The middle years of a woman’s life are surrounded by more myth and mystery than any other season she confronts. These myths can cause much fear and anxiety in the lives of middle-aged women as they approach menopause.
Menopause is a normal time in a woman’s life when her ovaries begin to shut down the production of the hormones estrogen and progesterone. It is defined as that point in time when permanent cessation of menstruation occurs following the loss of ovarian activity. There are currently more than 32 million postmenopausal women in the United States. Menopause does not occur at a specific age, although most women go through menopause near midlife. The mean age for menopause for women in the United States is 50 to 52, but in some cases it may occur much earlier or later.
Menopause normally occurs as a result of natural aging, but it can start prematurely if the ovaries cease to function for any reason. Many women become menopausal as a result of surgical removal of the ovaries prior to normal menopause. Removal of the uterus alone does not cause menopause; the ovaries produce hormones, not the uterus.
Some of the myths plaguing our thinking concerning menopause include:
Because menopause is the time in a woman’s life when menstruation ceases, it is important to understand what occurs during the normal menstrual cycle.
The reproductive years consist of the time from menarche, or the start of normal menses, until menopause. The ovaries produce the hormones estrogen and progesterone.
Estrogen is produced throughout the menstrual cycle — for most women, a 28-day cycle. Estrogen stimulates the endometrium, or the lining of the uterus, to thicken and become more vascular. This is to provide a potential home for a fertilized egg, which implants in and gets its blood supply from the uterine wall.
Progesterone is produced in the latter half of the cycle and further stimulates thickening of the endometrium. If the egg is not fertilized after ovulation, the hormonal levels fall and menstruation results.
As women approach menopause, their ovaries begin to fluctuate and produce less estrogen and progesterone, and ovulation becomes less frequent. As a result, menstrual periods are more irregular. When periods occur, the menstrual flow is often different as well. Instead of four to seven days of normal flow, a woman may bleed one day, spot for two days, bleed a day and spot for three more.
True menopause is the cessation of egg release from the ovaries with accompanying cessation of menstrual flow, and is usually accompanied by several of the classic menopausal symptoms. These include:
Menopause is often diagnosed when a middle-aged woman displays classic symptoms of the condition and cessation of menses. If there is any question about the diagnosis, a blood test can be taken to measure the level of follicle stimulating hormone, or FSH. During menopause, this hormone is elevated because the brain attempts to stimulate the ovaries, but they do not respond. Measurement of FSH levels should not be used to determine the appropriate dose of estrogen to use in treatment, however.
In addition to the symptoms of menopause, other changes occurring in menopausal women can be dangerous.
At menopause, the risk of heart attack and stroke increase because there is no longer enough estrogen to prevent atherosclerosis, or plaque buildup in the arteries.
Estrogen also acts to increase HDL, or "good" cholesterol, and to decrease LDL, or "bad" cholesterol. Lowered estrogen levels can lower HDL and raise LDL, thus increasing the risk of heart disease. Remember that heart disease is still the overall leading cause of death among women.
Calcium loss from bone is a normal part of the aging process. From menopause on, untreated women lose one percent to two percent of their bone mass each year. Estrogen acts to help keep calcium in bone so it remains strong. Even with weight-bearing exercises and adequate calcium/vitamin D intake, a woman’s bones may become less dense if estrogen is not present.
Seventy-five percent or more of the bone loss that occurs in women during the first 15 years after menopause is attributable to estrogen deficiency rather than aging itself. Combined estrogen replacement and calcium use can result in an 80 percent decrease in compression fractures of the spine during menopause.
Insufficient estrogen levels have also been associated with altered memory, an increased risk of Alzheimer’s disease, macular degeneration in the eye (which may cause blindness), and colon cancer. Skin becomes drier and thinner, and hair loss may occur as well.
The treatment of menopause is not limited to hormone replacement therapy (HRT). A well-balanced, low-fat diet, adequate exercise, 1,000 to 1,200 milligrams of calcium a day and 400 IU of vitamin E a day are recommended. Many physicians recommend estrogen as well, since it relieves some moderate to severe symptoms associated with menopause, especially hot flashes, sweating, irritability, vaginal dryness and atrophy and sleep disturbances. Hormone therapy seems to decrease the risk of colon cancer and macular degeneration, as well as bone loss associated with menopause. It has also been shown to reduce hip and spine fractures. Estrogen slightly increases the risk of blood clots and heart disease, and during their first year of estrogen use, women are at an increased risk of a heart attack.
