By Amy Rosenman, MD and Nancy Greep, MD
Menopause is the transition from our reproductive life to our post-reproductive life. At this time we can expect to live to about age 80 spending about one third of our lives after menopause. Our ovaries are genetically programmed to stop functioning at a particular age somewhere between the ages of 40 and 60. First ovulation becomes irregular which leads to irregular periods. Then the pituitary gland tries to convince the ovaries to continue working with an increase in its messenger hormone, FSH (follicle stimulating hormone), and resultant ovulation for short time. /this feedback goes back and forth until the ovaries no longer respond, no further ovulation occurs and periods stop. The average age to stop periods is 52. After periods cease, there is diminishing production of estrogen and menopause. During this process we develop the typical vasomotor symptoms of hot flashes and night sweats. To those who ask, "how will I recognize hot flashes?" The answer is a resounding "You will absolutely know them when they happen!"
Next we want to know what we need to do to take care of ourselves when we are menopausal.
It is important to prevent bone loss so it is important to consume at least 1200 - 1500 Mg daily of calcium as well as vitamin D 800 IU. We need to make sure we have aerobic exercise as well as weight baring exercise. We should have a bone density test and discuss the results and possible treatments if it shows bone loss.
Sexual relations may become uncomfortable so at the first sign of vaginal dryness and thinning, we should consider using vaginal estrogens. There are several options here: a vaginal ring that is changes every three months, or vaginal tablets that are inserted twice a week, or vaginal cream that is inserted 2 - 3 times per week. These are all effective, the cream works the fastest but the ring and tablets are easier to use and not absorbed into the bloodstream in any measurable quantity. As heart disease in women begins to increase in risk at menopause we must be assessed for risk factors by having our blood pressure, cholesterol, LDL, and triglycerides tested. We should also continue having annual mammograms as the incidence of breast cancer continues to increase as we age.
The Women's Health Initiative (WHI) originally reported 6 years ago caused anxiety about the taking of menopausal hormone therapies. This was an enormous multicenter study funded by the National Institutes of Health that showed an increased risk of breast cancer, venous thrombophlebitis (clots), and heart attack risk after five and a half years on Prempro (conjugated estrogens and medroxyprogesterone). The WHI had flaws. The average age of women entering the study was 63, not exactly answering the questions most women want answered. Should we take hormones or not? The WHI does not really help answer these questions at all. All it tells us is that if we are a 63-year-old woman we might not want to start hormone replacement. But the vast majority of women take hormones for menopausal vasomotor symptoms and vaginal symptoms. These are worse at the onset of menopause in the early fifties. Interestingly after over 6 and a half years on oral estrogen alone (women who had a prior hysterectomy), had no increase risk of breast cancer or heart attack. There are also other subsequent studies that actually demonstrated reduction of heart disease risk if hormones are started within 10 years of the onset of menopause or age 60.
There is some evidence that if vasomotor symptoms warrant it, the safest route of administration of estrogen is the transdermal route. This non-oral route includes patches, creams, gels, and mists. The estrogen goes across the skin directly into the blood stream. This avoids the first pass through the liver of the oral estrogens. There is significant evidence that this reduces the risk of thrombophlebitis, or clots that form in the legs and may travel to the lungs or brain. Reducing this risk is a good thing. Balancing the estrogen with progesterone in women with a uterus reduces the risk of uterine cancer. The safest form of progesterone is natural micronized progesterone (Prometrium). The evidence suggests that this does not increase the risk of either breast cancer or heart attack to the same degree as the oral conjugated estrogen and medroxyprogesterone studied in the WHI.
The recommendation at this time is to take the lowest dose needed to treat the symptoms for the shortest time frame. That said, it is still not clear if some women might benefit from long-term use of hormones to prevent heart disease, and bone loss, colon cancer, and possibly dementia. The jury is still out.