate declined sharply to 18% in 2002, and further declined to 16% in 2003. The HT user rate showed a slight increase after that and the current estimate is about 19% of all menopausal women. Many of the women who stopped using HT have started alternative treatments, such as phytoestrogens and/or traditional Chinese medicines. The WHI reports and the negative media reports caused an over-reacting fear of HT, particularly the increased risk of breast cancer, among the menopausal women in Taiwan, just like in other areas of the world. These results also caused concerns about the medico-legal issues of prescribing HT by the physicians. There has been a significant decrease in the number of office visits of menopausal women after the WHI reports. This has been one of the major concerns of the society in that the decreased office visits might cause delay in the detection of any problems among these women.
The members of our society are also providing treatment for prevention of bone loss and osteoporosis for peri- and postmenopausal women.
The major activities of this society are to provide updated information and guidelines about menopause care to both the health-care providers and the public. Our main objective is to maintain good health and quality of life of postmenopausal women in Taiwan.

President: Professor Emeritus Khunying Kobchitt Limpaphayom
Secretary General: Associate Professor Unnop Jaisamrarn
Website: tmsociety.net

The Thai Menopause Society was founded on July 13, 1993 and now has 1115 members. Ordinary members are individuals who are involved in research or clinical work on menopausal women and aging men. Membership is also open to those who have an interest in this area. Honorary members are distinguished individuals who have been invited by the executive board of the society to be members. These include academic experts in the field of menopause and individuals who have made a great contribution to the society.
To be called a ‘menopause specialist’ in Thailand, several requirements are needed as following: gynecologist as a background; working in a menopause clinic; being involved in academic activity relating to menopause.
In Thailand, the ‘menopause boom’ began after the 6th International Congress on the Menopause which was held in Bangkok in 1990. The use of HRT has increased since then. However, a nationwide survey in 1998 revealed that the overall use of HRT was 3.0% in general menopausal women.
The first menopause clinic in Thailand was established in 1992; before that, menopausal care was incorporated as part of the general gynecologic clinic. Nowadays, women can seek menopausal care in a menopause clinic in many public as well as private hospitals around the country.
Prior to the WHI study in 2002, a survey demonstrated a more than 50% prevalence of current HRT use in women attending menopause clinics in Bangkok. However, in 2006 only 25% were found to be current HRT users. Non-hormonal treatment has gained a growing popularity at present.
Apart from problems usually experienced in clinical practice, a particular problem that has been faced by all menopausal specialists in Thailand is the women’s attitude towards HRT. Almost 52% of women attending menopause clinics had concern about breast cancer.
Osteoporosis prevention and treatment is one of the major reasons that bring women to menopause clinics. Bone densitometry is available in most menopause clinics in Thailand. In a 2006 survey, osteoporosis was found to be one of the most common indications for prescribing medication in menopause clinics.
The objectives of the society are: to promote and conduct the study of all aspects of menopausal women and aging men; to provide national data on menopausal women and aging men; to establish a recommendation for the management of the menopause and aging in Thailand.
During the past 13 years, the Society has organized ten national meetings and two international meetings (1st Asian-European Congress on the Menopause, 2nd Scientific Meeting of the Asia Pacific Menopause Federation). The Society has also facilitated an outstanding research program on osteoporosis in Thai postmenopausal women.

President: Professor Randa Mostafa, Chairperson, Basic Medical Sciences Department, College of Medicine, Sharjah University, UAE

