The n e w e ng l a n d j o u r na l of m e dic i n e
b o ok r e v ie w s
Multidisciplinary Management
of Female Pelvic Floor Disorders
Edited by Christopher R. Chapple, Philippe E. Zimmern,
Linda Brubaker, Anthony R.B. Smith, and Kari Bø. 369 pp.,
illustrated. Philadelphia, Churchill Livingstone, 2006. $179.
ISBN 978-0-4430-7272-7.
T raditionally, the pelvis has been a
field of battle among urologists, colorectal
surgeons, and gynecologists. Simplistically speak-
ing, urologists pay attention to the bladder, gyne-
cologists the reproductive organs, and colorectal
surgeons the alimentary tract. Pelvic-floor disor-
ders often overlap, including both urinary and fe-
cal incontinence and pelvic-organ prolapse. These
disorders are common and costly, and their care
is complicated by turf battles that result in the
piecemeal treatment of women with these condi-
tions. The problem is further compounded be-
cause pelvic-floor disorders are often treated by
surgeons, when better treatment might be non-
surgical. This multidisciplinary book brings to-
gether urologists, urogynecologists, gynecologists,
geriatricians, physiotherapists, and pharmacists
to provide a comprehensive approach to the treat-
ment of disorders of the pelvic floor.
The book is well organized. Like most refer-
ence books on pelvic disorders, this one begins
with a review of anatomy and physiology, pro-
ceeds to clinical evaluation, and concludes with
medical and surgical management. What is dif-
ferent about this book is how it links the chap-
ters on anatomy and physiology explicitly to clini-
cal intervention. Often, reference books outline
pathophysiology in detail but provide little in-
sight into clinical management or give few rea-
sons why certain treatments work. Here, clear
anatomical and physiological explanations ac-
company guides to patient care. The authors con­
sistently present a wide-angle view of the pelvic
floor by explaining the current thinking in ap-
proaches to treatment and reviewing how that
thinking evolved. Although this book is not a
surgical atlas, ample photographs and illustra-
tions provide added insight into the descriptions
in the text. The text is well referenced, and I found
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the tables that summarize the current literature
helpful in forming my own opinions about treat-
ment outcomes.
My criticisms of this book are few. Although
there is a chapter on the painful bladder syn-
drome, the text does not address pelvic pain in a
comprehensive manner. None of the authors are
colorectal surgeons, and aside from a brief de-
scription of anal-sphincter imaging, little atten-
tion is paid to the role of imaging in the evalu-
ation of women with pelvic-floor disorders.
I am often asked, “What book should I pur-
chase to use as a reference on pelvic-floor disor-
ders when I am in practice and have to look
something up?” Usually, I respond that most ref-
erence books are too outdated to serve this pur-
pose. This book is an exception to that rule. As
for my own practice, my colleagues and I plan to
use this book as the background for a didactic
series in fellow and resident training.
Rebecca G. Rogers, M.D.
University of New Mexico Health Sciences Center
Albuquerque, NM 87131
rrogers@salud.unm.edu
The Menopause: Endocrinologic
Basis and Management Options
Fifth edition. Edited by Bernard A. Eskin. 353 pp., illustrated.
Abingdon, England, Informa Healthcare, 2007. $229.95.
ISBN 978-1-84214-327-8.
F or all of us who care for female pa-
tients 45 years of age or older, the interwoven
issues of reproductive aging and other somatic
aging make it difficult to identify the source of
patients’ concerns. Even the term “menopause”
refers to an event — the last spontaneous menses
— leaving us unsure about what term to use for
the rest of the time in a woman’s life.
This fifth edition of The Menopause brings to-
gether distinguished experts to improve our
understanding of how changes in reproductive
hormones affect women during and after meno-
pause. An effort is made to separate the early
2009
 The new england journal of medicine
effects of these changes from the effects charac-
teristic of later years. The word “menopause” is
used to describe the hormonal transition from
the last menstrual period to about 65 years of
age, and the term “geripause” is often used to
describe the period of a woman’s life after that.
