1. Background

The standard of health care in Thailand has improved dramatically after World War II. With the use of DDT, malaria, which used to be the number-one killer, has been put under satisfactory control. With the rapid reduction of death rate, population growth rose quickly, until in the late 1960s it was >3%, with a doubling time of about 20 years. A family planning programme (FPP) was therefore formulated to keep population growth rate in check. Fortunately for Thailand the FPP was very successful, and presently the population growth rate is being kept at about 1.2% per annum. Life expectancy at birth has also increased steadily, from 52.1 and 55.4 years in 1960 for males and females respectively, to 67.4 and 71.7 years in 1997. The female population aged 45–59 was 8.2 million in 1997 and will be approx. 9.0 million in 2000, which will need to be taken care of appropriately (Table I).

During the peak of Family Planning Programme activity, it was observed that some women in their fifties were still using oral contraceptives or the injectable. Through close inquiries, it came to light that they were using these methods for relief of climacteric symptoms which occurred when they were off hormonal contraception. This observation led us to a new perspective of family planning and emphasized the need of women in their passage from the fertile period into the climacteric.

Table I: Population projection 1996–2000 (medium estimate, x 1000)

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2. Development of a menopause programme

In 1987, a three-member team, an orthopaedic surgeon and two gynaecologists, attended the 5th International Congress on the Menopause in Sorrento, Italy, to bid for the following International Congress to be held in Thailand. The attempt was successful and the 6th International Congress on the Menopause was organized in 1990 in Bangkok with the participation of 150 Thai delegates, mostly practising gynaecologists. The Bangkok Congress was very successful and made a tremendous impact on the subsequent development of a menopause programme in Thailand.

In 1991, at the Fourth Meeting of the Policy and Coordinating Committee Meeting in Geneva, the Thai delegate proposed to HRP to develop a programme for the menopause, especially for perimenopausal women aged 45–60. HRP graciously accepted the proposal and in 1994 convened a WHO Scientific Group on ‘Research on the Menopause in the 1990s’ in Geneva. The ensuing publication (1996), entitled ‘Research on the Menopause in the 1990s’, has become a useful guideline for researchers around the world.

In 1993, the Thai Menopause Society (TMS) was inaugurated under the umbrella of The Royal College of Obstetricians and Gynecologists of Thailand. This Society has become very instrumental in the ensuing development of menopausal activities in Thailand.

In 1996, after almost two years of planning in collaboration with TMS, the menopause programme has been incorporated into the Department of Health to look after women in their midlife period. The main emphasis is on I.E. & C by the nursing staff and when necessary referring to the medical staff for HRT. Special services such as mammography and bone densitometry are available at larger or regional hospitals. The full programme will hopefully be completed in 2000.

Before 1990, menopause services were offered by only a handful of doctors with personal interest in hormone replacement therapy (HRT). There was widespread suspicion and lack of confidence in the use of HRT. However, after the 6th World Congress on the Menopause in Bangkok, menopause services have been increasingly made available in most hospitals, as a separate clinic or an integral component of the gynaecological service. To measure the use and compliance of HRT would be difficult at this point, but sales statistics show a progressive and steady trend in use of HRT in Thailand (Table II).

Table II: Hormone replacement market in Thailand

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3. Future trends

A holistic approach, taking into account socio-cultural elements, would be the key to the future development of the menopause programme in Thailand. The management of menopause should include diet, exercise and sensible use of hormones. Further research should be undertaken to standardize traditional Thai foodstuffs which have been shown to contain high levels of calcium and phytoestrogens. Traditional Thai dance and the Chinese Taiji/Qi Gong should be modified or standardized for the menopause. Low cost and/or low dose HRT should be investigated to make it affordable to common people. The use of high technology should also be adapted and regulated to reduce the national expenditure and therefore making the programme sustainable.

4. Menopause research in Thailand

More information can be found in the following publications:

Menopausal symptoms

1. Chompootweep S, Tankeyoon M, Yamarat M, et al. The menopausal age and cli-macteric complaints in Thai women in Bangkok. Maturitas 1993;17:63-71.

2. Chirawatkul S. Perception of the menopause among psychiatric personnel and middle-aged women in Khon Kaen, Thailand [abstract]. 6th International Congress on the Menopause, Bangkok, Thailand, 1990. A095.