The Emirates Menopause Society (EMAMS) was founded recently in April 2009 as a member of the Emirates Medical Association (EMA). The aims of the society are to help and educate Emirates women who are encountering the symptoms of menopause, as well as to conduct research in the multidisciplinary aspects of the subject. The EMAMS started strongly with over 50 members who are clinicians and academicians involved in treating women, doing research or making major contributions in the field of menopause. The founder, Professor Randa Mostafa, a clinical physiologist, invited gynecologists, endocrinologists, physicians, urologists, cardiologists and basic scientists to share in research, knowledge and the treatment of menopausal women in the United Arab Emirates (UAE).
The total population of the UAE currently stands at 6 million, comprised of both emirates and ex-patriates. The UAE is developing very fast because the country has undergone rapid development over the last 38 years, following unification of the Arab Emirates. The UAE is considered to be one of the leading countries in the Middle East in its provision of easy access to quality health care; this is free for local women and affordable for the majority of other people who receive tax-free salaries.
Data on the size of the menopausal problem in the UAE are limited. The median age of natural menopause in the UAE is 48 years and the average life expectancy of women is 76.2 years. The improved health services in the country allow UAE women to live longer and therefore they experience postmenopausal symptoms during approximately one-third of their lifespan.
Women in the UAE do not know much about the menopause, so it will be a challenging task for the EMAMS to raise awareness about menopausal problems through education of the public. With the aims of supporting interdisciplinary collaboration in scientific research in all topics surrounding the menopause and of collaborating with other international medical societies dealing with the medical problem of menopause, the EMAMS plans to organize the 1st UAE International Conference on Menopause in April, 2012 at the Cultural Palaces in Sharjah, UAE.  
As the first menopause society in the Gulf Region, we are on to the road to great success!

Chairman: Mary Anne Lumsden

The British Menopause Society (BMS) was founded in 1989 and currently has over 1000 members. Membership peaked at around 1500 in 2003 but there has been a steady decline in numbers since then. The BMS membership reflects the multi-disciplinary nature of the menopause in the British health-care system (NHS) with 40% gynaecologists, 20% general practitioners and the rest nurses, other doctors and health-care professionals.
There are around 4 million women of menopausal age in the UK. In 2002, nearly 2½ million women were on HRT but this has now fallen to just over a million. Most menopausal women in the UK will be managed by their primary care team, either a GP or a nurse and will only be referred to a ‘specialist’ if there are specific problems. Whilst menopause is not a recognized subspecialty, it is generally accepted that there are some people who have particular expertise in this area. These are predominantly gynaecologists but may be endocrinologists, sexual health doctors or specialist nurses. There are specialist menopause clinics around the country, although many have closed in recent years. The NHS currently financially discourages referral to hospital specialists which means the influence of hospital specialists is increasingly being confined to education and developing guidelines.
Relatively few gynaecologists prescribe for osteoporosis prevention. Following the Million Women Study, the Committee for Safety of Medicines (CSM) issued guidance stating that HRT should no longer be used for osteoporosis prevention, so bisphosphonates are now the main therapeutic option. Rheumatologists and other bone disease specialists now have the major influence in osteoporosis management.
Since its inception, the BMS has been committed to education and it continues to raise awareness of postmenopausal health-care issues and to promote optimal clinical management through its meetings and publications. The inaugural annual meeting in London in 1990 attracted over 600 delegates. Meetings are held annually over 2 days at major conference venues around the country and attract between 400 and 600 delegates. The BMS also runs three to four 1-day road shows across the country each year. The Journal of the BMS (now Menopause International), has been published quarterly since 1995 and has been Medline-listed for the last 5 years. The BMS handbook has received widespread recognition as a practical guide to menopause management and is now in its third edition. Both the journal and handbook are distributed free to members. The BMS produces regular ‘consensus statements’ which are updated in response to new information and are posted on the website. The BMS has established an Advanced Training Module in menopause management and has close links to the Royal College of Obstetricians and Gynaecologists with regard to special skills training. The BMS enjoys close contact and collaboration with other national and international menopause societies such as the IMS and EMAS (the BMS will host the next EMAS meeting in 2009). Further details of BMS activities can be found at www.thebms.org.uk.

President: Dr Eduardo Storch, Past Associate Professor, Clínica Ginecotocológica “A”, Facultad de Medicina, Universidad de la República, Montevideo

The Society was founded on December 15, 1991 and has only 11 members. They are all chartered gynecologists. The Uruguayan Association of Gynecology and Obstetrics has several ancillary associations, the Uruguayan Menopause Society being one of them. According to the Statutes, in order to be a member of the ancillary associations, it is necessary to first be a member of the Uruguayan Association of Gynecology and Obstetrics. This precludes the participation of physicians of other specialties, as well as that of nurses or paramedics in the already too small Uruguayan Menopause Society. This situation is currently being reviewed. Uruguay is a small developing country with a population of only 3,314,466 inhabitants, out of which 1,713,442 are women (51.7%). It has around 600 gynecologists of which only 150 are active members of the Uruguayan Association of Gynecology and Obstetrics (Sociedad Ginecotocológica del Uruguay).
In Uruguay, there is no formal postgraduate training in menopause. To be considered a specialist, several factors are taken into account such as dedication, time devoted to the subject including research, teaching, courses, medical and public dissemination, as well as national and international recognition.
There are 215,069 women in the country whose ages range from 45 to 55 years (6.5% of the population); 601,252 are over 45 (18%) and 501,055 are over 50 (15%). HRT is used by approximately 2.5% of the population and very few patients maintain the treatment over the long term. Alternative and complementary medicines are also used, most of which are self-prescribed.
The problems existing for the practice of the subspecialty are, above all, the current misconception of the public on HRT, the influence of the media and, of course, the financial difficulties to access drugs or clinical tests.
Those of us who treat menopause patients also treat osteoporosis, as do other colleagues. Rheumatologists are not the only ones to treat these patients.
The objectives of the association are to disseminate to the general population as well as the medical community, the new developments in our knowledge and research in the treatment and management of menopause, to prevent adverse effects, to conduct studies to improve our understanding of the problems in our local communities, and to promote health prevention activities especially for middle-aged and older women.

President: Nguyen Thi Ngoc Phuong
Website: www.hosrem.org.vn

HOSREM was initiated by a group of obstetricians and gynecologists who were pioneers in developing menopausal health care in Vietnam. Since 1997, this group has contributed many activities in the field of menopause as well as reproductive health, in Ho Chi Minh City and nationwide. In 2005, HOSREM was officially recognized by the Vietnam Government. The number of members is more than 700. Members include obstetricians and gynecologists, other doctors, senior midwives, pharmacists and paramedics. To be called a ‘menopause specialist’, a gynecologist does not need any other qualification.
There about five million menopausal women in Vietnam. HRT has been the main therapy used for menopausal women since the 1990s but the use is still very low. Other therapies are used such as herbal remedies, acupuncture and physical exercise. HOSREM has carried out some studies in menopausal women in Ho Chi Minh City: the mean age of menopause in 1998 was 44.91 years; in 2005 the mean age was 51.9 ± 6.9 years.
Vietnam is a developing country; menopause health care is still a new field. As a result, women have a very low awareness of menopausal health care (only a few see a gynecologist) and doctors have limited knowledge on its treatment.
Most doctors are conservative about HRT; especially they worry that HRT may increase risk of breast cancer so they prescribe HRT very carefully and are sceptical about it. Only a small group of key experts can communicate in English; therefore most doctors have limited access to new information from external sources such as the internet and international journals.
Doctors are generally very busy (they will see about 30–50 patients per day in hospital or the same in their private clinics in the evening); thus medical professionals do not have enough time for satisfactory menopause counseling. As a result, patients do not have the opportunity to discuss and receive adequate consultation for their problems. As in most of Asia, both women and medical professionals are reluctant to talk about sexual problems (still perceived as taboo).
Our members are the key medical force for disseminating knowledge of osteoporosis prevention and treatment. Osteoporosis patients have been treated by HOSREM doctors and other specialists, such as orthopedic surgeons, rheumatologists, internists, gynecologists and midwives, who are not HOSREM members.
The main objective of HOSREM’s activity is to disseminate and update knowledge of reproductive endocrinology and health care, including menopause health care, for members and women. HOSREM has cooperated with Women’s Unions of Ho Chi Minh City and women’s unions in other cities/provinces to hold annual meetings for menopausal women to educate them about menopause age/symptoms, how to manage/treat menopausal symptoms and how to improve their quality of life. HOSREM has organized many meetings and symposia to educate and update knowledge related to reproductive endocrinology, menopause and infertility for members of HOSREM.