April 2012
Younger women prone to fear of cancer recurrence
Research in Australia has investigated the fear of cancer recurrence (FCR) in younger women diagnosed with breast cancer. 218 women aged between 18 to 45 years completed an online survey, and of these 70% of women experienced clinical levels of FCR. The researchers also investigated the relationship between FCR and the use of health services, surveillance and self-examination, and noted that women who experienced higher FCR were more likely to:
- have unscheduled visits with their GP
- examine their own breasts more regularly
- have less frequent health practitioner administered medical surveillance (e.g. mammograms and ultrasound, mammograms)
- utilise complementary therapy, counselling and support groups.
The researchers conclude that younger women are more vulnerable to FCR, and highlight that health professionals should be aware that women may experience FCR well after their diagnosis and treatment phase.
To read the abstract of this research, visit the PubMed website.
Many of the participants in this research project were recruited through BCNA’s Review & Survey Group. If you would like to join the group and receive opportunities to participate in breast cancer research, surveys and reviews, please register at BCNA’s website.
Pregnancy following breast cancer is safe
Research presented at the recent European Breast Cancer Conference held in Vienna last month found that it is safe for women diagnosed with breast cancer to become pregnant at any time after their diagnosis, regardless of whether their breast cancer is oestrogen receptor-positive or negative. Previously, it was thought that the hormonal changes that result from pregnancy could possibly increase the risk of a recurrence in women diagnosed with oestrogen receptor-positive breast cancers.
A total of 1183 women from various countries participated in the study. The research highlighted that in fact, women with oestrogen-positive breast cancer were surviving the same amount of time without a recurrence compared with women who had oestrogen-negative breast cancer. Therefore the researchers concluded that it was safe for women to become pregnant after breast cancer, regardless of whether their breast cancer was oestrogen receptor-positive or negative.
To read more, visit the European CanCer Organisation website.
March 2012
Barriers to accessing follow-up care in Canada
Canadian research has assessed the rehabilitation needs of breast cancer survivors under the age of 50, to identify the factors that impact on the frequency that follow-up services are used. Rehabilitation services are those that are similar to follow up care and survivorship plans in Australia.
Researchers interviewed 35 breast cancer survivors, and found that the barriers preventing women from using rehabilitation services included a lack of available services, issues with travel, the costs of services, and the lack of support to address the specific needs that relate to being under 50. Personal barriers that affected participation included a lack of time due to family commitments and other medical appointments.
The research highlights that some of these barriers can be reduced by increasing the number of services available to women. The research also recommends that health professionals consider these barriers when they develop and promote services for women.
To read the abstract of this research, visit the US-based PubMed website.
Sexual wellbeing program to help breast cancer survivors
Researchers from South Korea have developed a 6-week program to help improve sexual wellbeing amongst breast cancer survivors, by addressing the physical and psychological aspects of sexual wellbeing. The results of the research found that the sexual wellbeing satisfaction increased in women who completed the program, compared with women who did not complete the program.
The authors highlighted that the program allows women to be actively involved in improving their sexual wellbeing following a breast cancer diagnosis.
To read the abstract, visit the US-based PubMed website.
BCNA’s comprehensive booklet, Breast Cancer and Sexual Wellbeing, was developed to assist women address issues such as the loss of desire, the physical symptoms of menopause including vaginal dryness, and building and rebuilding emotional and physical intimacy with a partner.
To find out more about the resource, visit BCNA’s webpage on sexual wellbeing.
June/July 2011
Experiences of young women undergoing fertility preservation
Researchers in Canada have undertaken research to examine young women’s experiences with fertility preservation referral, consultation and the decision making process. The research was undertaken in light of the American Society of Clinical Oncology Society recommendation that all young women should be referred to a reproductive specialist prior to beginning their chemotherapy and radiation therapy.
Fifty women participated in an anonymous survey with the results highlighting that just over half (54%) opted to undertake fertility preservation. This group included women who had made plans to start a family or add to their family before their diagnosis and women who hadn’t made such plans. Forty one per cent found the decision making process difficult and 50% found cost to be a significant barrier.
Women reported that there wasn’t enough time to make their decisions and some women highlighted that there wasn’t enough written information both before and after the appointment. The majority of women reported that access to a counsellor’s would have helped them in the process.