3. Sukvatana P, Tanapat Y. Menopause-related symptoms among Thai women in Bangkok [abstract]. Ibid. A097.

4. Dusitsin N, Snidvongs W. The Thai experience. In: Berg G, Hammar M, editors. The modern management of the menopause. New York: Parthenon; 1994:23-33.

5. Chaikittisilpa S, Limpaphayom K, Chompootweep S, Taechakraichana N. Symptoms and problems of menopausal women in Klong Toey slum. J Med Assoc Thai 1997;80:257-61.

6. Taechakraichana N, Nakornpanom PN, Limpaphayom K. Climacteric complaints of paramedical personnel. J Med Assoc Thai 1997;80:297-302.

7. Tungphaisal S, Chandeying V, Sutthijumroon S, et al. Postmenopausal sexuality in Thai women. Asia Oceania J Obstet Gynaecol 1991;17:143-6.

8. Limpaphayom K, Taechakraichana N. Correlation of menopausal symptomatology and serum hormones. Thai J Obstet Gynaecol 1993.

Osteoporosis and cardiovascular disease

1. Taechakraichana N, Limpaphayom K, Angkawanich P, Poshyachinda M. Correlation of bone mineral density among various measurement sites. J Med Assoc Thai 1997 (in press).

2. Taechakraichana N, Angkawanich P, Panyakhamlerd K, Limpaphayom K. Prevalence of osteoporosis in women attending menopause clinic at Chulalongkorn Hospital: utilizing different cutoff value. J Med Assoc Thai (in press).

3. Taechakraichana N, Panyakhamlerd K, Pasatrat S, Limpaphayom K. Prevalence of abnormal lipid profiles in early postmenopausal women. Chula Med J 1997 (in press).

4. Taechakraichana N, Limpaphayom K, Jaisamrarn U, Poshyachinda M. Bone loss in oophorectomized Thai women. J Med Assoc Thai 1997;80:384-90.

5. Yuktanandana P, Ngarmukos C, Parkpian V, Patradul A. BMD fracture threshold for hip fractures in Thai elderly women. Chula Med J 1996;40:477-86.

6. Poshyachinda M, Chaiwatanarat T. Assessment of bone mineral density in normal Thais. Asean J Radiol 1996;2:1-12.

7. Chittacharoen A, Theppisai U, Sirisriro R, Thanantaseth C. Pattern of bone loss in surgical menopause: a preliminary report. J Med Assoc Thai 1997;80:731-7.

8. Suriyawongpaisal P, Siriwongpairat P, Loahachaneonsombat W, et al. A multicenter study on hip fractures in Thailand. J Med Assoc Thai 1994;77:488-95.

Hormone replacement therapy

1. Taechakraichana N, Intraragsakul A, Panyakhamlerd K, et al. Estradiol and follicle-stimulating hormone levels in oophorectomized women using vaginal estrogen. J Med Assoc Thai 1997 (in press).

2. Taechakraichana N, Udomponglukkana S, Panyakhamlerd K, et al. Estradiol and follicle-stimulating hormone levels in oophorectomized women applying percutaneous 17b-estradiol over the medial surface of the left arm. Maturitas (submitted).

3. Limpaphayom K, Taechakraichana N, Poshyachinda M, Jaisamrarn U. Bone changes in postmenopausal Thai women with or without hormonal replacement therapy. J Med Assoc Thai 1995;78:573-7.

4. Limpaphayom K, Taechakraichana N, Jaisamrarn U. Hormonal replacement and lipid changes in postmenopausal women. J Med Assoc Thai 1996;79:10-5.

5. Panyakhamlerd K, Limpaphayom K,, Taechakraichana N. The effectiveness of hormone in relieving menopausal symptoms. J Med Assoc Thai 1996;79:273-7.

6. Limpaphayom K, Taechakraichana N, Kittinunvorakoon C. Serum estradiol and gonadotropins level in postmenopausal women with or without hormone replacement. J Med Assoc Thai 1997;80:145-52.

7. Chompootaweep S, Sentrakul P, Tunsaringkarn K, et al. Sequential oral conjugated estrogen/MPA and 17b-estradiol gel/MPA therapy in Thai menopausal women: effects on hormonal and lipids profiles. Thai J Obstet Gynaecol 1997.