A Time for Choices

Menopause is the physiological event in women, when menses (periods) cease to occur due to loss of ovarian function. The menopausal woman runs out of oöcytes (eggs) and so ceases to produce follicles. It is the follicles that are the source of ovarian hormones. So the hormones of ovulation cease to be produced after the menopause. Although sites other than the ovary produce female hormones (especially oestrogen), they do so in smaller quantities. It is common for menopausal symptoms to persist for 6 to 8 years before the event of "menopause" occurs. This time period is referred to peri-menopause or climacteric. Symptoms such as hot flushes, vaginal dryness, depression and irritability may result from falling or rapidly changing oestrogen levels. These can be reduced with medication. After the menopause (post-menopause) there is an increased risk of osteoporosis and coronary heart disease. Although all women are affected by menopause, some do not experience menopausal symptoms.

A wide variety of changes are attributed to menopause. Many are described below. In addition, several common diseases of concern to postmenopausal women are mentioned. The risk benefit balance can be discussed in consultation. The menopause is a time for choices. It is important to have the information to make those choices. That information can be discussed in a consultation with Mr Shaw.

Symptoms

Irregular uterine bleeding
In the years approaching the menopause a woman may produce eggs (ovulate) less regularly than before. This can lead to irregular or lighter or heavier periods, change in cycle length, or skipped menses. It is normal for the majority of women to experience up to 8 years of menstrual cycle changes before menopause. Abnormal uterine bleeding, including very heavy blood loss, menses lasting 2 or more days longer than normal, or bleeding between menses, may indicate an underlying disease process and requires further investigation.

Hot flushes
Hot flushes result from dilatation of blood vessels to the skin, causing the feeling of warmth or intense heat. The sensation of warmth travels as a wave over the body and can cause flushing. Although the exact cause of hot flushes is uncertain, oestrogen supplementation often relieves the symptoms. Other drugs have been used to treat hot flushes with variable success.

Vaginal and urinary tract changes
Loss of tissue lining the vagina or bladder can cause vaginal dryness, pain during sexual intercourse, local swelling and urinary symptoms. The vaginal pH becomes more alkaline and provides a better environment for certain bacteria to grow and so the risk of developing vaginal and urinary tract infections increases. Oestrogen, taken orally or applied topically, is often effective in relieving these symptoms.

Decreased libido
Although libido is affected by psychological and social factors, physical factors (including hormone levels) play an important role. Decreased libido is a common complaint in postmenopausal women, especially in those who have had a hysterectomy with removal of the ovaries. Some women, particularly those with surgically induced menopause, benefit from low dose testosterone therapy, often in combination with oestrogen therapy.

Impaired memory and concentration
Although the relationship between impaired memory/concentration and hormonal changes are not certain, many peri-menopausal women complain of these symptoms. Whilst many claim that oestrogen improves memory, it is not definitely proven. Recent studies have suggested that the development of Alzheimer's Disease may be associated with lack of oestrogen. However there are conflicting reports in the scientific literature.

Skin changes
A large degree of the aging manifestations in older skin are related to sun exposure and cigarette smoking. Sun damage is also the main factor associated with the appearance of age spots. The main protein in the skin that is responsible for skin thickness and resilience is collagen. The collagen content of the skin decreases at a faster rate after menopause.

Dental changes
After menopause, the incidence of gum disease and tooth loss increases. Tooth loss has been linked to osteoporosis. There is loss of bone in the jaw area and in sockets in which the teeth fit. Oestrogen supplementation appears to decrease the risk of dental changes.

Osteoporosis
Osteoporosis is a condition in which bone strength is lost due to decreased bone density. This causes an increased risk of bone fracture. Because the age related loss is accelerated in the absence of oestrogen, most cases of osteoporosis are seen in postmenopausal women, however there are increased reports of its occurrence in elderly men. Postmenopausal women require approximately 1500 mg/day of elemental calcium and 400 to 800 IU/day of vitamin D in the diet. Protective effects against bone loss are provided by oestrogen supplementation, SERMs or biphosphonates (see below).

Cardiovascular diseases
There is an increased risk of heart attack and cardiovascular disease in women after menopause. The association of declining oestrogen levels and CV disease is uncertain. After menopause the level of LDL (the 'bad' cholesterol) increases and that can lead to blocked arteries. In the past, oestrogen supplementation was thought to provide protective cardiovascular effects, but recent studies have not supported this, and suggest that they increase the risk of heart attacks in certain people during initial treatment. The results of these studies are complicated and you are encouraged to seek further information. Mr Shaw will be happy to answer your questions. It is important for postmenopausal women to maintain a normal cholesterol level and to exercise in order to counter the normal changes that occur.

