Menopause Management 

Menopause is a time frame which occupies the latter third of a woman's lifespan. It is not synonymous with deterioration and it is not a disease state. However, it represents an extension of our lifespan far beyond what the majority of human experience has seen until the last 100 years. Given this, it only makes sense that we understand our biology well enough to make this phase of life healthy and productive. 

Biologically speaking, menopause is the conclusion of reproductive function of the ovaries, both the ovulation and the hormone production. It happens over a period of time, usually about two years, and comes at an average age of about 51 in North America. Please see the section on Menopause for more detailed information about that.

Ovulation in and of itself does not produce any particular health benefits. However the hormones produced as a result of the ovulation, estrogens and progesterone, have tangible effects on health. Their loss at the time of menopause has certain consequences which we must bear in mind, and for which we may want or need to compensate. 

Managing menopause is really just the women's version of aging well.  It is not about any one thing, such as hormones. It is a whole multifaceted program of optimal health practices that can take place in this phase of stability and self focus.  If we expect to live well during this period of increased life span, we must take optimal care of our bodies so that they last for our ever lengthening life spans. Very simplistically, this is a matter of giving the body what it needs in the way of exercise and nutrition so that it might optimally maintain itself. It is also a matter of observing recommended guidelines on health screening and maintenance, so that anything which does go wrong can be corrected in an early stage. 

Various changes related to aging:

Accumulated DNA damage ( from UV radiation, harmful chemicals, viruses, and errors in cell division) and increased cancer risk

Loss of lean body mass or muscle

Deposition of body fat 

Loss of mobility 

Loss of bone density 

Decreased cardiovascular health

Decreased immunity 

Loss of sexual function

Loss of mental faculties like cognition and memory 

Clearly these changes call for heightened surveillance to aid in early detection and treatment of problems. They most emphatically call for a strong emphasis in ongoing fitness and nutrition, ideally from youth, through the reproductive years, and resolutely into menopause, seamlessly, and without interruption. 

Through regular evidence based health maintenance and medical care, we can preserve lean body mass, keep optimal weight, bone density and good cardiovascular health. We can help preserve sexual function, and our mental faculties. Effectively managing menopause helps with all of this. 

Menopause, or loss of reproductive hormones worsens all of these age related factors except perhaps accumulated DNA damage. So is menopause management as simple as " replacing " these hormones ? Of course not. 

Perspective: 

Our reproductive hormones serve many beneficial functions besides reproduction, such as in the maintenance of our bone density, our cardiovascular function, our urogenital tract, and they have roles in mood and memory. But, our very own reproductive hormones can,  during our reproductive years cause problems as well (even without any help from doctors !) You might be surprised, but our very own hormones are at the root of many problems like uterine fibroids, abnormal bleeding, and PMS.  And while it is not clear that estrogen causes breast cancer, it is clear that in some cases it can make it grow. 

Likewise, hormones, even " natural " bioidentical hormones give after menopause can cause problems.  Therefore we have to be mindful when considering their use. A powerful principal in medicine is

" PRIMUM NON NOCERE " which means " DO NO HARM". 

In this sprit, we do not automatically give hormone therapy to everyone at the onset of perimenopause  or menopause. We evaluate each patient's situation and individualize their therapy. 

According to ACOG ( American College of Gynecologists) somewhere between 50-82 % of women will experience vasomotor symptoms such as hot flashes or night sweats. These symptoms can last for months or years, and can disrupt sleep and everyday functioning. Many women require treatment of their hot flashes, and the only reliably effective way to do this is with estrogen therapy, with or without concomitant progesterone. 

Not all women need hormone therapy. Not all women are eligible for hormone therapy. Certain medical conditions having to do with abnormal clotting as well as a history of breast cancer are examples of contraindications to hormone replacement therapy. Anyone considering the use of hormone therapy needs a full medical evaluation and a discussion of the pros and cons of its use. 

Hormone therapy 

Recall that estrogen stimulates the endometrium ( uterine lining )  to thicken and that progesterone consolidates and dries out the lining. (Please See Menstrual Cycle 101 ) If the lining of the uterus is exposed to estrogen given for a prolonged time without the subsequent effect of progesterone, the uterine lining can become hyperplastic (overgrown and overly active) and even precancerous.  Therefore hormone regimens for women who still have a uterus must contain both some form of estrogen and some form of progesterone to protect the uterus from these problems. This is true even for premenopausal women. Recall that the combination birth control pill used before menopause  has this balanced combination of both estrogen and a progestin for just this same purpose. 