The researchers concluded that, when appropriate, referral should be undertaken by the surgeon as soon as the cancer is diagnosed. To help women make decisions about fertility preservation and if it is needed based on their treatment options, they should be provided with their pathology report.
To read the abstract, visit ASCO Annual Meeting 11.
If you have recently been provided with your pathology report and are unsure what it all means, our Pathology Fact Sheet may be of assistance. The fact sheet helps women to understand what is included in the report, what the terminology means and how to obtain your report after your treatment has ended.
To download a copy of the Pathology Fact Sheet, visit the Fact Sheets page of BCNA's website.
May 2011
Post treatment regret amongst breast cancer survivors
Research in the United States has regret amongst young women five years after their breast cancer treatment. The results highlighted that women had some regret about their treatment, with the most commonly reported regrets including decisions about surgery (24.1%), chemotherapy and/or radiotherapy (21.5%), reconstruction (17.8%) and problems with their health care providers (13.1%).
Women also reported regretting things that they didn’t do, rather than decisions they made. The researchers noted that women who were anxious about their future and had problems communicating with their health professionals were more likely to experience regret five years later than those women who didn’t have these problems. Women, who were diagnosed with a recurrent or new breast cancer in the five year time period, were also more likely to regret different aspects of their initial treatment.
The researchers concluded that greater psychosocial care is needed for women diagnosed with recurrent breast cancer as well as improving communication between health professionals and women.
To read the abstract of this article, visit the journal Psycho-Oncology’s website.
If you are feeling concerned about any decisions that you may have made regarding your treatment, please consider talking to your specialist or general practitioner.
If you would like to talk to other young women who may have similar concerns, BCNA’s Online Network is another way you can connect with women who have been through and are currently undergoing treatment for breast cancer.
April 2011
The physical and psychosocial impact of ovary removal for young women
Research undertaken by the Jean Hailes Foundation involving BCNA’s Review & Survey Group, has examined the impact of menopausal symptoms, psychological function, sexual wellbeing and body image of younger Australian women after their breast cancer treatment. Results from a survey of 114 women with early breast cancer, aged 40–51 years found that the majority of women (88%) felt tired and lacked energy, experienced a loss of libido (87%) and experienced hot flushes (83%). Women also reported having higher anxiety and depression scores.
Women who had their ovaries removed (referred in the abstract as ovariectomy and is also known as oophorectomy) were more likely to have worse physical menopause symptoms, (including hot flushes and night sweats) and sexual wellbeing issues. Sexual wellbeing issues identified in the abstract included sexual feelings for their partners and frequency of sexual activity. The researchers concluded that health professionals and women need to be aware of the different impacts resulting from the removal of a woman’s ovaries, and to make sure that further education and support is available for these women.
To read the abstract of the research, visit the US based website PubMed.
If you would like to be involved in research opportunities like this and would like to find out more about BCNA’s Review & Survey Group, visit BCNA’s Speak Out webpage.
Fertility knowledge and decision factors for young women
Researchers in Australia have examined young women’s knowledge about fertility information, their uncertainty around choice and preferences regarding fertility information at the time of diagnosis. The results from a survey of 111 women with early breast cancer who hadn’t completed their families found that the women had some knowledge about fertility, but not having enough information was associated with uncertainty when deciding whether or not to undertake fertility preservation.
One third of the women in the survey stated that they would consider in vitro fertilisation (IVF) as a method to preserve their fertility, and a further 38% stated they were unsure if they would pursue IVF in the future. The researchers highlighted the decision to utilise IVF wasn’t only related to women who were in a committed relationship at the time of diagnosis or their personal desire to have children in the future.
The authors concluded that there is a need for specific and timely fertility information to be provided to women at the time of diagnosis in order to help them in their decision-making process and to ensure that they are informed of all the available options.
To read the abstract of this research, visit the Journal of Clinical Oncology’s website.
Fertility decision aid - From this research, a new resource, the Fertility Decision Aid has been developed that provides newly diagnosed women with information about the different fertility options, and the optimal timeframes for decisions.
If you know a younger woman that has been recently diagnosed with breast cancer, or you have been recently diagnosed and are considering your fertility options, please talk to your treating health professional or breast cancer nurse about this free resource.
