Menopause

Objectives:

1. Identify types of estrogen supplements.

2. Describe the symptoms most often associated with menopause.

Menopause, also known as the change or change of life, occurs at a time in the reproductive life of women when the production of estrogen and progesterone, two hormones, changes dramatically.

After menopause, women are no longer able to have children and may become more prone to certain diseases. Women have gone through menopause at around the age of 50 for hundreds, if not thousands of years. According to some experts, even the ancient Greeks described it as occurring around the age 50.

Why do we seem to hear so much about menopause now?

Numbers, for one thing!  The baby boomers—people born between 1946 and 1964 are getting older. Almost 2 million women turn 50 each year now. In the year 2000, most of the nearly 42 million American women over the age of 50 were past menopause. That’s almost one out of every three American women.  And many of the female baby boomers want to understand what is happening to their bodies. Progress in research to answer their questions keeps menopause in the news. 

Some studies are examining how estrogen affects different parts of the body; others are evaluating the possible protective effects of this hormone on the heart and brain. Researchers are also exploring the possible risks associated with replacing some of the estrogen the body no longer produces after menopause. Sometimes these investigations stimulate even more questions, but scientists hope that this decade will be a time when we gain a better understanding of estrogen and its benefits and risks.

Menopause is a part of every woman’s reproductive life cycle. It is not an illness that necessitates treatment. To understand menopause, you first need to understand the whole reproductive process and how the body changes from stage to stage.

Some of the important times in a woman’s reproductive life are: Puberty is the time in a young girl’s life when increased estrogen production begins to cause physical changes in her body, such as the development of breasts. During this time her menstrual cycle begins, and her first “period” occurs, generally around the age of 12-1/2 years. This is known as menarche (me-nar-key).

What is Premenopause?

Premenopause includes the years between puberty and menopause. For many women their production of hormones is regular, so their periods are usually predictable. 

Perimenopause also formerly known as the climacteric, begins before menopause. Again the body begins to experience changes—both physical and hormonal. The symptoms we associate with menopause such as hot

flashes and irregular menstrual cycles may start to appear. The average perimenopause lasts for 4 years. It continues, by definition, through the 12 months following the last period. 

Menopause is a point in time.  The time of the last menstrual cycle. However, doctors cannot know for sure when the last period was until the patient has been period-free for 1 year without being pregnant, breastfeeding, or using certain medicines, all of which can also cause menstrual cycles to cease.

Natural menopause usually occurs some time between the age of 45 and 55.

Surgical menopause may occur at any age.  If the patient and  physician decide that removal of the uterus (hysterectomy) and/or both ovaries (bilateral oophorectomy) is medically necessary.

Premature menopause is said to occur before the age of 40. The following are factors that can affect when a woman has had her last period? If she  smokes, she could go through menopause about 1-1/2 years earlier than her friends who don’t smoke. Some studies indicate that thinner women, and African-American and Hispanic women also tend to go through menopause at an earlier age. Other evidence suggests that if a woman used oral contraceptives (“the pill”) or has had children, she might go through menopause just a little later than other women.

Postmenopause is the stage of life after menopause. It begins with the last period and continues for the rest of a woman’s life. One hundred years ago some women associated menopause with the end of life. The average life expectancy for a woman born in 1900 was 50.7 years. Indeed, throughout history many women did not live long enough to go through menopause. It’s easy to see why they connected menopause with death. However, advances in medicine and disease prevention have greatly increased life expectancy. A girl born in 1990 can expect to live nearly 79 years. This means that she will probably live a third of her life after menopause.

Final menstrual period/menopause

Some of the things to look for are:

Irregular menstrual cycles or changes in bleeding are often the first sign of perimenopause.  Most women experience irregular periods, sometimes longer cycles, other times shorter ones. The actual period may last longer or end more quickly. The flow could be lighter or heavier. There are many ways her cycle could change during perimenopause. Women with irregular periods should check with their doctor.

Hot flashes or flushes are one of the most common signs of perimenopause.  As many as 75 percent of Caucasian women have hot flashes.  In some ethnic groups, they are much less common. A hot flash begins with a feeling of heat in the face and upper body. The skin may appear flushed or red as blood vessels expand. Sometimes heavy sweating and cold shivering follow. Some hot flashes may cause only a slight feeling of warmth or a light blush. Others may drench the clothes. Night sweats are hot flashes that occur during sleep. Often, they are severe enough to wake a person, which can leave them feeling tired during the day. Hot flashes can occur several times an hour, a few times a day, or once or twice a week.

If a woman suffers from hot flashes she might want to try to identify if there is a trigger for her hot flashes.  Stress, caffeine, spicy foods, hot drinks, and alcohol are a few that seem to bother some women. Avoiding a trigger might help reduce the number of hot flashes that trouble her. Estrogen supplements are quite effective in controlling symptom.  70 to 90 percent of women using postmenopausal hormone therapy gain relief this way. However, if a woman prefers not to take estrogen, early studies of two antidepressants, fluoxetine and paroxetine, suggest that in the future they may prove to be promising possible treatments. Other steps to relieve hot flashes include:

  •     sleeping in a cool room,
  •     dressing in layers which can be removed at the start of a hot flash,
  •     having a drink of cold water or juice when a hot flash is coming on,
  •    using sheets and clothing that let the skin “breathe,” and
  •     avoiding spicy foods, alcohol and caffeine.

Once past menopause, the frequency of hot flashes should diminish. They usually disappear altogether in a few years.

Changes in the vaginal and urinary tracts occur with aging.  They result from the loss of the fatty tissue and collagen under your skin.  Lessened blood flow and estrogen levels changes contribute to the overall changes in the vaginal and urinary tracts. The tissues in the vagina become dry and thinner and secrete less mucus. This, in turn, makes them more delicate and susceptible to tearing and infection. Sexual intercourse may become painful, but some experts believe that if one continues to have sexual relations, they might have fewer problems with dryness or tightening of the vagina. A water-based lubricant, but not petroleum jelly, may relieve vaginal discomfort. Urinary problems such as frequent infections and urine leakage sometimes develop at this time also. While these changes are not unusual,one should still see a doctor who may help to control any problems that result. 

Libido or interest in having sex, as well as the ability to become sexually aroused, changes for some women. Some lose interest in sex or find it uncomfortable. Other women, however, become more interested in sex after menopause. Pregnancy is no longer a concern and they feel freer and more relaxed in general.

Problems sleeping and the resulting fatigue may bother some. Some sufferers might wake in the middle of the night because of night sweats or may need to go to the bathroom. Then they may have trouble getting back to sleep. Or, they could have a problem falling asleep when they go to bed or waking early in the morning. The tiredness that results makes working or performing mental activities during the day difficult. 

Physical changes are common at this time of life. These could be related to perimenopause or could simply be a result of getting older. Women might experience a thickening around the waist. They could lose muscle mass and gain more fatty tissue. Their skin might become thinner and lose its elasticity. Some women also experience joint and muscle pain and stiffness.

Memory problems, as well as psychological and emotional symptoms, such as depression, mood swings, and irritability, are some complaints of women in perimenopause. Some of these, especially memory problems, may be associated with growing older. Fatigue and mid-life stresses may contribute to these symptoms. Both middle-age women and men commonly report short-term memory problems. Whether changing estrogen levels causes any of these is not known, but the brain is one of several body organs sensitive to the effects of this hormone.

Changes in the hormones and body are not the only things that women may have to adjust to at this age. There are several potential mid-life issues that could create stress and make menopausal problems more difficult to handle. If the woman has a family, there are probably changes at home—the “empty nest,” children leaving home for college, work, or marriage. If she waited to start a family, young children are still in need of attention when she is possibly tired from having trouble sleeping.

Perhaps there are marital problems; she might even be going through a divorce. If she works, she may be taking a different look at her career, beginning to contemplate retirement, or feeling challenged by younger coworkers. A major stress might be caring for aging parents. As our parents grow older, we are all faced with many related issues, their illnesses, their need for assistance and caregiving and eventually their loss.

Scientists around the country are studying how women from various ethnic groups in American cities respond during menopause. Early results suggest that there are indeed differences between these groups in the types and severity of their menopausal symptoms. For example, African-American women report more symptoms such as hot flashes and fewer problems like stiffness, headache, or insomnia than other groups.

Hispanic women reported urinary leakage more often than others. Asian-American women had fewer symptoms in general. Women who were less active reported more symptoms.

Caucasian women, especially those with more education, were more likely to use postmenopausal hormones to treat their symptoms. These investigators also found that of the ethnic groups studied, African-American women had the most positive attitude about menopause, and foreign-born Asian-American women were the most negative in their feelings about this time of life.

If a woman has experienced surgical menopause, she may face more severe menopausal symptoms than someone going through natural menopause. The symptoms may begin soon after surgery. Her hot flashes may be more severe, more frequent, and longer lasting. She may be more likely to develop heart disease and osteoporosis. If the surgeon is able to leave her uterus and at least one ovary, menopause should occur naturally. If only her uterus is removed, her menstrual periods will stop. In some of these women who had surgery, symptoms of menopause may then occur immediately; in others they may develop later or not at all.

Understanding Menopause

Estrogen is produced by the ovaries, and as women age, significant internal changes take place that affect the production of this hormone. The two ovaries are small oval-shaped organs located on either side of the top of the uterus. At birth they contained about 700,000 sac-like follicles which each enclose an egg.

Only about 400 to 500 of these follicles ever mature fully and release an egg during a menstrual cycles. The rest degenerate and disappear over the years. The maturing follicles are involved in the production of estrogen and in the ripening of an egg.

