(word processor parameters LM=1, RM=70, TM=2, BM=2) Taken from KeelyNet BBS (214) 324-3501 Sponsored by Vangard Sciences PO BOX 1031 Mesquite, TX 75150 ================================================================= The following was prepared in response to questions on this subject posted in the Medicine Conference of Friends!Z BBS. Feel free to share this file. I ask only that it be uploaded "as is" including this header. I accept no responsibility for the purposes to which you put this information. Comments, questions, and feedback are welcome. Messages regarding medical issues should be left in the Medicine Conference which is Conference #1. I hope this information is of service to you. .....alex... Alex DeLuca, M.D. Sysop: Friends!Z BBS (212) 828-3989 ================================================================= A Family Practioner's View of the Menopause Menopause, because of the emphasis on youth in our society, is a difficult stage of life for women. Many of the emotional and physical changes attributed to menopause are, rather, general manifestations of aging and are not the result of decreased estrogen levels. The hope that taking estrogen-containing medications would protect women from normal aging, heart disease and other conditions is ill-founded. This essay will attempt to clear up some common misconceptions. It will briefly cover the physiology, symptoms and treatment of menopause and related conditions, and issues regarding the usefulness and risks of estrogen replacement therapy. PHYSIOLOGY, CAUSE, and SYMPTOMS The generally accepted definition of menopause is one full year without menstrual flow in a previously menstruation woman. The incidence of menopause by this definition is about 10% by age 38, 20% by age 43, 50% by 48, and 100% by age 58. The essential cause of menopause is less production of the female hormone, estrogen, by aging ovaries. This results in cessation of menses (periods). Some estrogen production continues, mostly as a result of non-ovarian conversion of other steroids. This non-ovarian estrogen production may be the reason why 25% of women experience no menopausal symptoms. Page 1 Hot Flashes This term describes an uncomfortably warm sensation that radiates up from the chest to neck and face and lasts seconds to a few minutes before subsiding. Eating, exertion, emotional stress and alcohol are know to precipitate hot flashes. It is believed that hot flashes are related to the rate of estrogen withdrawal. Menopausal women can experience up to 20 episodes per day. In most people, this symptom subsides after 2-3 years, but it may continue for 6 years or more. About 10-35% of menopausal women suffer from severe, disabling hot flashes. While no link between emotional makeup and symptoms has been demonstrated, clearly hot flashes can be a source of significant misery and annoyance. Atrophy of the Vagina As estrogen levels decline, the vagina becomes smaller and less compliant and lubrication decreases. This makes vaginal and urinary tract infection more likely. It can lead to symptoms of itching, painful intercourse, discharge, and bleeding. It is interesting that sexually active women show less vaginal atrophy. Cardiovascular Disease There is no evidence that estrogen decline is responsible for the increased incidence of cardiovascular disease that parallels the menopause. Data regarding the effects of taking estrogens on cardiovascular morbidity and mortality are conflicting. The two major prospective studies have produced opposite results, with one showing an increase in the risk of heart disease, the other a decrease. This is a vitally important issue...further research is desperately needed to resolve it. There does not appear to be an increased risk of thromboembolism (the formation of blood clots) among menopausal women taking estrogens, but those with a history of same who are taking estrogen preparations should be closely monitored. Osteoporosis Osteoporosis refers to a generalized weakening of bone that leads to an increased risk of fractures of various types. It is an important consequence of estrogen decline. Decreased activity, poor nutrition, and the general aging process also contribute to the development of osteoporosis. Although the process is irreversible once established, it can be prevented by the prophylactic administration of estrogen. Emotional Disturbances Symptoms such as headache, nervousness, and depression are common during early menopause. These are felt to be more a result of the emotional stress associated with this difficult stage of life than of hormonal changes per se. Some women report feeling better emotionally on estrogen therapy, but this may be a placebo effect. No specific psychiatric problems have been found to be linked specifically to the menopause. Page 2 Cosmetic Changes While breast atrophy, loss of skin tone, and redistribution of body fat to the abdomen and thighs have been attributed by some to the menopausal decrease in estrogen, clinical evidence does not support this. These