- Menopause is a normal life event that designates the end of a woman's fertility.
- Ovarian production of eggs and female hormones, as well as menstruation, decreases and eventually stops.The hormonal changes are often accompanied by characteristic symptoms, such as hot flushes, anxiety, poor memory, emotional instability and decreased sexual urge.
- The hormonal changes are often accompanied by characteristic symptoms, such as hot flushes, anxiety, poor memory, emotional instability and decreased sexual urge.
- Premenopause begins in the mid-40s and lasts until menopause, which occurs at an average age of about 51.
- Long-term health effects during the post-menopausal phase include increased risk of osteoporosis and heart disease.
- Treatment of symptoms may include positive lifestyle modification and prescription therapies such as hormone therapy. (HT)
- HT is the only treatment which will alleviate all symptoms of menopause.
- There is unfortunately little scientific evidence to promote the efficacy of black cohosh and other herbal remedies, and plant oestrogens (bio-equivalnet hormones).
Menopause is the beginning of a distinct life phase with its own particular health issues.
The term “menopause” means cessation of menstruation during the time of the climacteric. The climacteric is the transition period in a woman's life when the ovaries stop producing eggs regularly. Production of the female hormones oestrogen and progesterone declines, and menstruation decreases and eventually stops. Menopause is also sometimes called “change of life”.
The exact event of menopause (the permanent cessation of menstruation) can only be determined retrospectively after no menstrual periods have occurred for 12 consecutive months. The range for the age of natural menopause is approximately between 48 to 55 years old.
Diminishing oestrogen leves as a reslt of decreasing ovarian function cause menopausal symptoms. When you enter the menopause, your periods end because your ovaries no longer release eggs for fertilisation every month. As a result, production of the female hormone oestrogen stops. In normal circumstances, egg-cell production stops when the number of eggs a woman was born with has been exhausted, or their quality has deteriorated.
Some women go through perimenopause (the transitional period before entering menopause) and menopause (when your periods stop and you become permanently infertile) without suffering from any of the classic symptoms such as hot flushes, night sweats and mood swings. But if you don’t experience these symptoms it doesn’t mean you’re safe from the negative effect a lack of oestrogen has on your body.
Oestrogen is the hormone that helps protect against the external signs of ageing (such as dry skin) and also helps guard against the development of osteoporosis. It may or may not help protect against cardiovascular disease – this is a controversial issue. When going through menopause, it’s just a matter of time before many women will start experiencing the effect of decreased oestrogen levels.
To better understand the role of hormones such as oestrogen, progesterone and androgen in menopause, read the section on The role of hormones.
Natural versus induced
Natural menopause is a normal life event that designates the end of fertility, and may bring with it various physical and emotional changes.
Some women experience “induced” climacteric and menopause due to a medical intervention, for instance if there ovaries are removed before they enter their natural menopause. Induced menopause can also occur if the ovaries are damaged by radiation, chemotherapy or certain other drugs. In such cases, there is an abrupt hormonal decrease, usually resulting in sudden onset of menopause-related symptoms.
If you had induced menopause, early menopause (before age 40) or went for a prolonged time without menstrual periods (for example because of excessive exercising or dieting), you may be at a greater risk later in life for health problems such as heart disease and osteoporosis, since you spent a long time without the protective effect of oestrogen.
If you had a partial hysterectomy, where your uterus was removed but not your ovaries, you will usually continue to produce hormones and will therefore not experience early menopausal symptoms. However, sometimes a hysterectomy damages nerves and blood supply to the ovaries, resulting in some changes, which may worsen when the ovaries shut down further and natural menopause occurs.
Symptoms of perimenopause and menopause
During pre-/perimenopause there is a gradual decline in ovarian function and oestrogen production as the body begins to change in preparation for menopause. The decline and sudden absence of oestrogen has a huge impact on your body and emotions.
In the beginning hot flushes, night sweats (nocturnal hot flushes), sleep disturbances, mood swings and joint pains are the most common symptoms. Forgetfulness is quite common. These are followed by the thinning of the vaginal wall which can lead to vaginal dryness and result in sexual discomfort. Your skin and hair gradually thin and you have a greater chance of developing a belly. There is also a greater risk of heart disease and osteoporosis. Other symptoms include bladder incontinence and diminished libido.