During reproductive years, the hypothalamus, a part of your brain, releases gonadotropin releasing hormone (GnRH). This causes the pituitary gland, located at the base of the brain, to secrete luteinizing hormone (LH) and follicle-stimulating hormone (FSH). LH and FSH in turn stimulate the maturation of the follicles in the ovaries and the release of a new egg from its follicle each month. The follicle also increases production of the sex hormones estrogen and progesterone, which thicken the lining of the uterus. This enriched lining is prepared to receive and nourish a fertilized egg following conception. If fertilization does not occur, estrogen and progesterone levels drop, the lining of your uterus breaks down, and the period starts.

As perimenopause progresses, ovaries begin to shrink and follicles disappear at an accelerating rate. Hormone levels fluctuate as the ovaries attempt to maintain their former level of hormone production. Ovaries become resistant to FSH, and the pituitary releases more and more of it trying to keep up estrogen production. This can cause irregular menstrual cycles.

Why do menopause symptoms develop?

Levels of estrogen and progesterone can change erratically from month to month as one ages and get closer to menopause.  Pregnancy is still possible until periods stop for 1 year.  Ovaries stop releasing eggs around the time of menopause.

If unpredictable episodes of heavy bleeding occur during a menstrual cycle, a doctor may do a blood test for FSH. When the woman has been period-free for 1 year and has an elevated FSH level (usually over 30-40 IU,international units), she has reached menopause. FSH levels tend to fluctuate during perimenopause, so these test results alone are not used to diagnose menopause.

Even after menopause, estrogen production by the ovaries does not always stop completely. Although levels of estradiol, one form of estrogen, drop, a weaker estrogen, estrone, continues to be produced especially in fat tissue with help from the adrenal glands. Although this form of estrogen is weaker than the estradiol produced by your ovaries, it increases with age and with the amount of fat tissue.

Progesterone is another sex hormone also produced by the ovaries. Its job is to help prepare the uterus for the arrival of a fertilized egg and to shed this lining if an egg is not fertilized. If the ovary does not produce enough progesterone to do this, the lining may continue to grow until a drop in the amount of estrogen brings on a menstrual cycle. Heavy bleeding may then accompany that period as the uterus sheds its unusually full lining. Endocrine glands secrete hormones into the blood and interact with one another to help regulate total body metabolism, growth, and reproduction. 

Endocrine System

Sex- Many people think menopause brings a reduced interest in sex. Both men and women may find themselves taking longer to become sexually aroused as they age. However, medications such as antidepressants, tranquilizers, and high blood pressure drugs can alter sexual desire. Health problems such as heart disease, diabetes, or arthritis, concern about appearance and stress in one’s daily life can also inhibit sexual response.

In the year 2000, scientists at the New England Research Institute and the University of Massachusetts Medical School found that some women do experience changes in libido with menopause and that these women also believe that a lessening interest in sex accompanies growing older. Interestingly, the researchers determined that such changes are not related to estrogen loss, but instead to other factors such as attitudes, general health, and marital status.

Estrogen loss was related only to pain during intercourse. If a women  loses interest in sex around this time, she should talk to her doctor. He or she will consider all possible causes. Women’s bodies also produce some of the male hormone testosterone, and some scientists think that changes in testosterone levels can lead to a drop in libido. There is a little evidence suggesting that some women may benefit from a small amount of testosterone supplement, but the effectiveness of this treatment needs further study. Side effects of testosterone in women include skin problems, extra hair on the face and body, and voice changes.

Pregnancy

If a woman does not wish to become pregnant at this age, she should continue using contraception until her doctor determines that she is indeed past menopause. Since estrogen and other reproductive hormones are still produced by the body during perimenopause, an egg may still be released, and pregnancy is possible. Irregular menstrual cycles make it more difficult to predict the time of ovulation, when sexual intercourse is more likely to result in pregnancy.

If she is currently using “the pill” as contraception, her periods will continue to be regular even after she has passed menopause. An oral contraceptive, even one with a low dose of estrogen, may also help control symptoms such as hot flashes.  Most women do not lose their ability to enjoy sex. Loss of interest in sex is not usually related to lack of estrogen.  

HIV/AIDS

The possibility of pregnancy will disappear once a year has passed the last period. The chance of becoming infected by HIV (human immunodeficiency virus) and developing AIDS (acquired immunodeficiency syndrome) is something one must consider as long as they are sexually active. In fact, about 10 percent, possibly as many as 15 percent of all people diagnosed with AIDS in the United States are age 50 and older— more than 75,000 Americans. And this group is growing at an increasing rate.

Women who are recently widowed or divorced but were married for many years have probably never worried about AIDS. Now they may be starting to date again, and many have no idea that HIV is a risk or how it is spread. You can get HIV by having unprotected sex with an infected person. The virus, found in body fluids such as blood, semen, and vaginal secretions, can enter the body through any opening in the skin.

