Most women entering menopause are filled with questions and concerns. What are the associated health issues? What can be done to maintain our physical and emotional health during menopause? Would hormone replacement therapy be helpful? This guide is intended to answer some of these questions.
Menopause: Commonly Asked Questions
What is menopause?
Menopause is the cessation of menstruation. It is formally defined as one year from the date of a woman's last menstrual cycle. In the United States, the average age of menopause is 51, however, this can occur earlier or later. Cigarette smokers may undergo menopause a little earlier. Eight percent of women will go through menopause before age 40. For example, individuals who have received some types of chemotherapy or who have had their ovaries surgically removed no longer make the hormones necessary for menstruation. Some women have a medical condition called premature ovarian failure which also causes early menopause. The average woman will live more than one-third of her life past menopause.
What is perimenopause?
Perimenopause is the time period from when a woman's menses first become irregular until one year after menopause. This transition can take many years. During the perimenopause, many women experience some of the menopause symptoms.
Why does menopause occur?
A woman's ovaries produce estrogen. As a woman's eggs decrease in number over time, there is a decline in the amount of estrogen secreted. This loss of eggs and decline in estrogen levels causes menstruation to become infrequent and ultimately to stop. It also causes an increase in follicle stimulating hormone (FSH), which is an attempt by the body to get the ovaries to produce more eggs and hence more estrogen. Sometimes a blood test to check the FSH level will be performed to verify that menopause has occurred. FSH is elevated (greater than 30 IU/ml) after menopause while the estradiol (estrogen) level is low.
What are the symptoms of menopause? What can I do?
Many menopause symptoms can be linked to lowered estrogen levels.
Hot flashes: Hot flashes are sudden periods of sweating, flushing, and feeling overheated. Hot flashes can be followed by a period of being cold and clammy. When they occur at night, hot flashes can interfere with an individual's sleep, which can then cause fatigue, cognitive impairment, and mood disturbances. Wearing cotton clothing and layering clothing can help. Cool showers or baths, fans, and air conditioners can also provide relief. If your menopause symptoms are severe and disabling, discuss with your doctor medications that can relieve hot flashes.
- Vaginal dryness: Lowered levels of estrogen causes dryness and thinness of the vaginal wall. These vaginal changes can sometimes cause itchiness, burning, and pain with intercourse. This vaginal dryness and the change in the acidity of the vaginal environment can predispose women to urinary tract infections. Vaginal moisturizers, (such as Replens¨), or estrogen vaginal cream or rings will restore vaginal elasticity and moisture after one to three months. Intercourse may be aided by lubricants.
- Urinary tract infections: The lining of the urethra, or the bladder outlet, also thins during menopause. This can predispose women to urinary tract infections and may also contribute to urinary incontinence.
- Cognitive impairment: Many women complain of decreased memory and slowed thought processes during menopause. Most experts believe that interruption of sleep by hot flashes is the cause of decreased memory in menopausal women.
- Depression and mood disturbances: Many women experience mood changes and symptoms of depression during menopause. Whether these symptoms are a result of decreased estrogen levels, sleep deprivation, the many life changes that occur around menopause or a combination of these factors is unclear. Women who are experiencing depression should discuss their symptoms with their doctor. There are many beneficial treatments available.
Associated Medical Conditions with Menopause
In addition to menopause symptoms, other medical conditions may be accelerated after the cessation of menses.
Osteoporosis is a "bone thinning" disease. This thinning can result in brittle bones that are susceptible to fracture. We all reach our peak bone mass around age 30. From that time, our bones start getting thinner. Estrogen helps to maintain bone strength. During menopause, when the estrogen level starts to drop, the bone loss can increase. Calcium, Vitamin D, exercise, and medical therapy can all help slow bone loss.
How can I prevent or slow down osteoporosis?
- Lifestyle: Ensure adequate calcium intake. Menopausal women should consume 1200 mg of calcium daily. They should also consume between 400-800 IU of vitamin D daily. Smoking and excessive alcohol intake can hasten bone loss and should be avoided. Weight-bearing exercise such as walking, running, aerobics, or kickboxing can also help prevent bone loss. Unfortunately, swimming and bicycling, while providing a good cardiovascular workout, do not prevent bone loss.
