Hormone Replacement Therapy

September 14, 2011

Menopause is the cessation of menstrual periods. Women usually experience menopause at the age of 42-58, with the average age being 50-51 years. Menopause may occur slightly earlier in women who smoke or have a family history of early menopause. Otherwise, the age of menopause is unrelated to the age of the first menstrual period, use of oral contraceptive pills, pregnancies, or general nutrition. The term perimenopause refers to the entire time period of 3.5-4.5 years around menopause, when hormonal changes of menopause have begun.

Menopause is a time of significant hormonal changes. Since women today live one third of their lives after menopause, this health event also provides to women an opportunity to reevaluate life habits such as nutrition, exercise, and health surveillance.

The changes directly associated with menopause are related to the depletion of eggs from the ovaries. Women are born with more than a million eggs, which die or are ovulated during a woman’s reproductive years. After menopause, estrogen production from the ovaries falls to one tenth of that before menopause and no progesterone is produced. Menstrual periods stop, often after months or years of irregular periods preceding the menopause. Both the early and later symptoms associated with menopause are related to the low levels of estrogen.

Fifty to seventy-five percent of women experience at least one symptom of menopause, with the most common being the hot flush (flash). Hot flushes are usually described as a sudden feeling of warmth from the chest upwards, associated with facial flushing and sweating. They may occur once or several times daily. Night sweats and hot flushes are considered to be vasomotor symptoms, related to the effect of falling levels of estrogen on the heat-regulating center of the brain. Sleep disturbances, often related to night sweats, and irritability are also associated with menopause.

Most studies have not shown an association between depression and menopause.

Lowered estrogen levels may also cause thinning of the vaginal wall, decreased lubrication and elasticity of the vagina, and changes in the bladder and urethra. In some women these changes lead to discomfort with intercourse or problems with urination. Estrogen contributes to the collagen content of a woman’s skin, so the loss of estrogen may accelerate some of the skin changes usually associated with aging.

Osteoporosis and heart disease are later consequences of low estrogen levels. In the first years after menopause, bone may be lost at a rate of 1-5% per year. In some women, rapid loss of bone may result in fractures and chronic bone pain in as little as 10 years. Fractures of the vertebrae may cause loss of height, curvature of the spine, or back pain. Fractures of the hip are the most serious consequence of bone loss and can result in loss of independence or even death. Before menopause, women have a lower risk of coronary heart disease than do men, but after menopause the incidence of heart attacks increases rapidly until it approaches that of men in the same age group.

Some women may experience more symptoms than others after menopause. At least one quarter state that their symptoms are serious. These women may be the most likely to request some type of treatment for their symptoms. Conversely, some heavy women experience very few symptoms associated with menopause. Women make a type of estrogen in their fat cells, so heavy women may continue to have high levels of estrogen after menopause, even when their ovaries produce very little.

Lifestyle evaluation and changes should always be the first approach to relieving menopausal symptoms. A diet high in fiber and low in fat decreases the risk of heart disease, as does weight loss in overweight women. For some women, increased soy in their diet may improve vasomotor symptoms. Calcium and vitamin D intake should be optimized. A reduction in alcohol intake may decrease hot flushes and the risk of falls. Smoking cessation decreases the risk of heart disease and reduces the risk of osteoporosis. Exercise in general may improve mood, prevent weight gain, and improve sleep. Aerobic exercise reduces the risk of heart disease while weight-bearing exercise may decrease the risk of osteoporosis and falls. Vaginal lubricants and moisturizers can help vaginal dryness and regular sexual intercourse may prevent constriction of the vagina.

Whether or not to take estrogen replacement after menopause is one of the most confusing issues facing women today. Over the years there have been dramatic shifts in medical recommendations and public sentiment concerning the use of hormone replacement therapy (HRT). Accumulating information about risks and benefits of HRT suggests that emphasis should be placed on its use for the treatment of initial symptoms in the lowest possible dose for the shortest duration. In addition, there are now many alternatives to HRT that should be considered in the discussion of treatment options.

Estrogen is very effective in treating early menopausal symptoms. Hot flushes and night sweats are usually improved within days to about 2 weeks. Thinning and other changes in the vagina, bladder, urethra, and skin are usually reversible after one to two months of therapy. Women should take the lowest dose of estrogen that can relieve the symptoms.

In the past, many studies suggested that many women could benefit from taking estrogen after menopause for many years, even for the rest of her life. Long-term risks of estrogen treatment have been acknowledged for many years and include blood clots, a small increased risk of breast cancer, and endometrial cancer. The risk of endometrial cancer can be completely prevented by the addition of a progesterone-like medication to estrogen. This has become the standard approach for women who have not had a hysterectomy. Accumulated evidence suggested that HRT decreases the risk of heart disease by 50% as well as decreases the risk of osteoporosis and hip fractures. Several years ago, it was believed that these benefits so clearly outweighed any risks that most women should consider long-term HRT.

However, several excellent studies, including the Women’s Health Initiative (WHI) and the Heart and Estrogen/Progestin Replacement Studies (HERS), showed recently that HRT does not prevent heart disease as was previously believed. Estrogen continues to be recognized as the most effective medication for the prevention of osteoporosis after menopause, but most health care providers do not now support its long-term use for prevention of heart disease or improvement of general health.

Many women seek herbal remedies to provide relief of menopausal symptoms. There are numerous herbal preparations marketed as dietary supplements to treat menopausal symptoms. Unfortunately, studies to evaluate their effectiveness, side effects, and interactions with other herbals and prescribed medications are extremely limited. Current data suggest that black cohosh and soy may be effective in some women, and a handful of other herbals such as red clover are promising. At least part of the action of these herbals is through the estrogen receptor. A woman should always inform her health care provider if she takes any dietary supplements.

Some nonestrogenic medications have also been shown to relieve menopausal symptoms. Progesteronelike substances and androgens (male-type hormones) when given without estrogen may provide some relief of hot flashes. A variety of nonhormonal medications may specifically inhibit hot flashes, including veralipride and gabapentin. A variety of medications are available to prevent or treat postmenopausal bone loss, including raloxifene and alendronate. Raloxifene belongs to a group of medications called selective estrogen receptor modulators (SERMs), which may act as estrogens or as “antiestrogens,” depending on the cell type. For example, raloxifene acts like estrogen in bone cells by preventing bone loss, but it acts like an antiestrogen in the breast and brain by reducing the risk of breast cancer while worsening hot flashes.

For some women menopause is associated with very few symptoms and is in fact a welcome time point in the aging process. For many others, it is more troubling. Symptoms may be significant enough to require intervention with prescribed or nonprescribed medications. Because the study of menopause is so complex and is evolving so rapidly, women should seek many sources of information as they approach menopause.

SEE ALSO: Calcium, Cardiovascular disease, Coronary artery disease, Exercise, Menopause, Osteoporosis and osteopenia, Perimenopause

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