Some women live through the whole menopausal period without suffering any of the classic symptoms, but they’re a small minority.
Hot flushes. One of the first things to become seriously mixed up is the temperature-control centre in your brain, and that’s the reason for hot flushes.
Experiencing hot flushes (also called flashes) is the feature that has made the menopause famous because it’s the most common symptom. 75- 80% of women suffer these feelings of intense heat over the trunk and face with an accompanying flushing of the skin.
A hot flush generally lasts less than five minutes, and the sweating that accompanies this “attack” usually starts a minute after the feeling of palpitations.
The frequency of flushing may range from one or two per day to one every 15-30 minutes. Flushing is more pronounced late in the day, in hot weather, after ingestion of hot foods or drinks, or during periods of stress and tension.
Hot flushes can begin during perimenopause before menstruation stops. Most women have hot flushes for more than a year while 25- 50% will suffer them for up to five years if they’re not treated. New studies indicate that hot flushes often last 10 – 12 years.
Night sweats. Hot flushes at night are called night sweats.
Sleep disturbances. Insomnia (sleeplessness) can be caused by hot flushes at night which may be accompanied by night sweats as a result of fluctuating hormone levels. Insomnia may already be experienced some years before menopause, and it is a problem mainly because it can cause daytime tiredness.
Erratic periods. Very few women simply suddenly stop menstruating. Before ovulation stops altogether, the menstrual cycle generally becomes more irregular in length.Changes in the flow may be experienced – blood flow may be heavier or lighter. This can start anything from two to eight years before menopause.
Finally, the intervals between menstruations become longer, with missed periods or episodes of spotting only. The irregularity may last two or three years before menstruation finally ceases. When no bleeding has occurred for one year, the menopausal transition is said to have occurred.
Bleeding after this time can be a sign of a serious underlying problem and should be seen to as soon as possible.
Problems to look out for:
Although it is completely normal to have irregular periods and a change in flow, one should see a doctor if any of the following symptoms are noticed, as they could signal other problems:
- Spotting between menstrual periods
- Periods that last more than seven days (or two days longer than usual)
- Very heavy or gushing flow
- Bleeding from the vagina during intercourse
Mood swings, forgetfulness and other psychological symptoms. Psychological symptoms such as moodiness, irritability, anxiety, depression, tearfulness, forgetfulness and difficulty in concentrating are often the focus of jokes about the menopause, but there is no objective evidence that cessation of ovarian function is associated with severe emotional disturbance or personality changes.
Mood swings can be a problem particularly for women with a history of premenstrual syndrome or post-natal depression. During the perimenopausal time span, some women notice worsening PMS or experience it for the first time. Menopause ends PMS.
The symptoms of menopause can precipitate an underlying psychological problem, but it cannot cause it.
Joint Pain. Many women suffer joint pain as one of their earliest symptoms. Often starting during perimenopause, it may suddenly become painful to get out of bed, walk upright to the bathroom or get dressed. Quite often the joints of the back, fingers, knees and ankles are afffected. The severity of the joint pain may decrease after a few months.
Vaginal dryness and sexual discomfort. Sexual discomfort due to vaginal dryness is a common symptom. Decreased oestrogen can lead to thinning of the epithelial lining and the underlying tissues of the vaginal wall may become thinner and less elastic , a condition known as atrophy. This causes decreased lubrication, which in turn may lead to substantial pain during and after intercourse. As painful intercourse is seldom a turn-on, it might lead to a decline in the desire for making love.
Vaginal dryness and thinning may continue after menopause. Some doctors estimate that at least half of all women over 60 have some degree of vaginal dryness. Vaginal changes may also increase the risk of infections due to reduced local protection against micro-organisms which may enter the vagina due to self-contamination or sexual intercourse.
Middle-age spread and weight gain. Oestrogen is responsible for the female pear-type fat distribution and a lack of oestrogen will cause the fat distribution to change to the male apple-type fat (the so-called middle-age spread) distribution. This type of fat distribution is associated with an increase in the risk for cardiovascular disease.
Appetite may decrease, but the stress associated with this period often leads to an increase in appetite. The associated weight gain doesn’t do the mood any good either.
Other gastro-intestinal symptoms associated with menopause include nausea, flatulence, constipation or diarrhoea.
Decreased libido. Beginning in perimenopause, some women may experience a gradual decline in sexual desire (libido). However, 60% of women experience no change in libido, 20% experience a decrease and in 20% of cases libido improves.
Although no correlation has been found between oestrogen levels and libido, it appears that testosterone may also affect libido.
Other factors which could lead to changes in sexual function include:
- Painful intercourse due to vaginal dryness (atrophy)
- A woman’s perception of her changing body
- Incontinence which could lead to sexual avoidance
- Sleep disturbances due to night sweats
- Depression, stress and anxiety
- Many medications, including some anti-depressants
- Reduced libido and impotence in the male sexual partner
Urinary incontinence (leaking bladder). Decreasing oestrogen levels can weaken the pelvic floor muscles controlling the bladder and urethra (tube through which urine is passed from the bladder).
The tissue of your urinary tract also becomes less elastic. These changes can lead to painful urination (called dysuria), urination at night (called nocturia) and the need to urinate urgently (called urge incontinence). Another symptom which may be associated with these changes is stress incontinence, which is involuntary urine leakage, occurring with coughing, laughing, sneezing, exercising or sudden exertion.
However, stress incontinence can have organic causes and is not alleviated by hormone therapy (HT). HT will only have a positive effect on symptoms stemming from bladder irritability. Other problems that may arise are frequent bladder and vaginal infections.
How menopause harms the body
Oestrogen is the hormone that protects you against osteoporosis, cardiovascular disease and the external signs of ageing. Without oestrogen, it’s just a matter of time before everyone will start experiencing conditions such as atherosclerosis, osteoporosis and decreased mental ability. Atherosclerosis and osteoporosis are both potentially lethal and dementia isn’t something anyone looks forward to.
It’s therefore clear that menopause is the warning you get before your quality of life starts diminishing. It’s therefore a good idea to ward off these threatening conditions before they become serious.
Effect on the skeletal bones
Osteoporosis can be a serious long-term health consequence of the menopause. Osteoporosis is a silent disease until a bone breaks.
Oestrogen deficiency accelerates the bone depletion that occurs during the normal ageing process. About 25% of women gradually experience bone fragility and fractures with declining oestrogen production. A decrease in bone mass may lead to curvature of the spine, vertebral compression fractures, height loss and pain. Bone loss in the femur bones occurs at a slower rate, and women who don’t take hormone therapy (HT) may not experience femur fractures until 70 -75 years.
Hip fractures are a common injury in women with osteoporosis at an advanced age. About 20% of white women at the age of 80 who don’t take HT may develop hip fractures and usually require a long recovery period. Up to a quarter of those who do recover need to enter a long-term care facility, while 15% with hip fractures in this age group will die within six months, either from the fracture itself or from complications.
It has been proven that oestrogen replacement can slow the development of osteoporosis.
Effect on the heart
After menopause the risk of a heart attack rises steadily. Generally, the incidence of heart attacks rises in both sexes with advancing age. But the rate of increase is greater in women older than 50 than in men. As a result, the ratio of heart attacks in women to men after 50 decreases to 2:1 by age 65 and 1:1 by age 80.
In addition, the first heart attack is more likely to be fatal for women than for men. Oestrogen decrease is thought to cause unfavourable changes in levels of cholesterol and other blood fats, as well as in fibrinogen, a substance that affects blood clotting. These changes may increase the risk of heart disease and stroke. Heart disease is a leading cause of death among women.
Effect on fat distribution, muscle mass and skin
As age advances and oestrogen levels decline, muscle mass decreases, body fat increases and skin collagen gradually becomes thinner and less elastic.
The increase in body weight and total body fat is associated with a shift of fat from the peripheral sites of the body to the abdomen. In certain women this causes a change in shape from the more gynaecoid (female-like) to the android (male-like) fat distribution, which is thought to carry an increased risk for the development of cardiovascular disease.
Breasts: The glandular tissue becomes less and is replaced by fat.
Skin: As oestrogen levels decline, skin collagen gradually becomes thinner and less elastic. This causes sags and wrinkles. The skin also becomes drier.
Hair: Oestrogen stimulates hair growth. When oestrogen levels fall, hair growth slows down and the hair becomes thinner and less manageable.
Teeth: Decreased levels of oestrogen can lead to dental problems such as tooth loss, gingival bleeding and inflammation and loosening of the teeth. Tooth loss could also be due to an underying bone disease such as osteoporosis.
Effect on the brain
Oestrogen has definite effects on the functioning of the brain. It affects the blood flow to the brain, growth and survival of nerve cells and the way in which impulses are transmitted along nerve cells.
Low levels of oestrogen have been linked to a decrease in mental abilities and alertness, such as in Alzheimer's disease.
Oestrogen replacement may decrease one’s risk of developing Alzheimer’s disease.
Effect on fertility
As the number of ova (eggs) in the ovaries is reduced and ovulation becomes irregular and the ability of perimenopausal women to conceive decreases. Pregnancy is still possible, however, and to avoid it, you should use contraception until you’ve had 12 period-free months.
When to see a doctor
All midlife women are urged to consult their family doctor or gynaecologist for routine check-ups and advice about these conditions, particularly if you have a personal or family history of heart disease and/or osteoporosis. It is important to call a health professional without delay if:
- You have prolonged irregular bleeding. This may be particularly important if you are overweight.
- You experience bleeding after not having had a period for six months or more; among other possibilities, it may be a sign of uterine cancer.
- Mood changes are causing problems. If depression is severe or persists for more than two weeks, consult your doctor.
Your doctor will review your medical history and perform a physical examination. If symptoms occur inappropriately or too early, the doctor will also do blood tests. These tests are not essential but can assist in diagnosis and management. If blood tests show an elevation in the follicle-stimulating hormone (FSH) and a drop in the hormone oestradiol, you have reached menopause.
However, menopause is generally diagnosed when you’ve not had a menstrual period for 12 consecutive months and no other biological or physiological cause can be identified.
All women who’ve reached menopause have less oestrogen available to their bodies than before menopause. But not all women who are menopausal need to have that oestrogen replaced. In fact only about one in four women really needs hormone therapy (HT) for relief of menopausal symptoms.
There is an argument that menopause is a physiological and normal event and should therefore not be treated as an illness, in other words with medication. While this is true, it is also worth considering that women now live for many years beyond the menopause and that these changes in life expectancy are relatively recent.
It has been established that there are risks associated with living for many years with low levels of oestrogen in the body. These risks most importantly affect the bones and the heart.
There are different types of intervention, depending on the individual symptoms and needs of each woman.
Menopause is not managed according to a formula. Each woman should be evaluated as an individual and will often have selective investigations to establish whether she is:
- Healthy with no problems
- Healthy, but with significant risk factors for osteoporosis and/or heart disease
- Medically compromised, for example has had a heart attack, stroke, breast cancer, diabetes etc.
With your doctor, you should determine your individual health status and risk factors for developing diseases in later years and goals to be achieved in health prevention. If therapy is needed, there are several options available:
- lifestyle modification and home treatment
- nonprescription remedies and
- prescription therapies, including hormone therapy.
Lifestyle modification and home treatment
In general, strive towards a healthy lifestyle, which includes stopping smoking, controlling weight and managing stress. Stress-reduction techniques such as massage and meditation may help reduce some symptoms.
Hot flushes: Keep your home and workplace cool; wear loose clothing in layers that are easily removed; drink plenty of water and juice. Avoid caffeine, alcohol and spicy foods if they bring on hot flushes; exercise regularly to help stabilise hormones and prevent insomnia and avoid confined spaces and hot, humid weather, if possible.
Vaginal dryness: Short-acting, water-based vaginal lubricants (such as K-Y Jelly) can be used immediately before sexual intercourse to supply moisture (avoid petroleum-based products such as Vaseline). It may also help to take a warm bath before intercourse. Regular sexual activity can help improve natural lubrication and keep the vagina moist and toned.
Mood changes: Discuss your symptoms with other women, or perhaps a therapist if symptoms are very problematic. Ask others for consideration and understanding during this period of transition.
Decreased sexual desire: identify and address theprimary cause should be identified and treated. It may be physical changes (such as vaginal dryness) or low self-perception and lifestyle stmaking sex uncomfortable.
Incontinence problems can often be improved by doing regular Kegel exercises (pelvic muscle-strengthening exercises). Contract the pelvic muscles as if trying to close the vaginal opening. Hold the contraction for a count of three then relax. Wait a few seconds and repeat. Fast Kegels (squeezing and relaxing muscles as quickly as possible) can also help. Performing several Kegels per day (try for 50) can improve bladder control and may enhance sexual pleasure.
A healthy diet is extremely important to help reduce the risk of osteoporosis and heart disease. Adopt a low-fat, high-fibre diet rich in fruits, vegetables and whole grains, and get adequate vitamin D and calcium for strengthening the bones. Eat calcium-rich foods (such as dairy products) or take a calcium supplement, so your daily intake is 1 000 milligrams per day before menopause and 1 500 milligrams per day after menopause. Eating foods high in plant oestrogens (phytoestrogens) may alleviate menopausal symptoms and lower cholesterol levels. Good sources include lima beans, soybeans and soy products (such as soy milk, roasted soy nuts, soy burgers and tofu), nuts, seeds, fennel, celery, parsley and flaxseed oil.
Regular exercise helps to keep weight down, improve sleep, strengthen bones and lift mood. Weight-bearing exercises such as walking may also help prevent osteoporosis.
Chart your progress: Being attuned to bodily changes helps make perimenopause less confusing. Monitoring your menstrual cycle for several months and keeping track of your symptoms will give you a greater sense of control, as well as useful information to discuss with your doctor.
Along with a good understanding of your body and the changes it is going through, a positive attitude about perimenopause and menopause is important for dealing with any difficulties it may bring.
Prescription medication used for the treatment of menopause include hormonal therapies. Prescription medication may include one or more of the following:
Hormone therapy: Hormone therapy (HT) involves taking low dosages of oestrogen (oestrogen therapy or ET), or low dosages of both oestrogen and progestin (known as combined oestrogen-progestogen therapy or EPT) to relieve short-term symptoms and possibly reduce the risk of long-term diseases associated with menopause.There are benefits and risks to ET and EPT which may differ for each woman. The decision to use hormones, as well as dosages, routes and duration of use, must be based on your individual risk-factor profile: your personal and family medical history, particularly of certain cancers, heart disease, stroke and osteoporosis. For example, oestrogen-only therapy should not be an option for women who still have a uterus, as it could increase the incidence of endometrial (lining of the womb) cancer.
The hormone testosterone is sometimes prescribed to help when menopause has a negative effect on sex drive, particularly in the case of surgical menopause.
Other prescription medicines are also options for certain short-term menopause-related changes: low-dose oral contraceptives, clonidine and belladonna-containing products.
Some prescription drugs may not help with short-term complaints, but may help prevent long-term effects of lower oestrogen levels. Anti-osteoporotic medication such as alendronate, risedronate, zolendroic acid, sodium ranelate or racloxifene) help to slow or reverse bone loss in osteoporosis; several cholesterol-lowering or antihypertensive drugs can help prevent heart disease by controlling blood pressure and cholesterol.
The main ways in which HT is given are
- Oral – by mouth
- Across the skin – percutaneous/transdermal– as gels or patches (one of the safest options)
- As implants
- As a nasal spray ( not available in SA)
- As an injection
- In a hormone-impregnated intrauterine device
- Via the vagina as creams, foams, pessaries or oestrogen-impregnated rings
How safe is hormone therapy?
Rational analysis of the WHI trial results and subsequent studies proved that HT, when used correctly and for the right patient, is good for you. Experts now believe that HT is perfectly safe, provided it’s used correctly.
Effective hormone therapy is dependent on the patient’s individual profile. Age is the most important determinant when it comes to assessing benefits and risks and it is recommended that HT is used as soon as possible after menopause starts and not, for instance, only years later.In general, when using approved hormone-replacement therapies, the American Food and Drug Administration and healthcare professionals recommend using the lowest dose possible for the shortest period needed.
The benefits and risks of HT
Users of HT experience improvement in their quality of life and reap the benefits of both decreased menopause symptoms, increasing bone density, and – in some women – reduced risk for heart disease. If you’re a suitable candidate for HT, the sooner you start, the more effective it will be. It is always best to start HT treatment, when indicated, as soon as possible (never later than five years after menopause) and at the lowest dosage possible.
Possible side-effects of HT
But, as with all drugs, there are side-effects and risks associated with HT. Possible side-effects are far from life-threatening and may include bloating, headaches, breast tenderness, nausea, the return of vaginal bleeding or spotting. It may cause hypertension in some patients. All will be reversed as soon as HT is stopped.
The risks include the possibilities of cancer of the endometrium (lining of the womb), breast cancer, breast soreness, vaginal bleeding, high blood pressure and blood clots in the veins (venous thrombosis). The side effects and risks are now much lower than a decade or two ago because much lower dosages of HT (about 25%) are now used than 10 and 20 years ago. Since the oestrogen is not replaced to its previous pre-menopause levels, the term hormone replacement therapy is no longer used, but rather hormone therapy (HT).
Note that the higher risks end with the treatment – but so does the protection against osteoporosis and diseases such as colorectal cancer.
The effect of HT on the body can be summarised as follows:
HT relieves symptoms associated with menopausesuch as hot flushes, night sweats and vaginal dryness. In fact, HT is the only treatment that results in a dramatic improvement of all the symptomsof menopause. You’ll also sleep better and be less moody and your quality of life will improve.
HT can also provide the tissues of the urogenital tract with enough oestrogen to improve their function and to prevent vaginal dryness and recurrent bladder infections.
HT reduces the risk of developing osteoporosis. HT also reduces the possibilities of osteoporosis if you start the therapy as soon as possible after menopause. Oestrogen-related drugs such as SERMs (e.g raloxifene)may be prescribed as chronic medication for the prevention of post-menopausal osteoporosis.
HT reduces the onset of type 2 diabetes. Large studies indicate that HT may prevent type 2 diabetes. The reduction may be due to less weight gain around the belly, reduced insulin resistance or other unknown factors. HT is also associated with an improvement in insulin resistance in post-menopausal women. However, there is not enough evidence to recommend HT as the sole or primary indication for the prevention of type 2 diabetes in menopausal women.
EPT decreases the risk of cancer of the endometrium. The use of HT decreases the risk for cancer of the endometrium. In the past, HT was administered only as oestrogen with no addition of progestin, and a woman who still had her womb intact had the risk of developing cancer of the endometrium. By adding progestin to the HT regimen, this risk is prevented. HT (ET and EPT) is not recommended in women with a history of endometrial cancer.
Continuous combined oestrogen and progestin seems to be the only truly effective form of oestrogen delivery which will decrease the risk of endometrial cancer.
HT reduces the risk for colorectal cancer. The use of HT decreases the risk for cancer of the colon.
HT may improve or worsen mood and depression. Several studies suggest that perimenopausal and early postmenopausal women are at an increased risk of developing depression. Some studies suggest that HT may improve mood, while others show no effect on mood. Progestogens in EPT may worsen mood in some women, particularly those with a history of premenstrual syndrome, premenstrual depressive disorder or clinical depression. However, HT is not an antidepressant and should not be prescribed to treat depression. It is of interest to note that SSRI anti-depressants may indeed even alleviate hot flushes in some women.
HT may protect younger women against heart disease, but may also increases the riskfor older women. Careful analysis of studies indicated that HT may reduce the risk for heart disease if HT is initiated within two to three years after the onset of the menopause in woman age 50 – 59. However, indications are that HT, when inititiated more than ten years beyond menopause in women older than 63 years, may increase a woman’s risk for coronary heart disease. These are indications, not absolutes.
Experts conclude that HT should not be prescibed to primarily reduce the risk of heart disease. The correct treatment options for patients with an increased risk for heart disease include antihypertensives, cholesterol-lowering drugs and other medication, aimed to decrease the specific risk factors.
HT may increase the risk for stroke. Results of studies of the risk of stroke with HT have been inconsistent. Some studies, including the very large Nurses’ Health Study (NHS) and the WHI study, indicated an increased risk of ischaemic stroke, whereas other studies showed no effect on stroke risk. Experts conclude that HT is not effective in reducing stroke among women with established cardiovascular disease or for prevention of a first stroke, and it may increase the rate of first strokes, particularly in women starting with HT after their 60th birthday.
HT increases the risk of blood clots and deep vein thrombosis (DVT). The risk of developing blood clots is higher among patients older than 60 but there is no evidence that this increases the risk of death as a result of the clots. In fact, the risk is less than half of that during normal pregnancy. Women who have already had venous thrombosis have an increased risk of suffering further clot formation if they take oestrogen orally. However, according to observation this seems to be diminished if they use transdermal patches of HT. Experts conclude that women with a prior history of deep vein thrombosis or women who possess a specific clotting gene called factor V Leiden, are at increased risk for DVT with HT use.
HT may increase the risk of breast cancer. There is a slightly increased risk for breast cancer, especially after five or more years of HT (particularly EPT) use. Despite the increase in breast cancer incidence, the mortality is unchanged. It seems that breast cancer is detected earlier in women on HT because of increased awareness and annual mammographies.
The current consensus is that there is some increased risk of breast cancer associated with HT, particularly when HT had been started soon after menopause. The increased risk is more related to EPT use. However, when ET was extended beyond 10 to 15 years, breast cancer seemed to increase.
The use of ET in breast cancer survivors is still controversial. There is still no proof that ET use in breast cancer survivors is safe.
Remember, the risk varies widely among women, so individual risk factors need to be evaluated before starting HT. It is also worth remembering that deaths from coronary artery disease among women outnumber deaths from breast cancer, so the relative risk of both conditions needs to be assessed as well.
HT may increase ovarian cancer risk after longer use. Data on the role of both ET and EPT and the risk of ovarian cancer is conflicting. Many studies show either no association or a slight increased risk with HT use. But a large number of studies show an increased ovarian cancer risk. Data also suggest that the use of HT for less than five years may not lead to a significant increase in ovarian cancer risk, but that the use of HT for longer periods can be linked to a higher risk. Indications are that ET will lead to higher risks than EPT.
HT use in older smokers may promote lung cancer. Overall WHI data suggest that EPT, when initiated in older women with a history of smoking, may promote the growth of existing cancers. All smoking women in any stage of their life should be encouraged to stop smoking.
HT does not protect against Alzheimers Disease. New findings suggest that natural menopause has little effect on memory or other cognitive brain functions.
How should HT be used?
HT (oestrogen plus progestin or oestrogen alone) should be taken primarily for the treatment of menopause symptoms such as hot flushes, night sweats and vaginal dryness, and not primarily to protect against heart disease, as was previously the case. (If you are concerned about heart disease, rather talk to your doctor about medications called statins.)
The short- to medium-term use (up to ten years) of combined oestrogen and progestin to manage menopause symptoms is regarded as appropriate treatment. Added benefits will include protection against osteoporosis, colorectal cancer and type 2 diabetes.
Because hot flushes and the other unpleasant menopausal symptoms don’t usually last longer than five years, your doctor will interrupt the treatment after that time to see if you still need it. If you need HT to treat or prevent osteoporosis, the treatment could last longer, as long as a specialist has approved it..
There is no specific time HT should be stopped. It should be used for as long as necessary. As a guideline, however, the lowest effective doses of the the purest hormones should be used, and after five years an attempt can be made to withdraw HT. If symptoms recur, HT can be reintroduced at the dose that adequately controlled symptoms. If you’re over 60, and have been taking HT for more than five years, it may be best to change to a low-dose oral preparation or a skin patch. You may also need an annual mammography
Who can benefit from HT?
