Historical Perspective: A Brief History Of Time...and Menopause
Just a few generations ago, most women fell into one of three categories:
2) Breast-feeding, or
So dismal was the life expectancy for both men and women, that it's amazing how we take for granted how long we may all live. Just a couple of hundred of years ago, women had the extra lethal curse of problems related to child-bearing. So it is actually a new phenomenon that so many women are leading half their lives past the menopause. Should there be hormonal support for them?
Just because a woman doesn't make her own hormones anymore is no reason why she shouldn't get them from pills, patches, or creams. Certainly cataracts due to age are replaced with lenses for the well-being of the patient. What's the difference? And now we hear new catch phrases--that menopause is a right of passage and shouldn't be looked at as a disease or as an estrogen deficiency.
While not a disease, it certainly is the absence of what is supposed to be there. Not believing a post-menopausal woman should replace hormones is a prejudice from earlier days when it was considered unnatural. Although the source of the hormone is artificial, a woman having her hormones is as natural in later years as before the menopause. We must remember that the human body was never expected to live past the age of forty.
A hundred thousand years ago, if we were lucky to make it past stillbirth, infant death, childhood diseases, accidents, or hostility, we were usually shoved out of the cave before middle age anyway. Strokes, coronary artery disease, geriatric diabetes, broken hips, and heart attacks were never meant to be seen, because middle age was seldom seen.
But we did eventually crawl out of our age limits thanks to our brains. We did it by brushing our teeth so they wouldn't rot and we could continue to eat. We did it by discovering antibiotics so we could nip disease in the bud. We did it by living under civilized codes of behavior that lessened the chance of accident and hostile acts. We progressed. We developed massive food availability and industrial technology. We now comfortably pass age barriers that in the past walked us through the valley of the shadow of death. If hormones were good enough for the age a woman was meant to live, it should be equally good enough for these extra years our advances have bought us.
Men got along just fine with the extension of the life expectancy. But women were less than they were because hormones were felt to be dangerous. Or their doctors "didn't believe in them." Or they weren't given correctly, leading to pre-cancerous complications. But today, hormones are seen as unquestionably beneficial. They reduce the bad cholesterol and increase the good, preventing heart disease.They aid in the procurement and retention of calcium, another necessary ingredient for strong bones. Both the estrogen and calcium will hinder osteoporosis which can thwart a nasty hip fracture later on (usually a death sentence in itself) and prevent vertebral fractures. They also reduce or eliminate hot flashes, mood swings, menopausal headaches, and the vaginitis due to thinning of the vaginal tissues. Bladder support can be re-established with good hormonal nutrition, helping incontinence. Lubrication is improved for a continued healthy sex life in marriage past the menopause.
Unfortunately, there are some who shouldn't take hormones. Cancer patients, people with circulatory disorders like thrombophlebitis, and some women with fibrocystic breasts will not be candidates. But most other women should. Whether a woman's had a hysterectomy or not, a dosage regimen can be devised for her that will work safely and effectively. Whether a woman isn't quite at the menopause and needs some supplementation, or she's past it and needs full replacement, estrogen replacement therapy is not just a good idea, it is the standard of care! Sometimes it takes some tweaking to get it right, but it is acclaimed by the American College of Obstetricians and Gynecologists to be well worth it. As former president of the College, Dr. Luella Klein, a woman herself, once said, "Feminine forever!"
I think this says it all.
What Is Perimenopause?
In the United States, the average age of menopause is about 51. Many women experience this change before or after this age, and it would be simple if this were like a light bulb going out, signaling the end of estrogen production. It can be confusing, however, that the change is often a gradual decrease in hormone support. A woman may still be experiencing periods, but also hot flashes, mood swings, depression, and headaches. Although a woman may have enough hormone to cause a cyclic sloughing of the lining of her womb each month (the period), the decreasing levels may not be what her body has been used to all those years to keep away the other symptoms of menopause. Presenting with these symptoms, it's usually the continuing periods that prevents her from getting the help she needs, because the periods give the mistaken impression that she still has the hormones keeping business as usual.
Menopause is defined as not having had a period for one year. By that time, the clinical blood test, the FSH level, becomes permanently elevated which establishes the diagnosis. Some doctors take this to mean that menopause should not be treated until then. But the startling thing is that the APPROACH to menopause may take as long as ten to fifteen years before the periods stop. This approach has been termed "perimenopause."
Should a woman be denied treatment for symptoms of menopause ten years before her periods stop? Unfortunately, misunderstanding has caused many physicians to prescribe antidepressants or "nerve pills" during this time, instead of giving these women what they really need--hormones. True, on-going periods mean that a physician has to take just a little extra time to listen carefully to the patient, but isn't that what we're supposed to be doing anyway? Listening is the stethoscope for subjective symptoms. And if a woman has symptoms of menopause but is still menstruating, then her gynecologist has two choices--do nothing, or cheat by giving her hormones anyway.