This means postmenopausal women are especially at risk because the tissues of the vulva (the external female genital area around the opening of the vagina) or the lining of the vagina become more fragile and easily torn as estrogen levels fall.

Postmenopausal women having sexual contact with other women must remember that the membranes lining any body opening, including the mouth and vagina, are susceptible to HIV infection. 

Post Menopause 

Many tissues in the body are sensitive to the effects of estrogen—breast, bone, heart and arteries, central nervous system, urinary and genital tracts, and parts of the gastrointestinal system. Changing levels of estrogen could cause problems in some of these.

For example, as women age and go through menopause, bone loss increases significantly, and osteoporosis can develop. At this age cardiovascular (heart and blood vessel) disease begins to pose a significant threat to the continued health and well being of many women. Researchers are working to understand osteoporosis and the connection between menopause, aging, and heart disease. Perhaps then they will be able to provide safe and effective protection against these illnesses in later life.

Osteoporosis

Many older women, and some older men also, face the threat of osteoporosis. At present 10 million Americans have this bone weakening disorder, and another 18 million are at risk of developing this disease because of bone loss. Four out of every five of these older adults at risk are women. One out of every two American women over the age of 50 will experience an osteoporosis- related fracture during her life. For too many of those, the fracture, especially if it is a hip fracture, will end their ability to live independently.

These fractures are costly—both in dollars, but also in personal suffering. Treatment for osteoporotic fractures costs this country an estimated $13.8 billion per year. Vertebral fractures lead to curvature of the spine, loss of height, and pain. Hip fractures, which require major surgery and hospitalization, are the most expensive. Recovery from hip fractures may necessitate many hours of physical therapy. Worse, between 12 and 20 percent of those who suffer a hip fracture do not survive for 6 months after the break. At least half of those who do survive require help in performing daily living activities, and 15 to 25 percent will need long-term care.

Still, with time and appropriate therapy, many hip-fracture sufferers can return to living independently. Bone is living tissue that is continuously undergoing two processes —the breakdown of old bone and the formation of new bone in its place. When more bone is broken down than is replaced with new tissue, osteoporosis can eventually result. The bone becomes fragile. Its structure is less dense. Gradually, and without discomfort, bone loss leads to a weakened skeleton incapable of supporting  normal daily activities. Often, the first sign of osteoporosis is a bone that breaks under less stress than would usually be needed to break it, especially a bone in the spine, wrist, or hip.

For osteoporosis, the first step in prevention is achieving maximum “peak” bone density when one is young. This should be done before the age of 30 because after that women (and men) may begin to lose bone strength slowly. Initially, this loss is slow. In women it picks up speed around the time of menopause, slowing again a few years later, but bone loss continues into old age.

Building bone density is achieved by eating calcium-rich foods as well as those containing vitamin D, possibly taking calcium and vitamin D supplements (or getting at least 20 minutes of sunlight every day), and doing regular weight bearing exercise (walking, running, stair climbing, or using weights to exercise).

Preserving bone strength after menopause is the next step toward preventing osteoporosis. The same steps that helped build bone early in life will help slow its loss after menopause, but estrogen plays a role in building bone. Falling estrogen levels contribute to the increased bone loss that occurs at menopause. Replacing estrogen after menopause through hormone replacement therapy is considered the most effective way to control bone loss. However, estrogen effects are not limited to bone. Sometimes it can affect other tissues in the body in a positive or negative way. Researchers are taking a closer look at estrogen to determine the benefits and risks of hormone replacement therapy. They are also exploring ways to improve its use.

For example, scientists at the University of California at San Francisco demonstrated that some women whose bodies produce modest amounts of estrogen after menopause have more protection from hip or spine fracture after the age of 65 than women who have undetectable levels of estrogen in their blood. This suggests that older, postmenopausal women may benefit from low-dose estrogen supplements although further research is necessary.

There are several approaches, in addition to estrogen supplementation, to preserving bone after menopause. Drugs available to prevent further bone loss include bisphosphonates like alendronate and risedronate, calcitonin, and the SERM (selective estrogen receptor modulator) raloxifene. Still others, including fluoride, parathyroid hormone, and newer SERMs, are under investigation.

Cardiovascular Disease

The cardiovascular diseases (CVD), which include heart disease and stroke, are the number one cause of death in American men. Most of us know that. What many of us don’t always realize is that this is true for women, too. Between the ages of 45 and 64 years 1 in 10 American women have some form of heart disease. By age 65 one in four women have heart disease. In fact, more women that age die of heart disease and stroke each year than men do, more than 423,000 deaths in women in 1998.

 Heart disease kills more than twice as many women as the next biggest cause of death, all forms of cancer combined and more than 11 times the deaths due to breast cancer. Disorders of the heart and blood vessel system include atherosclerosis (a narrowing and hardening of the arteries), high blood pressure, angina (chest pain that results from insufficient blood getting to the heart), heart attack, and stroke. Estrogen appears to protect women against heart disease during their reproductive years.

