Menopause
Introduction: Menopause occurs when the last
period finishes and the ovaries no longer produce estrogen. Due to the lack of
estrogen the pituitary gland produces more FSH and LH, which is used to diagnose
that the woman is in menopause. Most women enter into the age of menopause around
50 or 51 in the US. At first, the follicular phase of the cycle is getting
shorter meaning that there is less estrogen production in the ovary. This leads
to shorter menstrual cycles. There are also more irregular menstrual cycles as
well. Finally after a last menstrual period periods stop altogether. Menopause
symptoms:
Hot
flashes are the most pronounced symptoms that women complain about with menopause.
The skin feels warm or hot, some women perspire, occasionally profusely. Head
and neck region are most affected and the skin in that region might look reddish.
What causes hot flashes? The lack of estrogen in the circulation opens up the
skin vessels and the sweat glands are sweating easier. Postmenopausal women
are more sensitive to hot pepper, alcohol and large meals that will all make hot
flashes worse. They last for a few seconds or a few minutes and lead to a sensation
of heat from the chest upwards in the neck and head. Some women get reddish skin
discoloration and the skin feels warmer than in the skin of the lower body. When
the bedroom temperature is kept on the cool side women with hot flashes will have
50% less symptoms.
Without treatment the episodic hot flashes last
for between 1 and 5 years. There are also psychological symptoms ranging from
emotional lability, to irritability, trouble falling asleep to depression. Menopause
can cause heart palpitations without ECG changes; nausea, joint aches
and muscle pains are also part of the symptom complex. Because of the estrogen
reduction there are marked changes in the lower genital tract with thinning
of the vaginal wall and urethral mucosa, the labia and the clitoris. This leads
to painful sexual intercourse, causes vaginal infections and frequent bladder
infections. Some women have no hot flashes. They seem to have enough androgen
hormones from the remaining ovarian function as well as from the adrenal glands
so that estrogen can be formed in fat cells and skin, which prevents hot flashes.
Osteoporosis and menopause are clearly linked. White women are
at a higher risk than black women. Other risk factors are smoking, alcohol abuse,
lack of exercise and certain drugs (like prednisone and levothyroxine). About
25% of women have severe osteoporosis and fractures of bones are found in about
50% of them , if they do not take estrogen replacement and calcium supplements
and exercise. The typical osteoporosis fractures are compression fractures of
the spine, fractures of the hip, wrist fractures and ankle fractures. Finally,
cardiovascular disease and strokes become more common as the cardiovascular
protective effect of estrogen is no longer active as it was during the reproductive
life cycle. Diagnostic tests: A menopause test is
a simple blood test where the FSH level is measured. This is the most important
single test, which when elevated, is sufficient proof that the woman is in menopause.
If the LH level is included in the test, this usually is equally elevated. If
there is suspicion for bone loss, a bone density test should be done by dosimetry
or other tests that your family doctor can order. If the patient's test result
is 1 standard deviation below the norm, the risk of sustaining a fracture is 3-5
fold higher. If the bone density is 2 standard deviations below the expected value,
the risk of a fracture is 6-10 fold! Blood tests such as total cholesterol, LDL
and HDL cholesterol as well as triglycerides should also be done.
Menopause
Treatment: As often in other areas of medicine, the value of a
diet and exercise program should not be overlooked. Exercise like power
walking (minimum 1/2 hour 5 times per week) will strengthen the bones due
to small pulses of natural growth hormone that is released by the pituitary gland.
Stopping smoking and quitting alcohol (large amounts) is definitely
beneficial. A zone diet program (Ref.1 and 12) or a similar
balanced diet (= low glycemic diet) has also been shown to free
suppressed cyclic AMP, which is beneficial in activating alternative estrogen
pathways. As mentioned above androgens can be metabolized in the skin and fat
cells and produce enough estrogen in some women to stop the hot flashes. Such
balanced diets play a major role in making this happen. If this is not
enough and hot flashes are still a problem, then low dose estrogen therapy
should be considered following the slogan: "Go slow and low...". Recently
there have been several trials that showed that the equivalent of 0.625 mg of
Premarine per day has beneficial effects on reducing strokes, heart attacks and
osteoporosis provided it was taken long enough. Once it is decided that estrogen
replacement therapy would be the way to go in a particular patient, it should
be taken for 5 or 10 years, perhaps even up to 15 years. This gives the maximum
benefit to the postmenopausal woman. However, there are some complications that
can occur and should be thought about: -
Some women have precancerous
conditions of the uterine lining or breast cancer and these women should stay
away from estrogen therapy. Others develop thrombophlebitis easily and they ,too,
should stay away from hormone replacement. -
Liver disease, such
as cholestatic hepatitis, is another reason not to take estrogen. -
There is a twofold risk to develop uterine cancer on estrogen therapy, but
with regular Pap smears and yearly endometrial biopsies this can be followed closely.
Even when uterine cancer occurs, there is enough time to do a hysterectomy in
most cases before it spreads. -
In order to mimic what nature does,
a small amount of progesterone was given cyclically to create a hormone cycle
similar to the one that happened during the reproductive cycles. It was thought
that this would minimize or eliminate the uterine cancer risk. However, the risk
of heart attacks and strokes in postmenopausal women is unacceptably high, so
that this is now no longer the accepted treatment modality by most physicians.
Discuss this with your physician. -
The risk of developing breast
cancer is about 1.6 fold higher than without estrogen replacement. Yearly mammography
is suggested as well as regular monthly breast self examination. This way, should
there be a suspicious breast lump, this would be biopsied right away before it
becomes an incurable problem. -
Having said all of this, hormones
(estrogen replacement) are not for everybody. Many women feel that it is unnatural
to interfere with nature and they prefer to leave things alone. I sympathize with
these women on the one hand; but I also understand the women who want to prevent
heart attacks, strokes and fractures. - There are benefits from the
use of soy products. Isoflavones contain or stimulate production of natural estrogen
and this may be more for women who want to keep it more natural.
To
prevent osteoporosis, the postmenopausal woman can also take elemental
calcium, 400 IU of Vit. D and biphosphonates (brand name:
Didrocal). Your family doctor can advise you further. |
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