I'm that cheating type of doctor.
If the woman is truly perimenopausal (that is, premenopausal but with menopausal symptoms), then if she doesn't smoke she usually can be placed safely on low-dose birth control pills until she is officially menopausal. At that time, post-menopausal estrogen replacement therapy can be initiated. Even though birth control pills will mask when that change occurs, blood tests can be utilized to tell when that conversion should take place. Even though a woman may not need birth control, it's no secret that the pill has many more benefits besides preventing ovulation. It turns out to be a perfect way to strengthen a woman's hormonal support during the perimenopause.
Since having established this web-site on the Internet, many visitors from the "Women's Wire" on CompuServe have taken advantage of its information. Of the thousands of subjects relevant to the fields of obstetrics and gynecology, two stand out as overwhelming concerns of the women with computers who frequent the site: infertility and perimenopause. Infertility is a passion all its own to those who want a baby. But perimenopause is a term considered by these women to be a cop-out. It's as if they interpret it to mean, "You're miserable, but technically you're not menopausal, so live with it." Perhaps this is because their doctors have told them that exact thing. But perimenopause is something that hormones definitely improve. And besides the symptoms, there are the other things to worry about, like the decline in estrogen being enough to contribute to osteoporosis and heart disease, both conditions prevented by estrogen replacement. Osteoporosis begins as early as age 35, so waiting until age 50 will give a 15-year head start for bone brittling.
In my practice, we cheat evolution by giving hormones to perimenopausal women, because evolution has cheated women by turning some things off before they're quite ready to stop living a youthful life.
Evista, the First Designer Estrogen
As the SERM turns...
Finally, "SERMs" are here. SERM is an acronym that stands for Selective Estrogen Receptor Modulator. Well, that was easy, wasn't it?
Rewind to the beginning, and it's clear that SERMs have been eagerly anticipated by gynecologists for a long time. The history of estrogen replacement began when someone finally realized that we weren't supposed to last beyond an age when menopause would occur. And it was reasoned that if women were designed the way they were, experiencing the benefits of hormones before menopause, then they should also have the benefits of hormones after the menopause.
Of the two main female hormones, everyone knew what estrogen did, but doctors were still a little fuzzy on all that progesterone did. So the estrogen was handed out, and the hot flashes stopped, the emotional upsets became less frequent, and bladder control improved. Then we began to see uterine cancer caused by and breast cancer accelerated by the estrogen that was prescribed. Suddenly it became obvious how important progesterone was.
Before the menopause, estrogen heaps up tissue in the lining of the womb (uterus), and then after ovulation progesterone matures this tissue. Handing out only estrogen after menopause causes tissue to heap up further and further, but it won't mature. One of the things that makes cancer, well, cancer, is that it is a mass of disorganized, immature cells that only occupies space, grows on nutrients competitively at the expense of the body, and thereby kills you. Progesterone, it was discovered, must be given when estrogen is administered, or a patient is at risk for developing pre-cancerous tissue in the uterus.
O.K., so the combination of estrogen plus progesterone became the standard, which adequately addressed this issue. But the plot thickened. Just as progesterone counteracts the harmful effects of estrogen, so too it acts as an anti-estrogen to some degree in fighting hot flashes, mood swings, and vaginitis. This meant that stronger doses of estrogen were needed to eliminate these symptoms when the mandatory progesterone was prescribed with it. This in turn would counteract the stabilizing effects of the progesterone, and vaginal bleeding would result. In other words, menopausal women would begin having their periods again.
Was this popular? (A rhetorical question.)
To decrease or eliminate cyclic bleeding, tricky protocols were used. Giving the hormones daily, without a break, seemed promising, but breast tenderness and eventual "break-through" bleeding were common. Briefer cycling based on five-days-on, two-days-off, was largely successful, but there were still those whose bodies wouldn't meet the gynecologist halfway on this. Even when a successful regimen was finally discovered, there was no guarantee that it would be successful forever, for the pills stay the same, but the woman changes over time. What might be the right combination of dose and timing now may not be a year later.
Suddenly, surgeons began telling the gynecologists to stop prescribing estrogen for their breast cancer patients, because some breast tumors had estrogen receptor sites that when filled enhanced tumor growth or promoted recurrence. But internists and orthopedic surgeons wanted their female patients to have the estrogen because it was proven that it prevents osteoporosis, which leads to broken hips in the elderly. And cardiologists wanted estrogen prescribed as well, because it was found to improve the cholesterol condition which would then lower heart disease in women. Being as women most often saw their gynecologists for routine wellness, the OB-GYN doctor became the clearing house for all the shouting.
