The most crucial fact of menopause is the absence of high levels of the hormones estrogen and progesterone. The replacement of estrogen, in particular, appears to reverse or stabilize many of the degenerative processes occurring after menopause. But whether an individual woman should take replacement hormones is a question that has to be answered by careful consideration of her own health risks. She has to know what risks could be lessened by this treatment and what risks could be heightened.
What we doctors have learned is that although many women are enthusiastic about taking ERT (Estrogen Replacement Therapy) or HRT (combined estrogen and progesterone therapy), many women are not. If started on HRT, many women simply stop it on their own. The most commonly cited reason that I hear is the fear of an increased risk for breast cancer. Even though replacement hormones can have a significant effect on decreasing risks of death from heart disease or disability from osteoporosis, the fear of breast cancer carries the day. So ERT/HRT should not be an automatic prescription written at the time of menopause.ERT/HRT should not be an automatic prescription written at the time of menopause.
I have found that the most useful approach is to evaluate the various risks and problems my patients are experiencing and then to use the current best regimen that is most satisfactory. I explain menopausal changes and consequences and determine individual risk. I also discuss what are NOT inevitable consequences of menopause.
Mental Symptoms
Significant mental problems are not necessarily part of menopause. In fact, some women don't get any mental or psychological symptoms, and not all of the symptoms that occur during menopause are caused by menopause. Anxiety and depression are common in women, more common than in men. Major episodes of these conditions happen throughout life, including menopause. The last thing I would want to do is to attribute my patient's symptoms to "the time of life" rather than evaluating the symptoms and recommending appropriate treatment.
No precise determination has been made of the degree to which hormone changes are responsible for the reputed mood swings of menopause. A very common cause of irritability and changing mood is sleep deprivation due to nocturnal hot flashes. Treatment for the hot flashes (called "vasomotor" symptoms) can reverse irritability and mood swings. Estrogen is, hands down, the most effective remedy. Phytoestrogens in foods (soy, yams) and vitamin E can be helpful. The drug clonidine (Catapres®) can also relieve symptoms.
Sexual Activity
Another untrue assumption is that, at menopause, your sex life is over.
Give up this idea and you'll improve your sex life, for the truth is that the declining levels of hormones are probably the least important factor affecting your sex life. But, remember, there can be some problems. Without estrogen, thinning of the pelvic support structures and the vaginal lining will occur — but continued regular sexual activity will maintain vaginal tone and glandular secretions. Several OTC products like Replens® and Astoglide® can solve problems with lubrication.
Urogenital Health
The atrophy that affects the vagina also affects the urethra (the tube emptying the bladder) and the supporting tissues of the bladder. The urethra loses its spongy, thick lining and appears more like a hollow tube. It is less able to stop urine flow at the end of urination and can contribute to an increased susceptibility to bladder infection. Urinary incontinence can also become a significant problem at this time.
Hormone replacement, which can be either systemic or local, in the form of a vaginal cream or ring, can reverse vaginal and lower urinary tract changes. Exercises for the pelvic floor, like the Kegel exercises are very helpful, particularly for women with urinary incontinence.
Osteoporosis
Estrogen has a strong effect on maintaining bone health. At menopause, there is a sharp decrease in bone mineral density (BMD) that lasts about five years, and, then, a steady, slow decline after that. The higher the bone density a woman has at the start of menopause, the better she can withstand this decrease. There are many factors that will make it likely that a woman has a low bone density that will put her at higher risk for osteoporosis and its complications. Genetic predisposition, dietary and exercise habits, use of tobacco, alcohol and medications, as well as specific illnesses, can all contribute.
Bones need building blocks, and an adequate diet is needed to maintain bone. Most women take in too little calcium over the years. Three servings of a dairy product (1000 mg of elemental calcium) premenopausally and five servings postmenopausally (1500 mg) are required to insure enough elemental calcium. Calcium supplements have to be evaluated for their elemental calcium content. Consult labels! Unless a woman is motivated to be on a very compulsive regimen, ingestion tends to be very sporadic. Weight-bearing exercise is also important.
Adequate intake of vitamin D plays a key role in bone health. Current recommendations may not be adequate. Women, 50 to 70 years old, should get at least 400 International Units (IU) and perhaps more.
Although I do inquire about risk factors, I believe every woman should have a bone density study to find out where she stands. The current best procedure is the DEXA (Dual Energy Xray Absorptiometry) first. The reports on these tests can be daunting. Pay attention tor the "T score" which compares you with young normal women. The "Z score" compares you to your peers, a group with declining bone density. The goal is to be among the women with excellent bone density, not declining bone density. It is helpful to get a DEXA two years in a row to see if the T score is declining rapidly. That is a strong reason to start treatment with medication.
Bone density, by itself, is only part of a woman's risk for fracture and deformity. Physical conditioning and balance are crucial factors in preventing falls. Even very elderly women respond remarkably well to training programs. A good diet, stopping excessive alcohol drinking and quitting smoking are measures that will benefit not only bone health, but other aspects of health as well.Physical conditioning and balance are crucial factors in preventing falls. Even very elderly women respond remarkably well to training programs.
Cardiovascular Disease
The question about whether estrogen is helpful in preventing heart disease, specifically coronary heart disease, the type that causes heart attacks, has become more complicated in recent years. Observational studies that looked at large groups of women, comparing those who took estrogen replacement therapy (ERT) and those who did not, have shown that those on ERT had a significantly lower incidence and death rate from coronary heart disease (CHD).