Treatment

Hormone Replacement Therapy
Hormone Replacement Therapy (HRT) can help relieve menopausal symptoms such as hot flushes, night sweats, sleep disturbances, and vaginal dryness and itching.

HRT is also effective in increasing bone mineral density. However, it is often only prescribed for less than five years because longer use in certain women is associated with an increased risk for breast cancer. There is also a small risk of blood clot and gallstone formation in some women. A recent study indicated that, whilst the incidence of heart attacks increased during the first year of treatment, it decreased after several years of treatment. A physician weighs all of these factors in view of a woman's medical history in deciding if an individual is likely to benefit from HRT.

Initially oestrogen alone was used as HRT, but this treatment was found to increase the risk for endometrial cancer (cancer of the lining of the womb). When oestrogen replacement is taken by a woman, progestagen must also be given to protect the endometrium from cancerous changes. For women with a uterus, HRT generally consists of an oestrogen and progestagens. HRT (oestrogen and progestagen) is available as tablet or patch formulation.

The progestagen may be provided as "sequential" treatment as a 10 day course at intervals, usually a month. These progestagen courses are followed by a period-like bleed and, as such, mimic the normal menstrual cycle. In women in whom the menopause is better established, it is possible to give the progestagen as a smaller but continuous dose and it is often then possible to avoid menstrual-like bleeds. For women who have had a hysterectomy, oestrogen alone may be used. Oestrogen alone may also be used for women who are unable to tolerate progestagens or have a high risk of cardiovascular disease associated with high cholesterol/triglycerides. Topical oestrogen is often effective in relieving vaginal symptoms of menopause. One vaginal preparation, a ring, Menoring®, provides enough oestrogen to be absorbed through the vagina into the circulation, thereby providing protection against osteoporosis.

Oestrogen may also be absorbed by rubbing gel on the skin or by inhaling a nasal spray. Oestradiol may also be given as implants. Favoured by some after hysterectomy, these small pellets are placed in the fatty layer under the skin and may be accompanied by testosterone. Subsequent implants are inserted under local anaesthetic in an outpatient setting every 4 to 8 months. Testosterone supplements occasionally cause facial hair, acne, irritability, liver abnormalities and can affect blood cholesterol levels. As absorption can be variable, Mr Shaw monitors your blood to check hormone levels. Liver function and cholesterol levels may also be checked occasionally.

SERMs
Selective oestrogen receptor modulators (SERMs), eg raloxifene (Evista®), have oestrogen-like effects in some tissues like bone, and an oestrogen-blocking effect in others such as endometrium and breast. In addition, they lower LDL and total cholesterol. SERMs help to maintain bone density after menopause but do not increase the risk of endometrial or breast cancer. Unlike HRT, SERMs can cause hot flushes and leg cramps. Like oestrogens, they are linked with a risk of blood clots.

Tibolone (Livial®)
Tibolone is a unique artificial drug. It is broken down by the body into several active substances which each work in different ways. Whilst some stimulate certain parts of the body like oestrogen, others inhibit oestrogen, perchance in the areas where oestrogen is detrimental. It also has the benefit of having a mild testosterone-like effect (see above "libido")

Biphosphonates
Bisphosphonates (such as Actonel®, or Fosamax®) are often used in the treatment of osteoporosis, especially in postmenopausal women. Not only do they prevent bone loss but they increases bone mineral density and have been shown to reduce the incidence of spine fractures and fractures of the hip.

Phytoestrogens
Soy, and other legumes, contains many biologically active substances including some isoflavones, of which some are phytoestrogens. Phytoestrogens are plant-derived compounds with oestrogenic activities. Oestrogen initiates its multiple actions by first binding to one of several receptors in a target organ such as the breast, uterus, blood vessels and bone tissue. Phytoestrogens generally bind to a specific oestrogen receptor where it has weak stimulating activities or oestrogen blocking effect. So in some tissues it mimics oestrogen and in other tissues it blocks the action of oestrogen.

Soy has been advertised as a treatment for menopausal symptoms. Some women have experienced relief of hot flushes with soy ingestion or supplementation. This has not been scientifically proven, but is feasible. Soy causes a mild reduction in serum cholesterol levels. An effect on bone density has not been proven. It is best to ingest the soy as food products and not pure isoflavone supplements because there are thought to be other beneficial components in the soy. In general, 3 to 4 servings a day of soy milk, tofu, or soy-fortified foods is recommended. Isoflavone supplements are not recommended for women at high risk of breast cancer.

Decisions about menopause and hormones can be difficult.
To be or not to be post-menopausal… that is the question!

There is not a no-risk option. Absence of oestrogen enhances the age related bone loss and adverse lipid profiles in the blood.. Taking oestrogen reverses these effects but elevates the venous thrombosis and breast cancer rates. A consultation can help you find the balance and make a choice about your lifestyle.