While the proportion of women reaching the menopause has steadily increased in the last century, the problems and effects have been experienced since ancient times. Thus the proportion of Maltese women aged 65 years and over has increased from 5.3% in 1901 to 10.9% in 1985. The increase has been greater in the sister island of Gozo (Figure 1)[1].

A number of women thus did reach menopausal age, but because of the absence of any available therapy had to put up with the symptoms. Thus even in Malta, osteoporosis is not a modern disease. The earliest evidence of osteoporosis in Malta comes from the skeletal remains dated to the late medieval period. In 1969 a collection of bones was found in a secret passage within St. Gregory's Church at Zejtun which had been rebuilt in 1492. These bones showed a number of paleopathological features. Three specimens - a femur, tibia and pelvis - showed gross and radiological features consistent with osteoporosis. These specimens were attributed to an elderly female who probably suffered from the senile form of the disease (Type II osteoporosis). Osteoporotic bones are not a frequent feature in palaeopathology since their inherently fragile nature predisposes to their accelerated destruction. Furthermore a fewer proportion of individuals reached an age where osteoporosis became evident[2].

Osteoporosis is a sketetal condition characterized by a decrease in bone mass. This decrease results in increasingly porous and more easily fractured bones. Though the whole of the skeleton is affected by the pregressive disorder, the effects of osteoporosis in the form of fractures become more evident in the wrist, spine, and hip. The osteoporotic process accelerates with the female gonadal deficiency that occurs after the menopause. The most common form of the disease, Primary Osteoporosis, includes postmenopausal or oestrogen-deficient osteoporosis (Type I) observed in women whose ovaries have ceased to produce the hormone estrogen; age-related osteoporosis (Type II) affecting those over the age of 70; and idiopathic osteoporosis of unknown cause that affects premenopausal women and middle-aged men. Secondary osteoporosis may be caused by bone disuse as a result of paralysis or prolonged immobilization; endocrine and nutritional disorders; specific disease processes; and certain drug therapies. The present emphasis in management is aimed at reducing the progression of Type I Primary osteoporosis. Prevention and treatment of this form of osteoporosis include oestrogen and/or progestin therapy of peri- and postmenopausal women, increasing the intake of calcium and other nutrients, promoting weight-bearing exercise, and the use of new drugs such as calcitonin.

No further mention of menopausal related disorders appears in the historical medical records until well after the isolation of oestrogen. One of the first experimental demonstrations of the existence of ovarian hormones was given by the Austrian gynaecologist Emil Knauer in 1896 who showed that female sexual characteristics developed in castrated animals when the ovaries were transplanted. Also during the later years of the 19th century, it was demonstrated that loss of ovarian function was responsible for the distressing symptoms of the menopause. The first attempts to replace lost ovarian function were made by the grafting treatment of ovaries. Subsequently dried ovarian tissue was administered orally. The starting point of much of the modern work on sex hormones can be regarded to be the work of Stockard and Papanicolaou in 1917 who demonstrated that the vaginal cells undergo characteristic changes throughout the menstrual cycle. Their work was the precursor of the cervical screening for cancer using the "Pap" smear. In 1923 Allen and Doisy demonstrated that injections of ovarian follicular fluid extracts caused specific changes in vaginal cells. Oestrone and oestriol were isolated from urine in 1929 and marketed by Schering in 1934. Effective oral therapy started with stilboestrol, and later the first orally-active steroid ethinyloestradiol[3].

The advances in the international medical field were apparently closely monitored by local practitioners. The hormonal role of the ovaries to prevent menopausal symptoms was already recognised in Malta by 1937. In his clinical departmental reports for 1937 and 1938, Prof. Joseph Ellul mentions that after radical surgery requiring the removal of both ovaries in young women, auto-innestation of the ovary in the vulva was performed. One case was performed in 1937 after hysterectomy and bilateral oophorectomy performed as treatment for uterine fibroids. In women with signs of ovarian insufficiency were managed by injection of hormone preparations in the form of Aestroform B. Two cases were managed in this way in 1938, one following a premature surgical menopause[4].

The detailed departmental annual reports were curtailed as a result of the onset of the Second World War. Thus no information can be gleaned about the attitudes of local practitioners towards menopausal symptoms during this period and subsequent years. By 1947 at least, auto-innestation of the ovary seems to have fallen in disrepute since the list of surgical procedures performed in the gynaecology department during that year and subsequently fails to include this operation. October 1948 saw the publication of the first issue of the student medical journal CHESTPIECE. In that issue a advertisment for Fertilinets, imported by agents C. Bonnici-Mallia of Valletta, was included. This medication consisted of "activated standardized hormone preparations for the efficacious combating of premature symptoms of advancing age, nervous debility, etc"[5].