There are good scientific reasons to back up a beneficial effect. First, there is the general observation that women have many fewer heart attacks than men until after menopause, and, then, it takes ten or more years for women to catch up with men in heart attack incidence. What scientific research has found is that estrogen has beneficial effects on the lining of blood vessels and also that it improves the cholesterol readings. These effects would tend to decrease the risk of heart CHD.
Critics of observational studies point out that some of the beneficial effect of estrogen may be due to a phenomenon called the "healthy cohort" effect. That means that the women who chose to take estrogen may be better educated, eat better, exercise more, and, in general, have a healthier life style than those who chose not to take estrogen. In order to eliminate, or "control for" the healthy cohort effect, a randomized prospective study is needed. "Prospective" means that instead of looking at what women did in the past (retrospective), we start studying two groups of women, one on the medication and one not, and see what happens in the future. In order to make the two groups equivalent, they are "randomized," the women are assigned to the study groups in a totally unbiased fashion. Another way to try to keep noncausative factors from influencing results is to "double blind" the study — all women in the study take pills, and all the pills look alike, some have active medication in them and some do not. Neither the women being studied nor the doctors and nurses treating them know which woman is on which type of pill.
That was a little digression, but it is important for you to know what is going on in this field. The reason for looking critically at the effects of estrogen and CHD is that estrogen has a downside when it comes to blood vessel disease. It can promote clotting — conditions called deep vein thrombosis (DVT) and pulmonary embolism (PE) are associated with estrogen medication — and, indeed, are more common in women than in men throughout life. So there has been a concern about whether women on ERT/HRT could have an increased risk in heart attacks or strokes, which are caused by clotting off of heart or brain blood vessels.
A key study looking at this question was HERS, the Heart Estrogen Replacement Study, which was conducted over a four-year period. This study looked at women who already had coronary heart disease to see if estrogen therapy would prevent further heart attacks. The result was that in the first two years, there were more heart attacks and serious symptoms in the estrogen treated group. Interestingly, there were fewer coronary complications in the second two years. These results raise further questions: Does it take longer for those beneficial effects on blood vessel tone and cholesterol to kick in? Is there a special risk group for clotting complications who should not take ERT? If so, how to identify them?
A second study is in process right now, the Hormone Replacement Trial of the Women's Health Initiative. This study is looking at how effective ERT/HRT would be in preventing CHD from developing in postmenopausal women. It is studying postmenopausal women without any evidence of CHD, some on hormone replacement and some not. In the early results, they have seen more clotting problems in women on replacement. This is not news, we know clotting is a risk with estrogen. The overall question is, which is greater, the risk or benefit from estrogen? The women in the study are encouraged to stay the course and maintain their commitment to the study. This is the only study that is really going to answer the crucial question about whether women on postmenopausal ERT/HRT have significantly less heart disease.
So whether to use ERT/HRT for CHD risk reduction requires careful consideration. Certainly if a woman had a history of clotting problems — DVT or PE — estrogen would be out. What I do is review the five major risk factors for coronary heart disease: smoking, abnormal lipids (cholesterol and other blood fats), hypertension, diabetes and family history. The postmenopausal status is considered another risk factor. The more risk factors a woman carries, the more I am inclined to recommend estrogen replacement to counter risk. This is much less of an issue for women with no major risk factors and whose lipid profile does not fall into a risk range after menopause.
Alternative Treatments for Menopausal Risks
As I mentioned before, many women simply will not take estrogen. Estrogen stimulates cells in both the breast and uterine lining, so it increases the risk of cancer in both. Adding progesterone (or a synthetic progestin) removes the risk on the uterus. The risk to the breast remains, and we know this is a major deterrent for many women. There are now concerns about a role for progesterone, specifically synthetic progestins, in contributing to breast cancer risk.
There are now some alternative drugs to estrogen that address important menopausal problems. Alendronate (Fosamax®) stabilizes and increases bone density. It is a good alternative to estrogen for preserving bone. Alendronate is poorly absorbed with food, so it has to be taken on an empty stomach. It also can irritate the esophagus (the food pipe), so you have to take it with a full glass of water, and you cannot lie down after taking it. I tell my patients to take their pill and go out for a morning walk.
Raloxifene (Evista®) is a SERM (selective estrogen receptor modulator), a drug that has some pro-estrogen actions and some anti-estrogen actions. It does stabilize and increase bone mass. It improves cholesterol readings. Raloxifene acts as an anti-estrogen on the uterus and breast, so it does not increase the risk for uterine or breast cancer. In fact, another SERM, tamoxifen, may even prevent breast cancer. Long used to treat women with breast cancer, tamoxifen decreases the recurrence rate and the rate of new tumors in women who have had breast cancer. Unfortunately, both tamoxifen and raloxifene do not stop and may increase hot flashes.
The statin drugs improve the cholesterol profile, increasing HDL (good) cholesterol and decreasing LDL (bad) cholesterol. They are good choices to decrease heart disease risk in women with high cholesterol readings.
Summary
At menopause, you need to take a comprehensive look at all the bodily changes that can occur and how you are being affected. You should consider genital and urinary changes, problems with hot flashes, bone health and coronary heart disease risk. Problems in all these areas can be improved by ERT/HRT. However, there are prices to be paid-the risk of breast cancer and thromboembolic disease. When you are contemplating any type of medicine, you need to make a risk/benefit calculation. It is important that you have a chance to look at the big picture for yourself and make a choice that is comfortable for you.