March 2011
Breast reconstruction in women under the age of 30
Research in the United States has examined the type of breast reconstructions that women under the age of 30 undertake and has found that younger women were more likely to undertake tissue expander reconstructions. The results found that as a result of younger women not having enough abdominal tissue fat, the number of tram flap reconstructions undertaken was lower than the national average and the number of contralateral prophylactic reconstructions was higher. The authors concluded that implant based reconstruction and or reconstructions that use other donor sites (such as back muscles) should be considered.
To read the abstract of this article, please visit the website of the journal The Breast.
Reconstruction is a key area of interest that BCNA is continuing to work on. To find out more about the work we have done, please visit the Breast reconstruction page on our website.
Pregnancy after breast cancer
With some women choosing to have children later in life, more increasingly oncologists are being faced with the question of women being able to have children after their treatment. Research from retrospective trials (a trial where the researcher collects data from past records but does not follow up with these women, to see how they are going) has found that pregnancy after breast cancer does not increase the risk of recurrence. Results also found that for women who had chemotherapy or hormone treatment their risk of having a child with birth defects was similar to those women who hadn’t been treated.
The authors concluded that the question as to whether a woman can become pregnant after her treatment should be discussed individually, and based on her particular tumour characteristics, stage of the disease and individual wishes.
To read the abstract of this article, please visit the US-based PubMed website.
February 2011
The impact of work and sickness absences after breast cancer surgery
Research from Sweden has examined the impact of work and sickness absences after breast cancer surgery and the factors associated with such absences. The results found that the majority of the women were employed when diagnosed and were working full time. At the time of the research, half of the women were on sick leave with the majority being on sick leave for a long time period. Factors associated with sick leave following surgery included younger age, low self rated health, poorer health than before diagnosis and having a strenuous work posture.
While the results are not consistent with similar research, the authors highlight that this could be attributed to previous research being undertaken at a later time after breast cancer surgery or after another cancer diagnosis.
To read more visit the US based PubMed website.
December 2010
Young women’s treatment decisions and their fertility concerns
Researchers in the United States have found that young women diagnosed with breast cancer are more likely consider survivorship issues than concerns about their fertility when making decisions about their treatment. Researchers spoke to 20 young women to determine how they made decisions about their treatment and what role fertility concerns played in this process. The main themes included women wanting to do everything possible to prevent the cancer recurring, fertility concerns being different for each individual and some women not being told about different fertility options, until it was too late.
The researchers concluded that for most young women, treatment decisions were mainly based on survival concerns and that fertility concerns were dependent on individual circumstances and the timing of their diagnosis. It was noted that there is a need for improved information about fertility and women’s options for fertility preservation, even if this information isn’t asked by the woman at diagnosis. The importance of providing timely information about fertility was also noted.
The researchers highlighted that oncology nurses (or breast cancer nurses in Australia) are in the best place to discuss this information and to assist women with fertility planning before treatment and during their follow-up care.
To find out more about this research visit the US-based PubMed website.
November 2010
Women treated for breast cancer while pregnant have better survival
Researchers at The University of Texas MD Anderson Cancer Centre, in the United States have found that women who undergo treatment for breast cancer while pregnant have improved disease free survival and an improved trend for overall survival. All women enrolled in the study, received a standard chemotherapy regime and additional therapies with those women who were pregnant starting chemotherapy after the completion of their first trimester. The results allow health professionals to be confident in recommending women to initiate chemotherapy treatment in their second and third trimesters.
To find out more about the research visit the Science Daily website
Breastfeeding safe to undertake after breast cancer treatment
Researchers in Brussels have found that women who have completed their treatment for breast cancer can breastfeed future children. Results found that breastfeeding doesn’t provide a detrimental effect on a women’s breast cancer outcome. The researchers concluded that for women to feel comfortable with undertaking breast feeding after treatment, they need to receive appropriate counselling and support.
To find out more information about the research visit the Medical News Today website.
October 2010
Accessing fertility information, an internet approach for young women
Researchers in the US have developed a website to help women find information about fertility issues that need to be considered after a cancer diagnosis. Half of the women involved in the research stated that they received very little information regarding fertility options from their oncology team and when they did they were most likely to be referred to a reproductive endocrinologist. The most frequent way to access information was via the internet with most women being aware of the treatment related factors that can affect fertility but least knowledgeable of infertility treatment.
For more information about the research visit the Oncology Nursing Society website.