Postmenopausal hormone therapy is formulated on the same principle, at least for women who have a uterus at the time of menopause. These hormones can be given in cyclic pattern or continuously every day. Oftentimes the cyclic regimen is given if the patient has irregular cycles in perimenopause, the time of transition to full menopause. Once she is fully in menopause, she may be more likely to be stable and have no extraneous bleeding on a continuous daily regimen. 

What research data informs our use of HRT ? 

WHI (Women's Health Initiative study ) 

The 2002 Women's Health Initiative its the flagship study on which we base the use of hormone replacement therapy. It was a RCT ( randomized controlled trial)  of over twenty thousand healthy postmenopausal women ages 50-77, whose average age was about 62. They were divided into three groups:

1. Placebo control group

2. Combined hormone therapy of conjugated estrogen and synthetic progesterone (Prempro)

2. Estrogen therapy only in women who had had a hysterectomy. 

After about 5.5 years on these regimens, a slight increased risk of cardiovascular disease and breast cancer emerged in the Prempro group compared to controls ( A tenth of a percent per year increase). This arm of the study was stopped. The other treatment arm on estrogen only showed no such risks. Both treatment groups showed a small increased risk of abnormal clotting (strokes, clots in the leg, etc) 

As a result of all of this recommendations were made to limit combined ( estrogen and progestin) postmenopausal hormone replacement to the least effective dose for the shortest effective time,  no more than 5 years, and to encourage women to employ fitness and diet as a means to reduce their risk  of cardiovascular disease and abnormal clotting. 

Criticisms of the WHI study included the older age of the participants and the fact that these findings might not apply to younger women. Happily, since then, continued and improved reanalysis reveals that women younger than 60 and within ten years of menopause may actually have a cardioprotective effect from hormone therapy. Reanalysis also has borne out the lack of increased risk for breast cancer in those without a uterus taking estrogen alone. Finally, bone density stabilization and reduced risk of colon cancer were observed as secondary outcomes of the study. 

It is unfortunate that more types of hormone therapy could not be studied. There are indications that hormone patches, which are metabolized differently than pills, may be associated with less risk of abnormal clotting and less cardiovascular risk. 

Recently, some attention has been given to the use of the progesterone secreting IUD ( intrauterine device) as a means of providing protection from uterine hyperplasia during administration of estrogen only hormone therapy. The progesterone from such devices inserted into the uterus is not believed to go into the systemic circulation in any meaningful way, treating instead only the uterine lining. Patients using this method of hormone replacement would be expected to have the more favorable risk profile of those taking estrogen only. This approach shows promise. 

Likewise vaginal estrogen preparations used for dryness pain or atrophy are NOT believed to cause any systemic effects. Thus they can be given without concern for the risks cited in the WHI. 

FAQs about alternatives to hormone therapy

What we have discussed above is the mainstay of hormone replacement therapy. Here are some other FAQs which might interest you. 

• Progesterone therapy alone does not prevent hot flashes and can have adverse effects. 
• Bioidenticals are not superior to conventional preparations in safety or efficacy, and can, depending on their source, be nonstandard in their dosing. 
• Phytoestrogens are not tested by the FDA for safety, efficacy or purity. A 2010 Cochrane meta-analysis of 30 placebo-controlled trials of high levels of phytoestrogens for the treatment of vasomotor symptoms found no evidence of benefit. 
• Selective serotonin reuptake inhibitors, SSNRIs, clonidine, and the gabapentin are effective alternatives to HT for the treatment of vasomotor symptoms  
• Paroxetine is the only nonhormonal therapy that is approved by the FDA for the treatment of vasomotor symptoms. 
• There are medications other than hormone replacement for first line prevention of cardiovascular disease and bone loss. 

Your menopausal management 

I must emphasize that menopause management should be individualized. At this phase of life, you and your doctor should be well established and have good open lines of communication. You should be in control of all your health records and familiarize yourself with your recommended screening tests. Your nutrition and fitness should be designed collaboratively with your doctor and done by routine and not sporadically. 

Reference : ACOG Practice Bulletin Number 141 January 2014 Management of Menopausal Symptoms