In spite of all the confusion, the answers were actually quite simple:
Women should take estrogen and progesterone forever, and if there were bleeding that couldn't be manipulated away, then they either stopped the hormones and their benefits, or they had hysterectomies, or they suffered the inconvenience of something they thought they were finally finished with (periods). And if they had breast or other cancer or blood clot problems, they were out of luck with preventing osteoporosis and heart disease, as well as the menopausal symptoms of emotional swings, depression, headaches, and hot flashes.
Meanwhile, breast cancer patients began taking tamoxifen, a drug which was found to fill estrogen receptor sites with "blanks," acting as an anti-estrogen as far as enhancing tumor growth. But it was also found that because estrogen sites were filled at all, albeit faultily, that tamoxifen acted as a weak estrogen in other respects. So the first selective estrogen receptor modulator (SERM) became the glint in the eyes of pharmaceutical researchers.
If the receptors could be filled selectively (the receptor-filling modulated), then perhaps the benefits could be selected for, but the harms selected away. Cardiologists and internists wanted heart disease protection, orthopedic surgeons wanted stronger hips, gynecologist wanted relief from the nuisances of menopause, and urologist wanted better bladder control.
But no one wanted cancer.
The first drug out of the gate is Evista (Raloxifene). It won't be the last, because the wish list of the doctors hasn't been filled completely, but it's a good start. This drug does not affect the uterus, so progesterone is not necessary to prevent cancer there. It does not affect the breast, so breast tenderness, a common side effect of hormonal therapy, doesn't occur. But it does address osteoporosis and heart disease. Perhaps not as well as big-gun estrogen, but satisfactorily for those who cannot normally take estrogen. It's also an excellent choice for those women who can't seem to beat the bleeding problem no matter how many combined regimens of estrogen and progesterone are used. Unfortunately, it won't help hot flashes and other symptoms of menopause, so being a good candidate for Raloxifene is limited to those who cruise through menopause without the symptoms.
The bottom line here is that if you're menopausal, you should protect yourself from osteoporosis and heart disease with estrogen. If you've had a hysterectomy, then progesterone isn't crucial, but it is if you still have your uterus. If you have periods once again and this is inconvenient for you, Raloxifene is a good choice (assuming hot flashes, etc., don't bother you). Also, if you have breast tenderness with conventional estrogen, Raloxifene should be considered. But if you have blood clot problems (thrombophlebitis, etc.), you're still out of luck. Well, for now.
As a precaution, let's all remember the Redux debacle. Raloxifene is a new formulation, and the tests that are touted only include about three years of data, so there's still the specter of the ill effects of the pharmaceutical learning curve. Meanwhile the race is on for the magic bullet that will treat menopausal symptoms as well as protect women from osteoporosis and heart disease, but not affect the uterus or breast. Until the perfect SERM is found, we still have to weigh all of the trade-offs. But this is a big step forward, and it will include a select group of women who couldn't take estrogen replacement before.
Well, that was easy, wasn't it?
Menopause: A New Beginning
Menopause by definition is "the permanent cessation of menstrual function following a decline of ovarian estrogen production".
This event occurs in all women regardless of race, socioeconomic background, or religion. Unfortunately women fear "the change" as the signal of the end of a way of life, but menopause should more appropriately be seen as the beginning of a new phase in life rather than an ending. A simple understanding of certain key points can make this natural transition much less disheartening.
"The change" on the average occurs in women between 48 and 55 years old. In the United States there are greater than fifty million women older than 50, and these individuals will be expected to live another thirty years, representing a full one-third of the average woman's life spent after menopause. Thus, postmenopausal women are becoming a larger and larger segment of society seeking health care today. Perimenopause, or "the climacteric," begins in the early 40's, extends though menopause, and lasts on the average four to five years. During this period nearly all women become symptomatic to some extent. Symptoms associated with this event are secondary to decreasing hormone production, mainly estrogen, and can be manifested in many ways.
The two most common symptoms reported by women experiencing the climacteric are "hot flashes" and changes in the menstrual cycle. Vasomotor flushing ("hot flashes") can last from less than a second to several minutes, and can recur at intervals ranging from occasional to more than one an hour. The symptom's cause is not certain but is believed to be a response of the brain to a decreasing estrogen stimulation. These can occur during the day but are more frequent at night, often awaking one from sleep. This interruption of sleep patterns may be responsible for fatigue, irritability, and depression often reported by women during the climacteric.