The socio-economic and demographical changes which occured in the post-war period resulted in a gradual shifting of emphasis on medical problems. Initial mention of disease caused by nutritional deficiency, including comments on calcium deficiency though not to osteoporosis, was made in 1952. Here mention was made about the relative infrequency of calcium deficiency syndromes possibly because the high calcium content of the local water supplements a considerable degree any possible calcium deficiencies of the foodstuffs. The 1950s also saw the introduction to the Maltese market of other medications aimed at controlling menopausal symptoms. The CHESTPIECE advertised Climatone tablets (1954) which were described as useful "to provide effective sedative-free control of menopausal disorders without side-effects [Paines & Byrne Ltd, U.K.; local agents Ches de Giorgio, Valletta] and Multigland (1956) "indicated in menorrhagia, hysteria, neuroasthenia, and menopausal disturbances [Armour Labs, U.K.; local agents Fabri & Tonna, Valletta][6].

Oestrogen replacement therapy remained controversial. It became fashionable in the 1960s, but when complications of therapy became apparent in the 1970s, the initial enthusiasm was dampened. Physicians became reluctant to treat menopausal symptoms while patients became wary of hormone therapy because of the widely publicized reports that oestrogens caused endometrial cancer. These attitudes were partly reflected in Malta. Oestrogen therapy was apparently in use during the 1960s, though the extent of the use could not be estimated. In a study of postmenopausal bleeding, one case from a total of 63 patients was found to be due to oestrogen administration. It was further advised that "the routine or prolonged administration of oestrogens in postmenopausal women is most undesirable". In the 1980s, with a better understanding of therapeutic regimens, hormone therapy once again gained in popularity. We have now apparently gone to the other extreme where medical practitioners may be prescribing these hormone preparations indiscriminately[7].

The overall clinical impression in the 1970s and 1980s was that, unlike the european counterpart, Maltese women as a population group suffered less from the effects of the menopause and osteoporosis. This was attributed to the high calcium content in water and the general tendency towards obesity. Peripheral fat stores are known to be another endogenous source of oestrogens. This latter observation also explained the higher incidence of oestrogen dependant cancers in women - namely the breast and uterus, which have been shown to have an association with obesity and fat intake[8].

A population study performed in 1981 showed that there was a gradual decrease in the overall height of the female population with increasing age. Thus the mean height in women decreased from about 153 cm in women aged 45-54 years to 147.6 cm in those aged more than 75 years[9]. The marked decrease in women mean heights, especially when compared to the minimal decrease in the male mean heights confirms that postmenopausal osteoporosis does occur in the local female population (Figure 2).

The extent of osteoporosis may however not be a very marked one, and may not result in an increase in clinical fractures. A recent study (1987-89) has confirmed the overall clinical impression that while osteoporotic fractures were commoner in females when compared to males, the incidence of osteoporotic hip fractures in Malta was similar to that seen in other Mediterranean countries being about a third the incidence in Northern European countries (Figure 3). The relative natural protection from osteoporosis was attributed to genetic factors, climatic conditions and dietary habits[10].

It appears that in previous years, the deficiency state of the menopause was understood by many to be "natural", and many women accepted the fact that they would have to put up with the menopausal symptoms stoically in the same way as previous generations did. Nowadays, a choice of therapy is available and many women are requesting preventive treatment to transform their lives for the better.

Footnotes

1. R. Camilleri: A demographic and socio-economic profile of ageing in Malta. CICRED/INIA: Malta, 1993

2. S. Ramaswamy and J.L. Pace: The Medieval Skeletal remains from St. Gregory's Church at Zejtun (Malta). Part I. Paleopathological studies. Arch Ital Anat Embriol, 1979, LXXXIV:p.43-53

3. G.H. Bell, J.N. Davidson, and H. Scarborough: Textbook of Physiology and Biochemistry. Livingstone: Edinburgh, 1953, p.901-902

4. J. Ellul: Appendix MB. Report on the Maternity and Gynaecological Departments, Central Hospital. Annual Report on the Health Conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1937. Government Printing Office: Malta, 1938, p.cxxii; J. Ellul: Appendix MA. Report on the Maternity and Gynaecological Departments, Central Hospital. Annual Report on the Health Conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1938. Malta Government Gazette Supplement no.CLIV, 29 December 1939. Government Printing Office: Malta, 1939, p.cxii,cxvi

5. Annual Reports on the Health Conditions of the Maltese Islands and on the work of the Medical and Health Department including the Emergency Medical Services for the years 1940-1947. Government Printing Office: Malta, 1941-1949, 8 vols.; Chestpiece, October 1948, vol.1 no.1

6. J. Galea: Report on the Health Conditions of the Maltese Islands and on the work of the Medical and Health Department for the year 1952. Government Printing Office: Malta, 1954, p.8; Chestpiece, Winter 1954, vol.1, no.10; Chestpiece, 1956, vol.1, no.12

7. E.S. Grech: Postmenopausal bleeding. Chestpiece, 1965, 1(17):31-34

8. C. Savona-Ventura and E.S. Grech: Endometrial Adenocarcinoma in the Maltese Population. An epidemiological study. Europ J Gynaecol Oncology, 1986, 7(3):209-217

9. G. Katona, I Aganovic, V. Vuskan, and Z. Skrabalo: National Diabetes Programme in Malta. Final Report. WHO: Geneva, NCD/OND/DIAB/83.2, 1983, p.41

10. Y. Muscat Baron, A. Muscat Baron, R. Galea, and M. Brincat: Epidemiology of Osteoporotic fractures in a Mediterranean Country. It J Gynaecol Obstet, 1993, 4:153-158