Calcium

The NIH recommends 1,000 mg daily for a woman over 50 using HRT or 1,500 mg daily for a woman over age 50 and not using HRT, or anyone over age 65, with a maximum daily dose of 2,000 mg.

Harvard Study

Harvard School of Public Health began following more than 84,000 nurses who did not have heart disease, cancer, or diabetes in 1980. After 14 years of observation, the researchers found that certain women were less likely to develop heart disease. These women:

- did not smoke

- exercised moderately (such as brisk walking) at least 30 minutes a day, and followed a diet that included a lot of fiber, the vitamin folate, and unsaturated fatty acids, but was low in trans fat, foods that increase blood sugar, and saturated fat.

Estrogen Supplements

There are three types of estrogen produced by the body—estrone, estradiol, and estriol.  Estradiol is the strongest and most important before menopause. More than 60 years ago, physicians realized that restoring estrogen to a woman passing through menopause could relieve some of the annoying symptoms of that time and possibly protect her against osteoporosis. In 1942 the Food and Drug Administration (FDA) approved the use of Premarin, conjugated (or mixed) equine estrogens (CEE) that come from the urine of pregnant mares, for treating the symptoms of menopause. Since then, several forms of synthetic estrogens have also become available to treat menopausal symptoms and to prevent osteoporosis. These come in a variety of forms including tablets, patches, creams, and vaginal inserts. Treatment with estrogen alone (“unopposed estrogen”) is called estrogen replacement therapy.

Types of Estrogens

  •     Pills Cenestin, Estinyl, Estrace, Estratab, Menest, Ogen, Ortho-Est, Premarin
  •     Cream Estrace, Ogen, Ortho Dienestrol, Premarin
  •     Vaginal Ring Estring
  •     Patch Alora, Climara, Esclim, Estraderm, Estradiol, FemPatch, Vivelle
  •     Injection Delestrogen, dep Gynogen, Depo-Estradiol, Depogen, Estra-L, Gynogen LA, Kestrone 5, Premarin, Valergen
  •    Progestins
  •    Pills/Capsules Amen, Aygestin, Curretab, Cycrin, Prometrium, Provera
  •     Vaginal Gel Crinone
  •     Injection Hylutin
  •     Combinations
  •     Pills Activella, Estratest, Femhrt, Ortho-Prefest, Premphase, Prempro
  •     Patch Combipatch
  •     Injection Depo-Testadiol, Depotestogen, Duo-Cyp, Valertest

 

Managing the Symptoms

Originally, doctors only prescribed estrogen alone. Since estrogen stimulates the growth of the endometrium (the lining of the uterus) in preparation for implanting a fertilized egg, it turned out that giving unopposed estrogen could lead to excessive growth of the cells in the endometrial lining and potentially endometrial cancer. Today the preferred treatment in women who still have their uterus is called hormone replacement therapy (HRT), or sometimes postmenopausal hormone therapy. In this therapy estrogen is combined with another female sex hormone, progesterone, to prevent uncontrolled growth of the endometrium. Progestin, a synthetic progesterone, is usually prescribed. Commonly taken as a pill, progestin is also available as an IUD (intrauterine device), vaginal gel, patch, or shot.

The progestins most often used are medroxyprogesterone acetate, norethindrone, and micronized progesterone. A woman whose uterus has been removed does not need progesterone and can use estrogen alone.

There are two methods for taking postmenopausal hormones—cyclic (or sequential) and continuous combined. Often in the cyclic or sequential method a pill containing 0.625 mg of conjugated estrogens is taken daily, with 5 or 10 mg of progestin added for 10-14 days each month.

This regimen may cause bleeding similar to menstrual periods in most women. Another approach is the continuous combined regimen in which 2.5 or 5 mg of progestin is taken every day with the estrogen. With this approach there is irregular spotting and bleeding that appears to diminish within a year in most women. If the light period or spotting is too annoying, the physician might consider altering the progestin dose. The patch is another way to administer postmenopausal hormones.

A patch is an adhesive material containing hormones that is placed on the lower abdomen or buttocks and changed once or twice a week. Sometimes the patch contains estrogen and a progestin pill is used to supplement it, if needed. A combination patch containing both hormones is now available. The patch method can be better for some women because hormones are absorbed slowly and directly into the bloodstream from the patch.

When a pill is taken, the medication goes first from the stomach and intestines into the liver where it is metabolized or broken down. This pass through the liver leads to higher levels of triglycerides and blood clotting factors and an increased incidence of gallbladder disease in menopausal women, as well as the positive effects estrogen has on cholesterol, LDL, and HDL levels. Some women have a bit of irritation at the site where the patch is placed.

If symptoms are limited to vaginal dryness, urinary leakage, or vaginal or urinary infections, one could use a vaginal estrogen ring or cream instead of the oral or patch form. The vaginal ring is a flexible ring placed in the upper part of the vagina. It contains such a low dose of estrogen that it may not protect against osteoporosis. It needs to be changed every 3 months.