Changes in the menstrual cycle begin in the early forties and are also secondary to waning estrogen stimulation which can cause either an increase or a decrease in cycle length or flow (either can be possible). Menopause is actually defined as a six month to one year period with no menses at all. Decreased libido and sexual enjoyment are also reported by many. Estrogen is responsible for maintaining all female tissues and its withdrawal results in a feeling of dryness and burning during intercourse and on occasion can even cause spotting after intercourse. Testosterone, usually thought of as a "male" hormone, is also present in women, and it's decline can also affect sex drive.
Although certainly not an ending, menopause begins a later phase in a woman's life where certain medical conditions are more prevalent. Screening and frequent physician follow-up become important factors in living a long, healthy life. All women approaching menopause should visit their physician. A thorough history and physical exam can reveal potential familial tendencies towards certain illnesses as well as examine current problems. Screening at this time can help diagnose problems more frequent in women in this population.
Hypothyroidism (under-functioning thyroid) has a much higher incidence in women over 65, and symptomatic women with a strong family history should be tested. If diagnosed this condition is easily treated with medications. It can often be associated with--or even a cause of--depression and obesity. Diabetes also has an increasing incidence with aging, and individuals with a positive family background, obese women (> 20% over ideal body weight) and women with a history of pregnancy-related diabetes should be tested with a fasting blood sugar every 3 to 5 years. Once diagnosed, treatment might be achieved with simple nutritional counseling for very mild cases, but some may require medication and further evaluation. With proper treatment a healthy, productive life is easily achieved.
Hypertension is the most common chronic disease in older women and carries with it an increased risk of stroke, congestive heart disease, and renal disease if not treated. Those at increased risk include smokers, individuals with increased cholesterol, obese women, and those with insulin-dependent diabetes. Most cases are mild but may become more severe and if left untreated may damage the kidneys, heart, and other organs which can escalate into more severe medical problems in the future. Those diagnosed will require further testing, and medication and lifestyle changes can greatly reduce the medical complications associated with hypertension.
Osteoporosis is a condition unfortunately common in postmenopausal women. Calcium and mineral deposition in bone are somewhat dependent on estrogen, and with it's withdrawal at menopause bones become weaker and more prone to fracture, particularly in the vertebral area. 75% of bone loss in women occurs in the first 20 postmenopausal years, and a woman not receiving estrogen replacement can expect to lose an average of 2.5 inches in height. Hormone replacement therapy, weight bearing exercise on a regular basis, and calcium supplementation are important in the maintenance of healthy bones.
Breast cancer is the disease most feared by women, being 32% of all cancers in women and the second leading cause of death in women today. For this reason screening mammography is offered to women in this age group. The American College of Obstetricians and Gynecologists recommends a mammogram every 2 years in the 40 - 49 age group, followed by every year after 50. Breast self-examination is equally as important and all physicians should instruct their patients on proper technique.
As important as screening for afflictions that are more prevalent in an older age group is instituting lifestyle changes that can decrease the risk of their development. Smoking is associated with heart disease, lung disease, multiple cancers, as well as other chronic diseases, including, or all things, cervical cancer. Smoking can even cause an earlier onset of menopause. Stopping this nasty habit can reduce the risk of developing these diseases, and at least one study has shown that cessation at any age or duration will improve the health of the lungs, regardless of the length of smoking (so it's never too late).
Exercise programs should be instituted which improve lipid profiles which in turn can decrease the risk of coronary heart disease and also help with weight control. All able women should participate in vigorous exercise for at least 20 minutes, three times a week. If this is not weight-bearing exercise then strength training should be added twice a week. A workout program need not be extreme to accomplish its goal. Walking 1.5 miles 3-4 times a week and performing ordinary calisthenics can give the body a great workout and provide enough weight bearing exercise to strengthen bones.
Lifestyle changes should also include weight and diet control. Evidence indicate that a good diet can decrease both the risk and severity of heart disease, diabetes mellitis, and hypertension, as well as other chronic diseases. A proper diet may even decrease the risk of developing certain cancers. Consulting with a nutrition professional may be helpful. Dietary supplements and vitamins, especially calcium, become important int the menopausal and postmenopausal age group to maintain healthy bones and bodies.
As mentioned earlier, many of the symptoms associated with menopause as well as some of the increased disease risks are secondary to the disappearance of estrogen. Estrogen supplementation can decrease or remove most symptoms as well as protect individuals from bone loss, heart disease, and protect the female tissues from thinning. Some controversy exists over the long term effects of hormone replacement, but with proper screening and maintenance by a physician, hormone replacement can provide a healthier future for most women.
In summary, menopause signals only the end of the reproductive years. Preventive care, lifestyle changes, and early diagnosis and intervention play a vital role in maintaining a postmenopausal woman's overall health and quality of life. Although menopause does represent an advance in years, it should also represent the beginning of a new, productive, exciting phase of life full of new career choices, education, and new adventures. Embrace it!