- Medications: FDA-approved medications for the prevention of osteoporosis include estrogens (e.g. Estrace¨, Premarin¨), alendronate (Fosamax¨) and raloxifene (Evista¨). FDA-approved medications for the treatment of osteoporosis include alendronate (Fosamax¨), risedronate (Actonel¨), calcitonin (Miacalcin¨) and raloxifene (Evista¨).
II. Cardiovascular Risk
Heart disease risk rises after menopause. Menopause eliminates the earlier "female advantage" for the heart.
In the past, observational studies suggested that long-term hormonal replacement therapy (HRT) may reduce coronary artery disease by 40-50%. These studies take a group of people and follow them over time and compare women who choose to take hormone replacement therapy with women who do not. The problem with these types of studies is that women who choose to take hormone replacement therapy may also be making other lifestyle decisions to reduce their risk of heart disease.
More recently, however, results of randomized controlled trials, in which women are divided into two groups, one group taking HRT and the other inert pills, have shown no cardiovascular benefit to taking HRT. The Heart and Estrogen/progestin Replacement Study (HERS) trial, in which postmenopausal women who had heart disease were studied, demonstrated an increased risk of heart attacks in the first year in women who took HRT, and no overall significant benefit of HRT after four years.
More recently, the Women's Health Initiative, a large trial of over 16,000 healthy postmenopausal women who were followed for an average of 5.2 years, was stopped prematurely because of a slight increase in cases of breast cancer among the women taking combined estrogen-progestin HRT (Prempro¨). In addition, the women who took HRT were found to have slight increases in the risks of heart attacks, stroke, and pulmonary emboli (blood clots in the lungs). As a result of these studies, HRT is no longer prescribed for the sole purpose of reducing the risk of heart disease.
Fortunately, there are many other measures you can take to reduce your cardiovascular risk. By maintaining a healthy body weight, avoiding cigarette smoking and excessive alcohol intake, getting adequate exercise, and treating diabetes, hypertension or elevated blood cholesterol, you can significantly reduce your risk of heart disease. You should
discuss your individual cardiovascular risk factors with your physician and determine what you can do to reduce you risk.
Some observational data suggest that hormone replacement therapy (HRT) reduces the risk for Alzheimers disease, colorectal cancer, total mortality, and skin wrinkling. However, these need to be confirmed by careful clinical trials.
What about hormone replacement therapy?
Because of the results of the Women's Health Initiative trial described on the previous page, at this time combined estrogen-progestin HRT is not recommended for long-term use because of the slightly increased risks of breast cancer, heart attacks, strokes, and blood clots. However, shorter-term use (less than five years) for the purpose of treating hot flashes is still acceptable. Although, longer-term use prevents osteoporosis, there are many other medications now available for the treatment of osteoporosis that do not carry the risks of hormone use, and therefore are preferred treatments.
What are the downsides of hormone replacement therapy?
Estrogens can increase the risk for blood clots (e.g. deep vein thrombosis and pulmonary emboli) and the risk for gallstones. Studies have shown that estrogen alone given to women with a uterus can increase the risk of uterine hyperplasia and cancer. Progestins protect the uterus but some may counteract the beneficial effects of estrogen on cholesterol.
Many observational studies have suggested that there is an association between estrogen use and breast cancer, and that the risk of breast cancer increases with longer-term use (greater than five years). These findings were confirmed in the Women's Health Initiative, which demonstrated that in an average follow-up time of about five years, there was a slight increase in the risk of breast cancer in the women who took combined estrogen-progestin HRT (Prempro¨).
What are the different hormone replacement therapy regimens?
Women with an intact uterus should receive estrogen in conjunction with a progestin to avoid the risk of endometrial hyperplasia. Women without a uterus (following a hysterectomy) do not need added progesterone. In the cyclical regimen, estrogen is given daily by either by pill or by a skin patch and a progestin is added for days 1-14 of each month. This method causes cyclic bleeding usually at the end of the progestin administration. This method is generally used in women who are recently postmenopausal. In the continuous method, women are given estrogen and low-dose progestin daily. This method can be associated with unpredictable bleeding for the first nine months. If heavy bleeding occurs, an endometrial biopsy or vaginal ultrasound may be done to evaluate the bleeding. In most women, within a year the endometrium, or uterine lining, will become atrophic and bleeding will no longer occur. There are many different types of estrogens and progestins available. You and your provider can discuss what regimen is the most appropriate for you.