Besides monthly bleeding, there are a few other possible side effects from taking estrogen and progesterone. Breast tenderness or enlargement, nausea, abdominal bloating, and headache are some of the more common complaints associated with using estrogen supplements. The addition of progesterone could lead to irritability and mood changes, almost like PMS, (premenstrual syndrome), which troubles some young premenopausal women.

Estrogens

  •     Conjugated estrogens Pill, cream, injection
  •     Estradiol Pill, patch, injection, cream,vaginal ring insert
  •     Esterified estrogens Pill
  •     Estropipate (estrone) Pill, cream

Progesterones

  •     Medroxyprogesterone acetate Pill, injection
  •     Norethindrone acetate Pill, patch (in combination with estradiol)
  • Micronized progesterone Pill, vaginal gel, suppositories

Combination

  •     Conjugated estrogens and
  •     Medroxyprogesterone Pill
  •     Estradiol and norethindrone
  •     Acetate Patch

Hormone Risks

Estrogen and estrogen with progestin appear to be effective and relatively safe, particularly if used for less than 5 years to control menopausal symptoms. However, there are still many unanswered questions about menopause and the benefits and risks of long-term hormone replacement therapy. For example:  Who will benefit from estrogen supplements, and who will be at increased risk of disease? Does estrogen prevent heart disease? Does it prevent heart attacks? What about estrogen in women who already have heart disease?  Does estrogen or progesterone cause cancer?  Is estrogen the best way to prevent osteoporosis? Will estrogen protect a woman’s memory? Does it prevent Alzheimer’s disease? What is the best method of providing estrogen and progesterone? Several long-term studies are underway. They should answer many of these questions. But here’s what we know now:

Does estrogen prevent heart disease?

Since heart disease in women only becomes a major health problem after the age of menopause, doctors have long suspected that estrogen protects women from heart disease.

What are the benefits and risks of using hormones?

PRO

  •     HRT and ERT reduce the risk of osteoporosis.
  •     HRT and ERT relieve hot flashes and night sweats.
  •     HRT and ERT relieve vaginal dryness.
  •     HRT and ERT improve cholesterol levels.
  •     HRT and ERT may reduce the risk of heart disease.
  •     HRT and ERT may improve mood and psychological well-being.
  •     HRT and ERT may prevent the decline of mental abilities with age.

CON

  •     ERT, without the use of a progestin, modestly increases the low risk of cancer of the uterus (endometrial cancer).
  •     HRT and ERT can have unpleasant side effects, such as bloating or breast tenderness.
  •     HRT and ERT may increase risk of breast cancer while they are being used; long-term
  •     HRT may increase cardiovascular events such as heart attack and stroke at first, but this increased risk appears to grow smaller over time.
  •     HRT and ERT increases the risk for blood clots.
  •     HRT and ERT in pill form may raise triglyceride levels and might contribute to gallbladder disease.

When hormones are discontinued, risk gradually returns to almost normal. 

Do estrogen or progesterone supplements contribute to breast cancer?

In 1997 the Collaborative Group on Hormonal Factors in Breast Cancer reviewed information collected on more than 53,000 postmenopausal women during 51 studies in 21 countries, representing about 90 percent of the data on this subject. They determined that using hormone replacement therapy, mostly unopposed estrogen, led to a small increased risk of localized breast cancer—an increase of 2.3 percent for each year hormones were used. This increased risk, which was greater in lean women than heavy women, returned almost to normal within 5 years of stopping therapy.

The researchers were unable to resolve whether the risk associated with estrogen and progestin differed from the risk from using estrogen alone. The Collaborative Group observed that in North America and Europe they would usually expect 45 cases of breast cancer per 1,000 women, ages 50 to 70, who had never used HRT. They suggest that the increased risk from hormone therapy would lead to an extra two cases per 1,000 women using HRT for 5 years, six cases per 1,000 using it for 10 years, and 12 cases per 1,000 for those using it for 15 years.

Several recent studies have examined whether the addition of progestin to hormone therapy changes the risk of developing breast cancer. In the year 2000 scientists at the NIH’s National Cancer Institute (NCI) reported on a review of medical histories of more than 46,000 postmenopausal women between 1980 and 1995; 2,082 of whom had breast cancer.

The NCI report showed that both estrogen and estrogen/progestin therapy led to a small increase in the risk of breast cancer, but the increase was greater with estrogen and progestin than with estrogen alone. Their analysis suggested that estrogen/progestin therapy over a 4-year period increased a woman’s risk of developing breast cancer by about 30 percent—a result similar to that reported by the Collaborative Group for hormone use for 5 years or longer. Lean women also appeared to be at greater risk than heavier women.  That same year a study at the University of Southern California reported similar results in a group of 3,534 women, 1,897 of whom had breast cancer.

