Download Dr. Burki`s Menopause Basics

Dr. Burki's Menopause Basics©By R.E. Burki MD, FACOG
WHO: All Women! More than 50 million women living in the United States today are
menopausal. Every day 5000 more US women transition into menopause.
WHEN: Usually somewhere between age 45 and 55. The average age of menopause is
about 51 and has not changed in recorded history. Smokers tend to have an earlier
menopause. Today the average life expectancy for a 50 year old woman in the US is about
80 years, which means women now will spend more than one third of their life menopausal.
For many women these are the best years of their life!
The life expectancy for women in 1900 was about 50, so that life after menopause with all
its health issues is really a relatively modern event. For many women in the developing
world menopause still never happens.
WHY: As a woman approaches menopause, her ovaries begin to slow down (perimenopausal period) and eventually stop working (menopause). From then until the end of
her life a woman is menopausal or postmenopausal.
HOW: Most symptoms of approaching menopause are due to lack of estrogen, a hormone
produced by the ovaries. Hot flashes, night sweats, palpitations, vaginal dryness and
discomfort with intercourse, bladder problems, smaller breasts, mood swings, and trouble
sleeping are all signs of decreased estrogen. More subtle long term problems associated
with aging that are not noticed as easily, but are actually more serious, are osteoporosis
(brittle bone disease), and acceleration of atherosclerotic cardiovascular disease
(responsible for heart attacks and strokes). Irregular menstruation (periods more or less
often, lighter or heavier bleeding, more or less cramping) in the perimenopausal period is
caused by the gradual slowing down of ovarian function. At the beginning periods tend to
come closer together, then further apart, and then they start skipping a month here or
there, until menstruation finally stops. In fact, menopause is defined as twelve consecutive
months without a period. It can only be confirmed after the fact, but treatment of
symptoms can, and often needs to be started, before a woman has actually reached
menopause.
TREATMENT AVAILABLE FOR MENOPAUSAL SYMPTOMS
ESTROGEN
As most of the menopausal symptoms are related to lack of estrogen, the logical and most
effective treatment for the symptoms of early menopause is estrogen replacement therapy.
There is currently no definitive evidence that postmenopausal estrogen replacement actually
causes breast cancer, but there are now several studies suggesting that long-term estrogen
use increases the risk of being diagnosed with breast cancer. The most recent studies
suggest that the risk of developing breast cancer is higher when a woman takes a synthetic
progestin along with estrogen replacement therapy. Whether natural progesterone has the
same effect has not yet been determined.
For years it was thought that estrogen played a crucial role in the prevention of heart
disease. Several recent well designed studies have shown no effect or a negative effect of
estrogen on atherosclerosis and heart disease, despite the fact that estrogen lowers
cholesterol. It turns out that Premarin, the most commonly prescribed estrogen, increases
several other factors associated with heart disease, such as triglycerides and CRP (Creactive protein). The observation that women on hormone replacement therapy are less
likely to have heart disease turns out to be related to the fact that these women overall
have healthier lifestyles and that women at high risk for heart disease were denied HRT by
their doctors. The American Heart Association no longer recommends estrogen replacement
therapy as the first line treatment for postmenopausal women with high cholesterol and
warns against starting women with established heart disease on hormone replacement
therapy. Both the American College of Obstetricians and Gynecologists and the North
American Menopause Society now recommend hormone replacement only for the short term
treatment of menopausal symptoms and not for disease prevention.
Symptoms and diseases that are improved or prevented by estrogen replacement include:
Hot flashes and night sweats
Dryness of the vagina and pain with intercourse
Urinary problems, such as urgency and frequent bladder infections
Mood swings and sleeplessness
Osteoporosis
Colorectal cancer
There is currently no agreement on whether estrogen prevents or at least delays the onset
of Alzheimer=s disease.
Possible side effect from estrogen replacement therapy:
- "Periods" (depending on which progesterone regimen is added)
- Increased risk of irregular, heavy bleeding and uterine cancer if taken without
progesterone for a long time
- Tender breasts (usually relieved by taking 400 -800 U of Vitamin E a day)
- Nausea and fluid retention (generally only in doses higher than the ones used for HRT)
Diseases that appear to be increased by HRT (estrogen plus progestin):
- Breast cancer (long-term use only, less than 1/10th of one percent per year of use)
- Blood clots and pulmonary emboli
- Heart disease and strokes
The estrogen dose has to be adjusted for every woman individually and we recommend use
of the lowest dose that controls your symptoms. Women with a uterus usually need to take
either natural progesterone or a synthetic progestin along with estrogen.
If you only have vaginal symptoms you may want to use only vaginal estrogen, along with
other measures to prevent osteoporosis and heart disease.
Women who have or have had breast cancer rarely are candidates for estrogen
replacement, but may benefit from very low dose vaginal estrogen to maintain vaginal
health and comfort.
Women who currently have a blood clot may not take estrogen. A history of a blood clot in
the past does not necessarily prevent low dose estrogen treatment for sever menopausal
symptoms, unless the clot was related to the use of estrogen or pregnancy. In women with
a history of blood clots clotting studies should be performed prior to starting estrogen
replacement. ERT slightly increases the risk of blood clots in all women, regardless of clot
history. The two biggest risk factors for blood clots remain age and inactivity.
