Menopause is a time of change in a woman’s life. Normal menstrual periods become irregular, heavy, light or absent. As the ovaries gradually stop working, fertility ends, and hormone levels can fluctuate. Although menopause usually occurs between ages 40 and 53 (virtually every woman has the menopause by 53), it can be premature (before age 40) or artificial (ovaries surgically removed). Most women go through the menopause within 5-10 years after a hysterectomy, even if the ovaries are left in.

After menopause begins, women start to suffer from medical problems that can be prevented and/or treated by hormones (heart disease, strokes, hot flashes, Alzheimer’s disease, depression, mental deterioration and possibly colon cancer). The degree of symptoms during the menopause is variable - ranging from severe to virtually symptom free. Menopausal symptoms can include: hot flushes, sweating, nervousness, fatigue, irritability, insomnia, numbness and tingling, urinary problems, and stomach pains - they can last a few months to a few years. In many women the vaginal tissues change (called "atrophic vaginitis") - symptoms include dryness, pain with urination or sexual intercourse, and itching.

An estimated 75% of women experience hot flushes during the menopausal period, and the problem continues for 5 years or more in 20% of these women. The estrogen dosage and brand necessary to control or reduce symptoms varies from person to person, requiring an individualized approach. Symptoms usually return if treatment is discontinued. Women generally feel better emotionally and physically when taking replacement hormones. While many approaches other than estrogen can help deal with menopausal symptoms, the most important reason for chronic estrogen replacement therapy ("ERT") is prevention of medical problems. Many medical authorities consider the low numbers of women taking estrogens to be a sign of failure by physicians to properly educate women.

Osteoporosis:

One out of four white women over 60 suffers from back or hip fractures. Tens of thousands of women suffer hip fractures each year - frequently dying of complications within 12 months. Wrist fractures are common. Spinal fractures (compression fractures) are extremely painful and difficulty to treat. Shrinking spines and poor posture (Dowager’s hump) cause pain, difficulty breathing, and abdominal pain. Osteoporosis of the spine can result in incredibly painful fractures from normal activities, including sneezing or coughing. Risk factors include lack of weight bearing exercise, genetics, calcium poor diet, high protein diet, cigarette smoking, old age, excess alcohol, thin body, hyperthyroidism, rheumatoid arthritis, chronic obstructive pulmonary disease (such as emphysema), diabetes, chronic liver disease, late onset of menstruation (menarche), irregular periods while young, early menopause (natural or surgical), and stopping of estrogen medication.

Bone loss is normal with aging, but it accelerates dramatically without estrogens. Weight bearing exercise, proper diet, estrogens, good posture and a healthy lifestyle seem to help. Taking calcium (1500-1800mg daily) helps - especially during the childhood and teen years. Vitamin D 400iu’s is now recommended. Cortisone pills and overtreated hypothyroidism worsen osteoporosis. Osteoporosis can be also be treated by the expensive and potentially dangerous drugs Fosamax, Didronel, and Calcitonin. The new medication Evista also reverses bone loss.

Heart attacks and strokes:

Prior to menopause, heart attacks are rare in women. After menopause the risk is the same as men. Estrogens affect the lipids (like cholesterol), and appear to reduce the risk of heart attacks and strokes by 30-50%. No other treatment comes close - including diet. A large part of the reason may be keeping the levels of "nitric oxide" normal in the artery walls which are necessary to keep these arteries open.

Other benefits:

In the 40-69 age group, untreated women have three times the death rate compared to women taking estrogens. Estrogens reduce the risk of Alzheimer’s disease. Depression, fatigue, thinning skin, dry vagina, slowed thinking and memory are usually improved with estrogen replacement.

Risks of taking hormones:

The biggest risk appears to be breast cancer. While not proven, some studies suggest a 10% increased risk of getting breast cancer, but not dying from it. Some studies suggest the risk of dying from breast cancer is lower in women who take estrogens. The absolute risk is still small, but highest in smokers. Hormones can act as "fertilizer" to cancers that are already there. Some studies are underway to evaluate the safety of hormones in women who have had breast cancer in the past - these women currently cannot take hormones. Side effects are relatively uncommon - the worst being sore breasts, which can often be prevented by taking lower doses for a few months first. Other side effects include fluid retention, enlargement of benign uterine fibroids, skin pigment changes, and a slight increased risk in gallstones and high blood pressure. Vaginal blood spotting can occur for a few months after dose changes.

Taking hormones (ERT):

Prior to taking hormones a mammogram, breast exam, pelvic exam, and pap smear are needed. Those without periods for 6 months (and with a uterus) must undergo a progesterone challenge test (or endometrial biopsy) prior to taking the hormones. The estrogen (usually Premarin) is taken daily. Those with a uterus need to take progesterone daily as well (the latest information shows no increase in heart attacks from progesterone), although alternative techniques are available. Unexplained bleeding must be investigated. The male hormone testosterone is sometimes needed to restore sexual interest. Annual mammograms and breast exams (and sometimes pap smears) are necessary. Blood tests to measure the estrogen "estradiol" are often needed. Approximately 15% of women don’t absorb Premarin well, and need to be switched to the synthetic "Estrace." Uterine cancer risk is increased when hormones are not taken properly. The use of plant estrogen like materials - especially from soy - is an interesting area of research and hope.

Summary:

There are risks in taking any medication. The need for medical follow-up and the potential side effects and breast cancer risk must be weighed against the enormous benefits. This is a serious problem, requiring serious treatment. Hormone replacement therapy is recommended for most women.

10/22/99