Fertility and reproduction considerations in women with breast cancer
Researchers in the US have reviewed the literature regarding fertility and reproduction decisions in premenopausal women with breast cancer, and have found that assessment and counselling regarding fertility preservation is a key component of the multidisciplinary approach and future treatments and fertility plans. The researchers highlight that due to the ongoing debate regarding different hormones for fertility protection there needs to be a greater involvement in clinical trials to increase the knowledge in this field.
For more information about the research visit the US-based PubMed website.
September 2010
The case for genetic testing in young women diagnosed with triple negative breast cancer
Researchers from the United States have recommended that women under the age of 50 who are diagnosed with triple negative breast cancer should undergo genetic testing. The researchers found that testing women with triple negative breast cancer could reduce further breast cancer risk by 23% and ovarian cancer risk 41%. Researchers found genetic testing is a cost effective strategy in terms of each year of life gained and quality adjusted year of life. Researchers are advocating that this recommendation should be adopted into current genetic testing guidelines.
For more information regarding the research visit the Journal of Clinical Oncology website.
Dense breasts make it harder to find breast cancer in young women
Research from the United States has found that early stage breast cancers in young women are often diagnosed at a later stage because they are harder for screening mammograms to find. While the research doesn’t identify why these cancers are harder to detect, it is assumed that young women’s dense breasts can be attributed. Dense breasts make it harder for cancer cells to be spotted on mammograms as they aren’t surrounded by fat cells which are seen in the breast tissue of older women.
To find out more information about the research visit the Breastcancer.org website.
2nd National Young Women’s Conference
The 2nd National Conference for Young Women Affected by Breast Cancer was recently held on the Gold Coast from 9-11 September. Around 150 young women attended from across the country to meet and share their experiences with other women and to hear advice on how to manage the issues affecting them. Speakers covered issues such as: the latest treatments for young women, sexual wellbeing, exercise and breast cancer, lymphoedema and financial issues during your cancer journey. If you would like to know more about what was presented, the conference presentations can now be accessed via the 2nd National Conference for Young Women's website.
More information and a conference summary report is also available on the BCNA website, and a Young women Affected by Breast Cancer Group has been established within the BCNA online network for those who attended the conference and those wanting to connect with other young women.
August 2010
Women rely on others who have been there before to help them with their diagnosis
Research undertaken in the US with young women diagnosed with breast cancer has found that women rely on those who have been through breast cancer treatment before, for support and information about what lies ahead. In the abstract the authors have defined this as experiential support. Young women identified that they also received support from their friends and family in the form of information and emotional support. The researchers identified that those young women who had experienced treatment and surgery before can provide firsthand information, insight, suggestions and hope.
For more information about the research visit the Journal of Psychosocial Oncology website.
The needs, concerns and experiences of younger women with breast cancer
Researchers in the UK have found that women under the age of 40 have specific needs that differ from other women diagnosed with breast cancer. The authors found that after a diagnosis of breast cancer, young women felt ‘out of syn’, in the sense that their life was going in a different direction to others their age, and that their body was different to what it was before.
Women highlighted the need for childcare facilities at hospitals, information on how to tell their children about mum’s illness and information about fertility and sexuality issues. Other needs included information about the emotional impact of cancer and the need for support from their peers and ongoing support for life after treatment.
For more information about the research visit the Wiley website.
Young women are more likely to stop taking hormone therapy
Research from the US has found that women under 40 have the highest risk of discontinuing their prescribed hormone therapy. Researchers found that women who had a lumpectomy, other medical illnesses, a prior history of chemotherapy, were married and had longer intervals between prescription refills were more likely to stop taking their hormone therapy.
While researchers are unsure why young women discontinue their therapy, it is suggested that the side effects of the therapy (joint pain, hot flashes or fatigue), not wanting to be reminded of that time period in their life, looking after their children and wanting to start their own family can effect their decision to stop their hormone therapy.
Researchers are concerned that women are not getting the full benefit of undertaking five years of hormone therapy, which includes a reduced risk of recurrence in a women’s breast and other parts of her body.
For more information about the research visit the American Society of Clinical Oncology website.