How is estrogen used?
Estrogen can be taken systemically, to the whole body, or locally, to the vagina only.
Systemic estrogen can administered as pills, patches, cream or gel, either alone or in
combination with natural progesterone or a synthetic progestin (see below). Systemic
estrogen is the most effective way to relieve systemic symptoms, such as hot flashes.
Vaginal estrogen is used either as a cream, a suppository or a soft estrogen releasing
ring that stays in the vagina for three months at a time. Vaginal estrogen is the best way
to relieve local symptoms such as vaginal dryness and irritation and urinary urgency
caused by lack of estrogen.
Many different estrogen products are available, some of animal, some are of plant origin
and some are synthetic. The synthetic products tend to be closest to the natural human
estrogen.
PROGESTERONE
Reasons to add progesterone to estrogen replacement therapy:
- Decreased risk of uterine cancer
- Only women who still have a uterus need to take progesterone.
Possible side effects of progesterone:
- Depending on how you take your progesterone pills (every day or only part of the month)
you may have monthly (light) bleeding, breast soreness or other PMS like symptoms.
- High dose progesterone may increase cholesterol.
- Natural progesterone and certain newer synthetic progestins appear to have less negative
effect on the cholesterol profile and are better tolerated by most women than Provera
(medroxyprogesterone acetate).
- Recent studies suggest that long-term use of combination estrogen and progestin
increases the risk of breast cancer more than estrogen alone. The main progestin used
in these studies was Provera.
How is progesterone used?
Progesterone is available either as natural progesterone or in several synthetic forms
(progestins).
Natural progesterone is available as pills or cream.
Progestins are available as pills, alone or in combination with different estrogen
preparations.
Synthetic progesterone is also available in patch form, but currently only in
combination with estrogen.
TESTOSTERONE
Testosterone is produced both in the adrenal glands and the ovaries (and of course in much
higher amounts in the testicles!). As women age, both adrenal and ovarian testosterone
production decreases, but never completely stops, unless the organ is removed. Lack of
testosterone, i.e. in women who had their ovaries removed during a hysterectomy, is
thought to be responsible for decreased libido (sex drive), less overall vitality and
sometimes depression.
High doses, especially of oral testosterone, have a negative effect on cholesterol and can
cause acne, oily skin, hair growth and weight gain and liver damage.
In low doses testosterone can be given either as pills, cream or patches and be very
beneficial to women with symptoms of abnormally low testosterone levels.
There are no good studies on the effect of long-term testosterone supplementation in
women.
EVISTA®
Evista® is a new drug for postmenopausal women that acts like estrogen on bone and
cholesterol, but unlike estrogen, it does not stimulate uterine and breast tissues. It does not
cause uterine bleeding and breast pain and may even lower breast cancer risk. Evista®
does not treat the symptoms of menopause such as hot flashes and night sweats, but
prevents and treats osteoporosis. Like estrogen it slightly increases the risk of blood clots,
but unlike HRT it does not increase the risk of heart attacks and stroke. In one large study
of thousands of osteoporotic women it even decreased the risk of heart attacks and strokes.
Evista® is not a drug for early menopause, but may be the ideal drug for the menopausal
woman who no longer has symptoms.
Women on Evista® who experience vaginal dryness and/or bladder symptoms may safely
add low dose vaginal estrogen.
CALCIUM
Postmenopausal women should be receiving 1000-1500 mg of elemental calcium in their
diet every day to maintain strong and healthy bones. This is often hard to achieve with a
typical American diet and calcium supplements may need to be added. These should be
taken with meals, as stomach acid is necessary for their absorption. They also should be
spread out over two or three meals. One of the cheapest calcium supplements is TUMS®.
Each tablet contains 500 mg of calcium carbonate (approximately 200 mg. elemental
calcium). Calcium citrate is slightly better absorbed, but more expensive.
At least 400 units of vitamin D a day are needed for the body to absorb calcium from the
intestinal tract.
VITAMIN D
This is an important vitamin necessary for bone metabolism. A woman should consume 400
U (800 U for women over 70) of vitamin D a day. One multivitamin or two to three glasses
of vitamin D fortified milk contain 400 U of vitamin D. Note that other dairy products do not
have vitamin D added. Many calcium supplements also contain vitamin D.
VAGINAL LUBRICANTS
Women who are breast feeding or menopausal (both are times of less estrogen production)
may experience lack of lubrication with intercourse. There are specially designed lubricants
on the market that are of great help. They should be water, not oil based. Saliva may work
as well and is always available!
EXERCISE
Now more than ever exercise is very important for your health and well being. It helps
preserve your bones, your heart and your figure! Increased muscle mass translates into
both increased quality and duration of life for all older women.
POSITIVE ATTITUDE (most important!)
Menopause is not the end of life and happiness, not even of a fulfilling sex life. In fact many
women feel much better without crampy periods and the worry of getting pregnant. They
finally have more time for them selves to develop neglected talents or further their careers.
You still have more than a third of your life ahead of you! The life expectancy of your
generation will probably be over 80 years. Make the most of it! You are not over the hill!