Recently I hosted an evening discussion for Personalized Primary Care Atlanta members on
the topic of menopause. Here is a summary of our discussion:
·
Menopause is defined by no menstrual cycle for
one year.
·
The average age of menopause in the US is 51.
·
90% if American women experience menopause
between ages 45 and 55.
·
Prior to menopause women go through a period of
transition, often referred to as perimenopause.
·
During this time of transition women may begin
by having irregular menstrual cycles with changes in cycle length and periods
of heavier or lighter flow.
·
Later in transition women may skip one or more
menstrual cycles and may begin to have symptoms related to menopause.
·
Irregular menses relate to anovulatory cycles
and low levels of progesterone
·
For several years prior to menopause women may
have higher than normal estradiol levels and lower than normal progesterone
levels. FSH levels may also be high.
·
Following menopause FSH levels are high and estrogen
and progesterone levels are low, however menopause is not defined by hormonal
levels, and because of individual differences in hormone levels and also normal
fluctuations in levels throughout the cycle, hormone levels can be difficult to
use as parameters of change.
Common symptoms of menopause are related to a decline in
estrogen levels. For most women symptoms last several years. However, in some, symptoms may continue for up
to 10 years. About 10% of women in their sixties continue to have hot flashes.
Menopause Symptoms:
·
Hot flashes (last 2-4 minutes, affect the upper
body and face, occur frequently at night)
·
Insomnia (may be a manifestation of temperature
regulation trouble—hot flashes)
·
Heart Palpitations
·
Forgetfulness
·
Changes in sex drive
·
Irritability
·
Vaginal dryness
·
Trouble with control of urination
·
Changes in body composition—reduced muscle mass
Menopause Risks:
Menopause increases the risk of osteoporosis. Women lose
bone density quickly during the first five years following menopause. Menopause is also associated with an increased
risk of cardiovascular disease. Women develop more insulin resistance, lower
HDL levels and higher LDL cholesterol.
Managing Menopause Symptoms:
Approaches to managing menopausal symptoms include hormonal
therapies, off -label use of non-hormonal therapies, and natural remedies.
Hormone Replacement
Therapy
·
Hormone replacement therapy is no longer
recommended for menopausal women for the purpose of prevention.
·
Hormone replacement therapy has been extensively
studied in the form of conjugated equine estrogen in a dose of 0.625 mg and medroxyprogesterone
at a dose of 2.5 mg in postmenopausal women with an average age of 63 in the Women’s Health Initiative
trial. This trial involved approximately
161,000 women and reported on a number of outcomes. The Estrogen and Progesterone arm of the
trial was terminated in 2002 and found that women using the two hormones had a
higher risk of blood clots, heart attacks, strokes, and breast cancer. The same women had a lower risk of colon
cancer and bone fracture.
·
Women in the Estrogen alone part of the study
had higher risk of strokes and blood clots, but not breast cancer and heart
attacks.
·
Three years following discontinuation of the
study women treated with Estrogen and Progesterone continued to have a higher
risk of cancer, including lung cancer.
·
A subgroup analysis of the study found that most
of the risk conferred by hormone replacement therapy was related to the age of
the treated women. Women treated from the time of menopause forward for five
years did not experience significant increases in health risk.
·
For a sense of the magnitudes of health risk I
recommend looking at the handbook
Changes in Practice a
Decade Later
Hormone replacement remains the most effective treatment of
menopausal symptoms. However, not all women require hormone replacement to get
through menopause. Currently women’s health experts prefer to use the lowest
dose of hormones available to control symptoms. Today, oral estrogen is
available in one half the dosage that was studied in the Women’s Health
Initiative study. There are several
different types of estrogen and progesterone available on the market. All estrogens appear to carry a similar risk
of blood clot. However, it remains uncertain whether
different types of estrogens and progestins confer different health risks. In
the case of progestins, they do seem to vary more in their activity and side
effect profiles. The adverse effects of hormone replacement are speculated to
relate to dose. Current practice has shifted toward the use of transdermal estrogen
and progesterone through patches—also available in low dose. Transdermal estrogen
confers a lower risk of deep venous thrombosis, and it is thought by some that to
be safer with respect to other health outcomes.
Vaginal estrogen is an effective means to treat the urogenital symptoms
of menopause—vaginal dryness and urinary symptoms, and does not require
systemic progesterone to protect the uterus as do oral and transdermal
estrogen. It is felt that if use of
hormone replacement is limited to the first five years following the time of natural
menopause (around age 51), the cardiovascular risks may be lower. Tapering
hormonal therapy slowly after several years may produce fewer symptoms than stopping
cold turkey and can help facilitate the transition to menopause for some women. Some women may choose to live with the health
risks related to hormone replacement and may continue treatment for longer than
five years—reporting improved quality of life.
What are
“Bioidentical Hormones?”
Bioidentical hormones typically refers to custom compounds of
hormones that are also manufactured and marketed as pharmaceuticals. However,
bioidentical hormones are not tested and regulated. Given the range of hormone
replacement now available on the market with numerous dosing options, many women’s
health experts agree that it is safer to use products that have been more
thoroughly investigated and that are regulated in the U.S. through the FDA.
Non-hormonal options
for treating hot flashes are available as off-label use of prescription
medications and include:
·
Selective Serotonin Reuptake Inhibitors and
Selective Norepinephrine Reuptake Inhibitors: paroxetine (Paxil), venlafaxine
(Effexor), bupropion (Wellbutrin), fluoxetine (Prozac)
·
Gabapentin (a seizure drug)
·
Clonidine (a blood pressure drug)
Natural Products
·
Plant Based Estrogens (Phytoestrogens)
/Soy: Not FDA regulated, might work in
the body like a weak estrogen, might also have some health risk.
·
Black Cohosh : Also not regulated by FDA, lack
of conclusive evidence that it helps, but has a fairly good safety record
For more information I also recommend the:
