Does this sound familiar to you? It’s 2:00 a.m., and I am wide-awake. I’ve sweated right through my pajamas, and I need to change the sheets. I’m exhausted just thinking about planning tomorrow’s outfit – I’ll need at least four layers just to survive the flashes and make it through a day of work. My joints ache, and I live on Advil. And I can’t remember what was on my to do list.
This is a typical day for a menopausal woman. One year of no menses is the definition of menopause. The years leading up to menopause are called perimenopause, and frequently menopausal symptoms start to occur in those years prior to the last period. And then, many women suffer from menopause symptoms for several years after the last period. All in all, a woman will spend about a third of her life post-menopause.
So, what’s a woman to do, and what should she be concerned about during this time of life?
Vasomotor symptoms & hormone treatments: Hot flashes and night sweats can be very disabling, especially since sleep often gets disrupted. Hormone replacement with estrogen and with or without progesterone can really help a woman cope with these symptoms. There are many different formulations available, and every woman at this stage of her life should have a detailed discussion with her physician to review the pros and cons of using hormones. The main reason that hormones are often recommended is that relief is usually noticeable within two-to-four weeks. These medicines have been very well studied – in fact, they have been proven to be MUCH more effective than placebo at alleviating vasomotor symptoms – and continue to be scrutinized to better understand the risks and benefits.
Additional ways to cope with vasomotor symptoms: Other therapies have been touted to help alleviate symptoms related to menopause, but the data is less convincing. Clonidine is a medicine normally prescribed for high blood pressure that has been shown to improve hot flashes for some women. Effexor, which is an antidepressant, can help as well. Black cohosh is an herb that has been studied; in newer randomized control trials, however, it has not been proved to be better than placebo.
Additional symptoms of menopause: Most women focus on the disabling vasomotor symptoms and brain fog that accompany this time of life, but there are other significant physical changes that can occur from estrogen deprivation that markedly affect the body in negative ways, too. Estrogen deprivation is associated with bone loss and osteoporosis. Age, as well as menopause, contributes to the marked increase in bone fragility fractures. Cardiovascular illnesses and death markedly rises in women post-menopause. By the age of 70, the risk of cardiovascular death in women is equivalent to men, but prior to menopause, women are much less likely to have illness from such disease. Genital atrophy and vaginal dryness, as well as urogenital complaints (i.e., soreness, itching, decreased lubrication, discomfort during intercourse), also increase post-menopause. The central nervous system may also be adversely affected by a loss of ovarian hormones.
Hormone Replacement Therapy (HRT) – the basics: The beneficial action of estrogen is its ability to prevent changes in healthy tissue. It can have profound effects at slowing or halting tissue damage. Starting hormone replacement therapy (HRT) by age 60 or within ten years of the onset of menopause maximizes the risk-benefit profile. The dose of estrogen and progesterone is also important. Lower-dose HRT may be as effective at preventing bone loss and treating symptoms while also being associated with lower risks. Lower doses of estrogen are associated with decreased risk of heart disease and strokes, while higher doses are associated with a lower risk of heart disease, but an increased risk of stroke. The route of administration is also important. Oral estrogen first goes to the liver, thus increasing the risk of blood clots, but non-oral formulations of estrogen have been shown to have no increased risk of blood clots and/or embolism. Ask your doctor for more information on what would work best for you.
Benefits of HRT: If started soon after menopause, estrogen therapy has established benefits reported in multiple studies, including protection from bone loss and osteoporotic fractures and prevention of urogenital atrophy. Additionally, studies have reported lower rates of heart disease, decreased overall mortality, and less fat distribution and wrinkling due to protection against collagen loss. HRT may also be associated with less arthritis, decreased incidences colon cancer, and lower amounts of tooth loss. At the level of the brain, when started early, it has been associated with fewer incidences of Parkinson disease and dementia. Additionally, HRT may help prevent memory loss.
Risks of HRT: Use of estrogen and progesterone is not without risk. Increased rates of postmenopausal bleeding is noted with hormones, and a rise in endometrial cancer has been noted if progesterone in not added to estrogen therapy in a woman who still has her uterus. A history of breast cancer is a contraindication to the use of hormones, as breast cancer may have hormone receptors. The Women’s Health Initiative (WHI) study noted an increase in breast cancer when the combination of estrogen and progesterone was used, but not in women who only used estrogen (i.e., as seen in those with a prior hysterectomy). A large WHI study found an increase in heart attacks, strokes, and blood clots, but the initial results did not separate out the data by age of initiation or by years since menopause. Later analysis revealed that this markedly affected the reported risks of these events. Indeed, in the large WHI study, death rates were increased in the HRT group, advanced breast cancer was increased, and dying from lung cancer was increased, but again this data was not stratified by age. If HRT is started soon after menopause, many cardiovascular events may be prevented and this may affect the data.
Use of HRT is a personal decision that every woman should have with her doctor. The choice of estrogen and the dose should be individualized. Those with significant risk factors such as personal history of breast cancer or strong family history of significant cardiovascular disease or active liver disease may be discouraged from using HRT. For these women, alternatives need to be discussed (and we will do so in our next blog post!)
For more information on menopause and HRT, contact us.