July 2010
Fear of cancer recurrence in younger breast cancer survivors
Research undertaken in Australia involving young women with breast cancer, which included women from BCNA's Review & Survey Group, has found that younger women (aged 45 years or less when diagnosed) are more at risk of experiencing higher levels of fear of recurrence. Initial results have found that higher levels of fear of recurrence were seen in; women diagnosed at a younger age, those that had cancer which had spread to areas near the breast (locally advanced disease) and the frequency of unplanned medical appointments.
Results of the research will be used to assist in the development of interventions for women who experience high levels of fear of recurrence.
For more information see the PDF on Wiley’s website and scroll to page 16. Please note that this file is very large (2.37MB) and may take some time to download.
June 2010
Pregnant women and chemotherapy
Research undertaken in Germany has found that women who are diagnosed with breast cancer while pregnant can be treated as close as possible to clinical guidelines for chemotherapy without affecting the health of the unborn child. The research found that those involved received on average two cycles of chemotherapy while pregnant and on average their babies were born at 36 weeks weighing slightly less than those babies who had not been exposed to chemotherapy. Of the babies born with complications after being exposed to chemotherapy, the majority of the complications were not related to the treatment but other factors.
Visit the ScienceDaily website for more information.
Conference: 2nd national conference for young women affected by breast cancer
A reminder that the 2nd National Conference for Young Women Affected by Breast Cancer is being held at the Gold Coast this September. The conference will provide women with the opportunity to network and to share and raise awareness around the needs and issues of young women diagnosed with breast cancer.
If you would like to attend, a limited number of travel grants are available from the conference organisers. These applications close on Friday 11 June 2010 and can be accessed via the YWCA website www.ywcaustralia.org.au
March 2010
Health professionals and discussions with people with cancer about fertiity
Research from the US has found that health professionals who were uncomfortable discussing fertility preservation (FP) options were less likely to raise the topic with young people with cancer. Health professionals reported that their level of discomfort was related to lack of knowledge, language or cultural barriers, not wanting to add additional stress and uncertainty about methods of FP. Further, many health professionals did not feel it appropriate to discuss these options with women with a poor prognosis. In the United States, the American Society of Clinical Oncology guidelines suggest that FP discussions should take place with all young people undergoing treatment for cancer, however not all physicians are following the guidelines. Researchers suggest that communication training may improve the quality and frequency of these discussions, and that the whole healthcare team should be involved in this process to take the sole burden from oncologists.
Visit the ScienceDirect website for more information on health professionals and fertility discussions.
December 2009
Options for preserving fertility
Researchers from Sharett Institute of Oncology in Israel suggest that using radiation may be an alternative for women wanting to preserve fertility while undergoing treatment for breast cancer. A group of 65 women under 38 years of age, who were 12 months post-chemotherapy, were involved in the study. Results showed that a high percentage of women used fertility preservation (95.4%), but that after treatment only 33.9% became pregnant. Researchers suggest that rates of women who are able to conceive after chemotherapy maybe higher than currently thought however, for a number of reasons. A large percentage of the women who did not conceive were single (82%), many already had three or more children, and for 66% of women, pregnancy was not considered appropriate due to cultural norms. Further, researchers recommend that single or unmarried women should be routinely offered access to fertility preservation.
Visit the Journal of Clinical Oncology website for more information.
November 2009
Challenges of returning to work after breast cancer treatment
Researchers have argued that employers and physicians should play a more supportive role in assisting women to return to work after a breast cancer diagnosis. A literature review conducted by researchers at the Katholike Universiteit Leuven in Belgium and Maaschricht University in The Netherlands found women received little advice about returning to work. Women reported that returning to work was an important factor in "getting back to normal". However fatigue, concentration and arm pain impacted upon women's ability to do so. While supportive environments were found to be helpful, the researchers recommend that individual needs must be addressed in the workplace.
Visit the Wiley InterScience website for more information.
August 2009
The impact of breast cancer on employment
A study by the Dana-Farber Cancer Institute, Harvard Medical School and Brigham and Women's Hospital in the US has found that chemotherapy treatment for breast cancer negatively impacts on continued employment. Data from insurance claims in the United States involving 3233 women who had been diagnosed with breast were reviewed. While most women did continue to work, women who underwent chemotherapy were more likely to stop work, retire or remain on long term disability income supports. Researchers suggest these findings can be used to develop interventions to support women to continue working.
Visit the NCBI website for more information.