How do I make a decision regarding hormone replacement therapy?
For the short term, estrogen use is effective for the treatment of menopausal symptoms and is probably safe. There is no magic formula for deciding whether or not to take hormone replacement therapy. Assessing one's personal risk is helpful. Women who have unexplained vaginal bleeding, active or chronic liver disease, a history of breast cancer or premalignant breast lesion, a history of advanced endometrial cancer, or a history of deep vein thrombosis or pulmonary embolus should probably avoid hormone replacement therapy. There are other medical conditions that may be relative contraindications to HRT. Your health history should be carefully discussed with your provider prior to starting hormone replacement therapy.
What are the side effects of hormone replacement therapy?
The most common side effects of estrogen therapy are nausea, headaches, breast tenderness, and vaginal bleeding. If these persist, the dose of estrogen may be lowered or hormone replacement therapy can be discontinued. Side effects seen with progestins are breast tenderness, weight gain, edema, PMS-like symptoms, depression, and irritability. If these occur, changing the frequency of withdrawal bleeding from monthly to every other or every third month might be more acceptable to the patient. However, it is not clear as to whether progestin therapy every other month is as protective against endometrial hyperplasia.
Are there alternative estrogens?
Medications called selective estrogen receptor modulators (SERMs) have been developed recently. Raloxifene (Evista¨) is a SERM. The usual dose is 60 mg a day. In the Multiple Outcomes of Raloxifene Evaluation (MORE) trial women who took Raloxifene showed a 30-50% reduction in vertebral fractures and a 76% reduction in breast cancer. Since there were only a small number of breast cancer cases among the study participants, the effects of raloxifene on breast cancer risk reduction is currently being studied in an on-going trial.
Other benefits of raloxifene include an increase in bone density, reduction of spine fractures, and improvements in total and LDL, or "bad", cholesterol. Disadvantages include a three-fold increased risk of clots (just as with estrogen), a possible increase in hot flashes, and no effect on hip fracture risk reduction. Moreover, unlike estrogen, raloxifene fails to increase HDL, or "good", cholesterol.
What about non-hormonal treatments?
Loose clothing and environmental temperature control can help hot flashes. Vaginal dryness can be treated with a moisturizer, or with topical vaginal estrogens, which have little or no absorption into the system and are safe. Increased physical activity can also decrease hot flashes.
Some women find that dietary soy, a source of natural estrogens, decreases hot flashes. Phytoestrogens are plant-derived. Isoflavones are potent in estrogenic activity, but also have anti-estrogenic effects. These are present in soy, chickpeas, red clover, lentils, and beans.
Population-based data suggest lower rates of menopausal symptoms, heart disease, and breast and other cancers in populations that consume more phytoestrogens, but other factors have not been sorted out. Limited clinical data suggest that there is a reduction in hot flashes and bone loss as well as improvements in cholesterol levels and blood pressure. More data are needed before a final recommendation can be made on the use of phytoestrogens.
Supplements advertised as "female herbal remedies" vary widely and have not been regulated by the FDA. There are little data on either effectiveness or safety.
Hot flashes may also be alleviated by certain antidepressants, such as those in the class of drugs called selective serotonin reuptake inhibitors (SSRIs) including medications such as Prozac¨, Zoloft¨, and Celexa¨ or selective serotonin noradrenergic reuptake inhibitors (SNRIs) such as Effexor¨. Some women use soy supplements and herbal remedies such as black cohash to relieve hot flashes, but there is very little research to indicate whether these supplements are effective or safe.
Cardiovascular risk can be reduced by lifestyle changes, such as modifying your diet, getting regular exercise, avoiding smoking and excessive alcohol intake, and treatment of high blood pressure and elevated cholesterol.
Osteoporosis may be prevented by performing weight-bearing exercise at least three times per week, making sure that you are getting adequate calcium and vitamin D, and avoiding smoking and excessive alcohol. There are also several drugs available that have been shown to prevent and treat osteoporosis.
For More Information
Additional health information is available at www.brighamandwomens.org. If you need a physician or another hospital service, our Physician Referral Line at 1-800-BWH-9999, is available to help you Monday through Friday, 8 a.m. to 5 p.m.