Not all menopausal women need hormone therapy (HT). Only one in four experience symptoms so severe they need treatment. Secondly, not all women are suitable candidates for HT.
You may be one of the women to benefit from HT if :
- Your menopause started recently, you are younger than 60 years and suffer severly from hot flushes and other menopausal symptoms.
- Your menopause started recently, you are younger than 60 years and suffer severly from hot flushes and other menopausal symptoms, and are at risk for hip fractures. You may benefit from HT combined with anti-osteoporosis drugs.
- you suffer from premature menopause (before 45 years of age). This should be treated to prevent the changes that occur due to the lack of hormones happening too early. Studies show that this prolonged exposure to hormones does not increase breast cancer risk or any other risks (besides clots). Once the natural age of the menopause is reached , the risks are the ame as for any other woman.
Who should NOT take HT?
- a personal or family history of blood clots, stroke or breast cancer.
- older than 60 and who had never taken HT before.
- a family history of breast cancer or a personal history of breast lump should not take combined oestrogen and progestin therapy.
- with a family or personal history of or increased risk for heart disease, stroke, deep vein thrombosis or hypertension.
elevated cholesterol or lipid levels. Talk to your doctor about statins as studies show women are under-treated in this regard.
Non-prescrition medication and natural remedies
Unlike HT, alternative remedies don’t have to conform to the strict requirements of the SA Medicines Control Council before they’re made available to the public. They are not registered with the MCC and purity and testing are unknown. Research has proved beyond all doubt HT works, and works well. Unfortunately that can’t be said for alternative remedies.
Some researchers believe plant oestrogen in the herb black cohosh and in soya (but not in soya tablets) can relieve hot flushes. Although some women swear by them, a new American study by the National Institutes of Health has once again proved plant oestrogen is nothing more than a placebo. People often assume medicines derived from plants are safe, but there’s no proof this is really the case. Some herbal medicines can have serious side effects, such as damaging your liver. They also interfere with the effects of other medication. Black cohosh has been documented to cause liver damage in some women. IN the USA all black cohosh therapies have a “black box” warning about potential liver toxicity.
It’s ironic: people who want to use natural remedies avoid HT, yet all oestrogen prescribed by doctors has a natural origin (either plant or animal). The oestrogen is adjusted slightly so it corresponds exactly with the oestrogen naturally produced by the human body. It’s so natural, the female body can’t distinguish between its own oestrogen and EHT.
Studies have also shown that high amounts of soya in the diet is effective to treat some menopause symptoms, but that phyto-oestrogen extracts from soya supplements are not. Other herbals that may be effective in providing some relief from menopause symtoms are Dong Quai (Aelica sinensis), licorice root (glycyrrhiza glabra) and chaste berry (vitex agnus castus).
The bottom line: Some natural remedies do relieve some symptoms. They do not act like HT and are not as effective in relieving symptoms of menopause as HT.
Keep in mind that:
• Approved hormone therapies are available on prescription only
• Bio-identicals will have the same risks as the products they're identical to -- namely a heightened risk of breast cancer and serious heart problems. There may be other, as-yet-unknown risks, as well.
• Beware of claims that bio-identical products can be made based on hormone levels measured from a woman's saliva sample. Hormone levels fluctuate constantly. Saliva tests aren't specific enough to determine drug dosages.
• No drug containing the hormone estriol (the weakest of the three estrogens produced by the body) has been approved by theMCC.
Previously reviewed by Dr Mike Davey, President of the South African Menopause Society, Dr Tobie de Villiers, gynaecologist and committee member of both the South African Menopause and International Menopause Societies and Prof B. Schaetzing MD, FCOG(SA), FRCOG, PhD. Part-time Consultant, Dept of Obstetrics & Gynaecology, Faculty of Health Sciences, University of Stellenbosch
Reviewed and updated by Dr Alan Alperstein, obstetrician and gynaecologists in Cape Town, February 2011