Will estrogen supplements help memory and perhaps even prevent Alzheimer’s disease?

The brain is sensitive to the effects of estrogen, and because men and women may experience memory problems as they age, some scientists have thought that giving estrogen supplements to women might protect their memory and might even be used to treat, delay, or prevent Alzheimer’s disease (AD). Studies so far have been promising in some areas in animals but inconclusive in humans.

Are there any other risks from using postmenopausal hormones?

There are two other notable risks—blood clots and gallbladder disease—that accompany the use of estrogen during or after menopause. A third risk— endometrial cancer—is a problem only in women with a uterus who receive no or insufficient progestin along with the estrogen. Estrogen and some of the designer estrogens or SERMs carry an increased risk of blood clots in the blood vessels. A blood clot can be life threatening if it comes loose and travels to the lungs or brain.

If one has a history of venous thromboembolism (blood clots in the veins), are very overweight, or are often unable to move about for health reasons, they need to seriously consider this risk associated with using estrogen. The average menopausal woman has a risk for blood clots of one in 10,000 women per year, but the use of estrogen increases this to almost three in 10,000 women. This is slightly less than the risk of accidental death, for example, dying from a motor vehicle accident, an allergic reaction to a drug, or a medical or surgical procedure. Some women, such as those with heart disease, are at much higher risk for blood clots if they take hormones—as many as one in every 250 women per year may get blood clots as a result of the therapy.

Using oral estrogen increases the chance of developing gallbladder disease because the estrogen first passes through the liver. Gallstones might be produced as a result, and one might then need surgery to remove the gallbladder. Thus, if one has a history of gallbladder disease, liver disease, or high triglyceride levels, but wants to try estrogen, she might consider using estrogen in a skin patch, thus bypassing breakdown in the liver.

Talk to a doctor about the medical history of the patient and her family, especially any relatives with osteoporosis, heart disease, stroke and cancer. Patients should discuss the potential benefits and risks of postmenopausal hormones and whether there are other treatments that could be used instead. Discuss health concerns. If they are bothered by symptoms such as hot flashes, they might wish to use estrogen in the short term, maybe for 5 years or less. Most studies indicate that any increased risk of breast cancer that might be associated with the use of estrogen does not become significant until it has used it for at least 5 years. Even then, after stopping, the risk appears to return almost to normal.

If hot flashes or other symptoms are not particularly bothersome, one could wait and begin hormone therapy when they are in their sixties. Some studies have indicated that this will still provide significant protection against osteoporosis and bone fractures, while avoiding the risks possibly associated with being on such therapy for many years. Always remember that one can discontinue the hormone supplements at any time. Patient’s should review their cases with their doctors at least once a year. Then they and their physician can make any changes necessary as more information is reported from hormone studies.  When making this decision, one should talk with their doctor about other ways to prevent or treat the more disabling conditions that often accompany aging. For example:

Heart Disease—Healthier cholesterol levels can be achieved by watching fats in the diet and regular aerobic exercise such as walking, running, swimming, or bike riding. If one is overweight, this combination of diet and exercise may also help them lose weight, which would relieve some of the strain on the heart. A variety of medicines are also available to control high blood pressure and to lower total cholesterol, triglycerides, and LDLs and to raise HDLs.

Osteoporosis—A diet rich in calcium and vitamin D and weight-bearing exercise will help keep bones healthy. After menopause, women are at high risk of developing osteoporosis, it may be necessary to supplement this with one of the drugs currently available to build bone or prevent loss of the bones that she has.

Breast Cancer—Routine visits to the doctor for regular breast examinations, and mammograms every 1 or 2 years after forty, according to the National Cancer Institute, are the best way we have to detect breast cancer as early as possible. The risk of breast cancer increases with age.  Breast cancer screening continues to be important. Hormones can increase breast density, which can make reading mammograms more difficult. One study has suggested that discontinuing the hormones 2 weeks before a mammogram will eliminate some of that increased density, but more research is needed to prove this.

Urinary Problems—If one suffers from urinary leakage or urinary incontinence, such as an inability to get to the toilet in time or losing control when they sneeze, laugh, or step off a curb, they should consult with their doctor.  There are a variety of causes for loss of bladder control, including lower levels of estrogen, infections, diabetes, and medication side effects. A doctor might prescribe specific drugs designed for this problem.

Kegel exercises, which are designed to strengthen certain pelvic muscles, giving more support to the bladder can also help. In addition, a doctor might suggest that estrogen cream applied locally or insertion of a vaginal ring containing estrogen. Some experts believe caffeine can irritate the bladder and should be avoided if one has urinary control problems.

Dietary Supplements

Right now there is a lot of discussion about phytoestrogens, estrogen-like substances from some plants, such as soy products. Phytoestrogens are also found in other plant materials such as legumes, vegetables, cereals, and some herbs. These “plant estrogens” work like a weak form of estrogen. The fact that Asian women eat a lot of foods containing soy and seem to report fewer hot flashes increased the interest of researchers in this subject. Eating soy can improve cholesterol levels. It has also been suggested to increase bone density and even to protect against breast cancer, but solid evidence is lacking.

Today some women use soy and herbal products such as black cohosh, wild yams, dong quai, and valerian root which claim to relieve menopausal symptoms like hot flashes. There is little, if any, proof for these claims. However, since these products are considered dietary supplements, they are covered by less stringent regulations than those involving prescription medicines and can be sold without the supervision or approval of the FDA. The manufacturers are supposed to make sure these substances are safe. The FDA can only step in if there are many serious reports of adverse effects, but there is no way of insuring the quality of these products.

Soy contains plant estrogens currently under study. Researchers hope to determine whether such products can have the same therapeutic effects as estrogen. But, also, they want to know whether using plant estrogens brings risks, especially risks similar to those of estrogen, such as endometrial cancer.

Until there is a better understanding of these substances, one should proceed cautiously. One should always tell their doctor about any dietary supplement they take.  There may be dangerous side effects. If one decides to increase the amount of foods with phytoestrogens, they should let their doctor know. If this does cause an increase in the level of estrogens in the body, this could interfere with other prescription medications being used or could even cause an overdose.

Good Health

Menopause and aging in general do not necessarily lead to illnesses that demand treatment; they are normal steps in any woman’s life. Menopausal women will not necessarily get sick and have to take a lot of medicine as they age. Also, aging does not have to mean disability and years in a nursing home. In fact, in 1997 investigators at Duke University reported that even though the number of older people in this country is growing, the rate of disability in the elderly is falling at an ever-increasing pace. They found that in 1994 approximately 1.2 million fewer older people were disabled than would have been predicted based on the rates in 1982. There are things everyone can do to maintain their health and mental abilities as they age: 

Exercise: Studies have shown that even people in their nineties can improve their walking and reduce their risk of falling by exercising.   Exercise benefits the heart and bones and helps maintain a healthy weight.

Eating wisely:   A balanced diet will provide most of the nutrients and calories the body needs to stay healthy. Two nutrients that can be safely taken as supplements are calcium and vitamin D.  One should eat a variety of foods from the five major food groups, choosing foods that are low in fat and watching how much sugar, salt, sodium, and alcohol are consumed.  Look for foods that have lots of nutrients, like protein and vitamins, but not a lot of calories—these are called nutrient-rich foods.

As we age, we need fewer calories for energy, but just as many nutrients.

Drinking plenty of water is essential.

Alcohol should be used in moderation—only about one drink a day for a woman, according to the Department of Agriculture’s Dietary Guidelines for Americans.

Health Information

Through exercise and diet, maintain healthy weight. Studies have shown that being overweight, especially around the abdomen, can increase the chances of developing diabetes, heart disease, high blood pressure, and osteoarthritis of the knee as one grows older. Having a waist measurement greater than 35”, even if the weight is normal, also puts one at greater risk for these health problems.

Women should have regular checkups. The doctor can do routine screening tests, pelvic and breast exams, and a Pap test for cervical cancer. After the age of 50, mammogram should be done every 1 to 2 years.

After the age of 50, women should have checkups for colon cancer.

Around menopause, women should have a bone density test, such as a DEXA-scan (dual-energy xray absorptiometry) to see if they are at risk for osteoporosis.

After age 40, reading may become more difficult—Regular appointment with an eye doctor may be necessary.  The doctor may also want to check for glaucoma, which becomes more common after age forty. It can damage vision before one realizes it.

Medicine should be taken as instructed and doctors should knows all the drugs currently taken. This includes over-the counter ones such as vitamins, dietary supplements, painkillers, and antihistamines.

Future Information

Physicians may never be able to make a single recommendation about using hormone supplements for all women approaching menopause. There are too many factors to consider that can vary from woman to woman. Personal and family medical history and health risks, lifestyle, and menopause symptoms are just a few. However, in the coming years physicians should have more reliable information about menopause with which to counsel their patients as a result of research underway now.

For example, a scientist at the University of Washington in Seattle hopes to develop a computerized guide for the World Wide Web that women could use to help them as they approach menopause. By providing the scientific basis for the benefits and risks of lifestyle changes, medications, and hormone replacement therapy, women will be able to choose the best way to handle their menopausal symptoms, as well as health problems after menopause, such as reducing their risk of bone fractures.

The site might even provide features such as a chat room and access to an expert for answers to individual questions. Testing is underway to determine which age groups could benefit the most from such a website. Studies such as these should provide and disseminate the knowledge needed to make it easier to understand the transition through menopause in the future—if not for us, then perhaps for our daughters. Until then, remember that you have much more health information available than our mothers might have had during their menopause.

Remember a third of one’s life is after menopause.

Additional Required Reading:             Menopause Metamorphosis

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