In an effort to be inclusive of issues that affect
older women, the editor has included chapters on
aging that cannot be clearly linked with estrogen
deficiency (e.g., chapter 26, “Hearing Impairment
in the Menopause and Beyond”) but that are still
very useful for the clinician who is caring for
these patients.
The strengths of the book lie in the excellent
chapters on the endocrinology of the menopausal
transition and in a very good review, written by
the book’s editor, of the debates on how and
whether cellular senescence is linked with repro-
ductive senescence (chapter 1, “The Menopause
and Aging”). For clinicians treating patients who
are caught up in the “bioidentical hormone” con-
troversy, chapter 20, “Pharmacology of Hormonal
Therapeutic Agents,” is very helpful, if perhaps be­
yond those readers with just a passing interest in
steroid biochemistry. This chapter and chapter 10,
“Sex Steroid Hormone Metabolism in the Climac-
teric Woman,” together make for an excellent re-
view of our knowledge on the subject to date.
The chapters on sexuality during and after
menopause and quality-of-life assessment during
menopause provide the primary care physician
with clinical tools that can be used to determine
which among a patient’s concerns can be attri-
buted to changes in ovarian function and which
may be related to other issues. The Menopause
Rating Scale, a quick, well-validated office ques-
tionnaire, is also included in the book and dis-
cussed as a quality-of-life measurement tool. It
can be used to help balance the risks and benefits
of hormone-replacement therapy by assessing the
quality of life before and after estrogen replace-
ment. (Appendix 7.2 of the questionnaire has an
obvious error that the publisher will correct for
the next printing of the book.)
Another strength of this book is its thorough
discussion of many problems faced by older
women, including osteoporosis, cardiovascular
disease, cognitive decline, urogenital issues, and
breast cancer. The reader should be aware, how-
ever, that whereas some of this information is
very clearly evidence-based, some is based more
on practice and opinion. It is important to evalu-
2010 n engl j med 356;19  www.nejm.org  may 10, 2007
The New England Journal of Medicine
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Copyright © 2007 Massachusetts Medical Society. All rights reserved.
ate each of the recommendations based on the
evidence.
The final section of the book focuses on treat-
ment and wellness, including hormone-replace-
ment options, complementary and alternative
medicine, nutrition, and exercise. We are remind-
ed in the foreword, written by Leon Speroff, that
the menopausal transition provides an opportu-
nity for both clinicians and their patients to seek
a vital and healthy second half of life.
Kirtly Parker Jones, M.D.
University of Utah
Salt Lake City, UT 84132
kirtly.jones@hsc.utah.edu
Management
of the Perimenopause
(Practical Pathways in Obstetrics and Gynecology.) Edited
by James H. Liu and Margery L.S. Gass. 531 pp., illustrated.
New York, McGraw-Hill, 2006. $62.95. ISBN 978-0-07-142281-9.
W ith the myriad of medical textbooks
that are available, it is rare to find one that
covers a novel topic. Perimenopause is a topic that
has largely been met with indifference, and for
this reason Management of the Perimenopause is a wel-
come addition to the library of any physician who
cares for female patients at this stage of life.
There has been a lack of rigorous research on peri­
menopause, but an important exception is the
Study of Women across the Nation. This study,
funded by the National Institutes of Health, pro-
vides longitudinal data on women from diverse
backgrounds. Other cohort studies have made
major contributions and provide a global view-
point of this time in a woman’s life.
One of the major challenges in producing a
textbook on perimenopause is to define its time
frame. Some guidance is provided by the Stages
of Reproductive Aging Workshop, developed un-
der the auspices of the American Society for Re-
productive Medicine, but this resource is difficult
to use in a clinical setting. Management of the Peri-
menopause acknowledges that additional informa-
tion will be required before a time frame for
menopause can be clearly defined. With that ca-
veat, the text covers a wide range of problems,
some specific to the menopausal transition and
some found throughout the lifespan.
The book is easy to use, with key points high-