The greatest risk of estrogen therapy is related to breast cancer. In the Women’s Health Initiative study they found no increased risk of breast cancer in the first four years of combined therapy, with a 26 percent increase after that time. Interestingly, women who develop breast cancer while supplementing with estrogen have a lower risk of dying from the cancer than women who do not take estrogen, develop breast cancer and die.
For most women, the benefits of hormone replacement therapy must be weighed with the risks. Unless a woman has had a hysterectomy, it is essential that she take progesterone to counteract the effects of estrogen on the lining of the uterus. Estrogen alone increases the risk of endometrial cancer. With the addition of progesterone, the increased risk is nullified.
There is data that suggests that HRT might help significantly with what is called "global well-being." When many women discontinue HRT, they generally do not do or feel well, and may need to continue HRT.
There are several methods of hormonal therapy. Estrogen can be taken in pill form or in a skin patch, called transdermal delivery, or in an estrogen-impregnated vaginal ring. The skin patch allows the estrogen into the body without passing through the liver to be metabolized, as it is when taken orally. Some women don’t like patches. They can loosen with sweating or bathing, and 20 to 30 percent of patients develop a skin rash from the patch. Estrogen creams or gels that are absorbed through the skin are also available. The hormone can also be injected by needle or implanted under the skin in the form of pellets.
Estrogen and progesterone can be taken together in a single pill, or they can be combined in a patch or cream. With this combination, most women eventually stop having periods. Unfortunately, some women have continuous spotting for a number of months before their periods stop.
Estrogen and progesterone can also be administered cyclically: The estrogen is taken daily, either in pill or patch, and the progesterone is taken for 12 days a month. Most women will have periods with this regimen. When menses become very light, conversion to daily estrogen and progesterone usually results in no periods.
If you have a family history of breast cancer, you may want to consider the benefits and risks of HRT more carefully. On the other hand, if you have a family history of osteoporosis, HT should be strongly considered. The WHI study showed there was decreased risk of osteoporosis and a decreased risk of spine and hip fractures in estrogen/progesterone users. Be sure to discuss all the ramifications with your healthcare provider.
A woman’s ovaries naturally produce testosterone. After menopause, this hormone (which affects energy and the sex drive) can fall. Blood tests can be performed to see if you need to supplement with testosterone. The hormone can increase energy and libido in menopausal women, and it can be given in combination with estrogen, in a separate pill, or in a cream.
Some women prefer "natural methods" of hormone delivery, using herbal or other nutritional preparations. Although these forms of medication might relieve the symptoms of menopause, they are not as closely scrutinized by the Food and Drug Administration, and their potency and effectiveness can vary widely. There is little documentation of their effect on the risk of heart attack, stroke, osteoporosis or Alzheimer’s disease.
New HRT Medications
For women who cannot take estrogen, or who do not wish to take estrogen, there are now other medications that can be utilized to maintain or improve bone density. New drugs called selective estrogen receptor modulators, such as raloxifene and tamoxifen, can block the effect of estrogen on breast tissue and mimic estrogen’s beneficial effects in other body systems. The benefits may include a decrease in osteoporosis and cholesterol. Unfortunately it won’t relieve menopausal symptoms such as hot flashes, night sweats and vaginal dryness.
Raloxifene is not yet proven to have all the benefits of estrogen, such as decreasing the chance of colon cancer and blindness from macular degeneration. However, raloxifene does lower total cholesterol and triglycerides and decreases the risk of osteoporosis. Raloxifene may be beneficial for women who fear estrogen or who have breast cancer. The major downside of raloxifene is the increased risk of blood clots, and therefore it should be avoided in inactive persons.
If you are considering hormone replacement therapy or deciding whether you should change the way you currently treat menopause, weigh the benefits and the risks involved. And don’t begin treatment before you discuss your options with your healthcare provider.