Kathryn Jean Lucas, MD
611 N 35th St
Morehead City, North Carolina 28557

Menopause Information

inside health

MANAGING MENOPAUSE

By: K. Jean Lucas, M.D.

WHAT IS MENOPAUSE?

Just as puberty signals the onset of a woman's capacity to reproduce, menopause marks the end of the body's ability to become pregnant. Menopause is defined as not having a menstrual period for one year. The average age that menopause occurs is 50. Unless you have had your ovaries removed surgically and therefore, had an abrupt lowering of the estrogen level, the years approaching menopause are characterized by the gradual reduction in estrogen production by your ovaries. The symptoms of estrogen deficiency may be present years before a woman actually stops having her periods.

SYMPTOMS OF MENOPAUSE

Different symptoms may occur for different women even though the physiological process is the same. Adaptation to the changes during these years is also related to your general health, ability to cope with changes, presence of supportive friends and family, a positive outlook, and overall satisfaction with life. Exercise and an appropriate diet will also play a role in how well the following symptoms are managed. The severity of your symptoms is also related to how fast the estrogen level decreases. Surgical removal of the ovaries may cause more severe symptoms than the natural and gradual reduction of estrogen over the years. A hysterectomy refers only to the removal of the uterus and does not cause symptoms of menopause other than cessation of periods.

Hot Flashes and Night Sweats: These are the most common symptoms in menopause. Loss of estrogen affects the ability of the body to regulate heat properly. The brain senses a hotter temperature than is present in the environment and proceeds to get rid of the heat by sending a signal to the woman that she's hot, then by dilating superficial blood vessels (primarily in the face and neck) and by sweating. Night sweats are hot flashes at night and may disrupt sleep.

Vaginal Dryness: The vagina is very sensitive to changes in estrogen. The cells lining the vagina require estrogen to remain healthy and moist. Lack of estrogen causes vaginal dryness which may lead to pain with intercourse.

Urethral Discomfort: The neck of the bladder (the urethra) also depends on estrogen to keep its lining cells healthy. Without estrogen, it may become inflamed or irritated. The symptoms of changes in the urethra lead to burning with urination, a sense of urgency to urinate, or frequent urination. These problems often occur after intercourse and can lead to an increased frequency of bladder infections.

Pelvic floor relaxation: Depending on the number of children a woman has had, the supporting muscles which hold up the uterus and bladder can begin to become weaker. Estrogen deficiency also contributes to this problem. As a consequence, there may be leakage of the urine from the bladder with a sudden increased pressure on the bladder such as coughing or sneezing. Some women develop a more severe leakage of urine which may require surgical or medical treatment.

Sleep Disturbance: Estrogen deficiency may cause a change in sleep patterns similar to those in depression with early morning awakenings and inability to go back to sleep. The sleep disturbance may be further exacerbated by night sweats. Sleep deprivation leads to fatigue, mood changes, and irritability.

Mood Swings and Depression: Premenstrual syndrome may worsen in the years preceding menopause because of changing progesterone levels as well as estrogen. The perimenopausal years are also a time to "take stock" of one's life and plan for the future years. Many women have a feeling of emptiness because their children have grown and left home. Other women, who have never had children, realize that their ability to become pregnant is gone forever. Others may feel a great relief knowing they cannot become pregnant again.

Weight Gain: As estrogen levels decrease, metabolic rates tend to decrease as well leading to a lower requirement of daily calories to maintain weight.

Skin and Hair Changes: In some women, dry skin, dry hair, and a loss of hair is related to decreasing estrogen levels.

LONG-TERM EFFECTS OF ESTROGEN DEFICIENCY

Increasing risk of heart disease: Estrogen affects cholesterol; it increases the good to total cholesterol ratio. As estrogen decreases, so does this protective effect on the cholesterol and on the heart. Estrogen also improves the functioning of the blood vessels and may prevent their ability to spasm (or suddenly close up) leading to heart damage. Pre-menopausal women (unless they have diabetes) have a very low risk of heart disease. The major risk factor for heart disease in women is loss of estrogen by going through menopause.

Osteoporosis: Bone is dramatically lost as estrogen levels decrease. Bone loss may be as much as 5% of the total bone mass per year for the 5 years following menopause leading to an increasing risk of hip and back fractures as one grows older.

WHY SHOULD WOMEN TAKE ESTROGENS?

When the average life span of a woman was 40 years old, no one worried about menopause. In fact, the whole negative connotation to menopause came because of its association with death. With the lifespan of women increasing well into the 70s, one third of her life is after menopause. It is important to prepare to be healthy during those years as well. Since estrogen replacement does prevent osteoporosis and decreases the risk of heart disease and Alzheimer's disease, it is well worth taking.

Since every woman experiences menopause differently and has different risk factors for osteoporosis and heart disease, one needs to consult with her physician regarding the risks and benefits of estrogen therapy and the manner in which the estrogen is administered.

TYPES OF ESTROGEN

Oral: Examples are Premarin, Ogen, Estrace. Newer drugs contain predominately estradiol which is the most active form of estrogen. These hormones are taken with a progestational agent in order to prevent cancer of the uterus. Cycling the two hormones mimics the body's menstrual cycle and menstrual periods will occur. In some women, use of the progestational hormone at a lower dose throughout the cycle prevents periods from occurring after about 6 months. The therapy needs to be individualized for each woman by her doctor. If a woman has had a hysterectomy, she does not have to cycle the hormones and can take only estrogen daily.

Transdermal Patches: provide estrogen through the skin directly into the bloodstream. It may not cause as much fluid retention as the pills, but it also does not have the beneficial affect on cholesterol. Many women are also allergic to the glue which holds the patch on.

Estrogen shots: usually given every 3-6 weeks as a shot in the muscle

SHOULD MALE HORMONE BE REPLACED?

The ovary produces testosterone (male hormone) as well as estrogen. When the ovary gradually decreases its ability to produce estrogen, it also gradually loses the ability to produce testosterone. In most women, the loss of the small dose of male hormone is not noticed. The adrenal gland produces weaker male hormones and is the primary source of androgens (male hormones) after menopause. In some women, loss of ovarian androgens may lead to decreased libido (desire for sex), decreased muscle strength, and fatigue. Addition of androgens to the hormone replacement regimen may improve these symptoms. Unfortunately, androgen replacement may cause facial hair growth and acne.

WHAT ABOUT BREAST CANCER?

Two studies recently have focused attention to the increased risk of breast cancer in women on long term estrogen use. Overall, there is a 10% increased risk of breast cancer with estrogen use. Whether this effect is seen because these women are seeing their physician regularly and, therefore, being screened for breast cancer more often or whether it is a true effect of the hormones on the aging breast, no one really knows for sure. However, women on estrogens who develop breast cancer have a normal lifespan. Breast cancer in women on estrogens does not appear to increase mortality.

If one examines all the causes of death in women, the major cause of death in the postmenopausal woman is heart disease. Estrogen use decreases the risk of heart disease by 50%. Postmenopausal women also have an increased risk of hip fractures and may die as a result. Estrogen therapy decreases the risk of hip fracture by 50%.

Including the risk of breast cancer and the prevention of heart disease and fractures, the overall mortality in women from these causes decreases by 41%. This information is backed by large population studies of women who take and do not take estrogens.

Ask your gynecologist or internist about your individual benefits and risks to taking estrogens.

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