US research recommends screening for high risk younger women
A presentation at the recent American Society of Breast Surgeons Conference highlighted the importance of screening for younger women at risk of developing breast cancer. Genetic testing, MRI and mammographic screening were included in the guidelines to improve early detection in this group. In Australia, a program is in place to support high risk young women to undergo surveillance screening. The Medicare MRI rebate for younger women at high risk of developing breast cancer was launched in December 2009. The campaigns page of the website includes further information on rebates for young women at risk of breast cancer, you can also visit the Doctor's Guide website for more information.
June 2009
Accuracy of internet based information on MRI scans
Researchers from Harvard University and the University of Washington in the US have found that most websites promoting the use of MRI were commercially sponsored and more often described benefits rather than limitations of MRI screening. The study involved a review of internet based information on MRI use for women with breast cancer. Researchers suggest that health professionals should encourage women to view the most credible sites available.
Visit the NCBI website for more information.
Vitamin D deficiency in premenopausal women
Researchers in the US report that the current supplement recommendations for people with vitamin D deficiency is not sufficient to increase vitamin D levels in women with breast cancer. Vitamin D is vital for bone health and deficiency has been associated with an increased risk of developing breast cancer. The study looked at the prevalence of vitamin D deficiency amongst premenopausal women with breast cancer. Bone mineral density tests were conducted at the beginning of post-surgery chemotherapy, and again after one year of taking a vitamin D supplement after treatment. Of the 103 women taking part, 74% were deficient at the beginning of the study. After one year of taking the supplement, only 15% of women achieved a sufficient bone mineral density.
Visit the Journal of Clinical Oncology website for more information.
Coping strategies of young women with breast cancer
Researchers in the US have found that quality of life (QOL) and coping strategies among younger women with breast cancer are dynamic processes. The study involved 267 young women with breast cancer who were within six months of diagnosis. Three surveys were completed over an eight month period. Coping strategies used by women included seeking support, spirituality and wishful thinking. These methods declined over time, and women reported using detachment strategies longer term. The researchers also suggest that a woman's QOL may predict the types of coping strategies used by women.
Visit the NCBI website for more information.
March 2009
New research into pregnancy and breast cancer
Research conducted by the MD Anderson Cancer Centre in the US has found that women diagnosed with breast cancer during pregnancy do not have a higher risk of recurrence and disease progression than women who develop breast cancer while not pregnant. MD Anderson Cancer Centre has the largest registry of pregnant women with breast cancer in the world. The study included 652 women who were less than 35 years of age when diagnosed. Of this group, 104 women were diagnosed with breast cancer during pregnancy or within one year of pregnancy. Both pregnant and non-pregnant women had approximately the same rates of recurrence and disease progression. Further, the two groups also have similar survival rates after ten years. Researchers found that pregnant women were often diagnosed at a later stage, as breast changes may have been attributed to the pregnancy or breast feeding.
Visit the NCBI website for more information on pregnancy and breast cancer.
Recurrence risk in younger women
Another study conducted by the MD Anderson Cancer Centre aimed to find the most successful treatment to reduce the risk of recurrence in young women. Results suggest that young women with Stage II disease achieve the best outcomes with mastectomy combined with adjuvant radiation therapy. Young women with Stage I disease had good outcomes with both breast conserving therapy and mastectomy. The addition of chemotherapy to either of these options was also found to be beneficial. Researchers suggest these results will assist medical professionals and young women to make the optimal treatment decisions, based on their personal experience of breast cancer.
Visit the NCBI website for more information on the risk of recurrence in younger women.
Long term affects of Goserelin in premenopausal women
A study, lead by researchers from Cancer Research UK, has found that Goserelin is an effective treatment for premenopausal women with early breast cancer. Participants in the study were randomly selected to receive either Goserelin alone, Tamoxifen alone, both therapies, or neither therapy. All participants had undergone primary therapy of surgery with or without chemotherapy. The study aimed to measure event-free survival, (breast cancer recurrence, a new tumour or death) and overall risk in the presence or absence of Tamoxifen. After 15 years, there were fewer events in the group of women who received Goserelin alone. Further there was a small benefit in receiving Goserelin in conjunction with Tamoxifen. The researchers concluded that for women who did not take Tamoxifen, Goserelin provided a significant benefit on survival and recurrence.
Visit the Oxford Journals website for more information on the long term affects of Goserelin in premenopausal women.