changes are most likely part of the more general process of aging. MEDICAL MANAGEMENT OF MENOPAUSE The objective of medical practioners in treating the menopausal women is to alleviate any disabling symptoms resulting from estrogen deficiency and to provide support for the host of emotional and functional problems that are often associated with this phase of life. Estrogen Replacement Therapy Estrogen deficiency does cause serious medical problems, for example osteoporosis, and estrogen replacement can be of great value in avoiding these conditions. However, there are risks to taking estrogens, and the decision to administer them is not a simple one and requires a "cost-benefit" analysis. There is no one right answer; each woman, in consultation with her physician, must make the decision. First we will consider the risks of estrogen replacement therapy, then the benefits that can be expected from such treatment. Risks of Estrogen Replacement Therapy -- Endometrial Cancer The major risk associated with this treatment is cancer. There is an increased incidence of endometrial carcinoma (cancer of the lining of the uterus) in menopausal women taking estrogen regularly. This risk correlates with the dose and duration of treatment and declines with cessation of treatment. The risk is apparently not related to the type of estrogen administered. What is the magnitude of the risk? Case-controlled studies reveal an incidence of endometrial cancer of 4.5 to 13.9 times higher for estrogen users compared to non-users. Other studies have shown that at dosages of 0.625 to 1.25 mg of conjugated estrogens cause a seven-fold rise in the incidence of endometrial cancer when taken daily for 2 to 4 years. The mechanism of the malignancies caused by estrogen medication is related to the effect that estrogen has on the lining of the uterus. Estrogen stimulates the growth and differentiation of the uterine lining such that if pregnancy were to occur it would be supported. Prolonged, continuous use makes for excessive stimulation inducing a state called "cystic hyperplasia of the endometrium" which is a pre-malignant condition. The addition of another hormone, progestegin, to the estrogen program does help reduce the risk of endometrial cancer. Page 3 However, it also causes the return of light to moderate menstrual periods and causes an unfavorable change in serum lipoproteins which might lead to an increased risk of cardiovascular disease. Large, controlled, long term, prospective studies are not yet available; such studies are needed to better determine safety and effectiveness. -- Breast Cancer This remains an area of controversy. Some studies suggest an increased risk of breast cancer with the use of long term estrogen replacement therapy, other studies show no such effect. What is know is that women with the type of breast cancer that has "estrogen receptors" experience stimulated cancer growth with estrogen exposure, while those with the type of breast cancer without these receptors improve with estrogen administration. -- Cardiovascular Morbidity and Mortality We covered the high points of this risk earlier. -- Other Adverse Effects Administered estrogens can also cause fluid retention, elevated blood pressure, gallstones, glucose intolerance, and headaches. Recurrent uterine bleeding (which can make the diagnosis of uterine cancer tricky) is also common. Benefits of Estrogen Replacement Therapy -- Disabling Hot Flashes As mentioned above, usually this problem is self-limited. Symptoms severe enough to be disabling are an indication for replacement therapy, and relief during the one or two year period in which the symptoms are usually severe can be a blessing. A program of estrogens in the dose range of 0.3-1.25 mg taken daily for three weeks with one week off will prevent hot flashes. The lower dose is usually adequate. Addition of a progestin is not necessary if therapy is planned to be of one year or less duration. Attempts to taper off the estrogens can be attempted every 3-6 months. -- Postmenopausal Osteoporosis This condition can be prevented by long-term prophylactic estrogen therapy. Controlled studies clearly demonstrate decreased rates of vertebral, wrist, and hip fractures. Exercise, and good nutrition including enough calcium and vitamin D also slow the bone wasting, but are not as effective as estrogen. Risk factors besides estrogen deficiency for osteoporosis include: tobacco, heavy alcohol use, thin body build, and prolonged bed rest. The decision to use estrogens to prevent bone loss is a difficult one. The condition is largely irreversible and resumes once the therapy is discontinued; therefore treatment must be begun when the menopause first manifests, and must be continued indefinitely. Courses of treatment of 10-15 years are not uncommon. Page 5 If a woman is willing to accept the increased risk of endometrial cancer, the uncertain cardiovascular risk, and the regular gynecological follow needed to screen for endometrial cancer in return for the best possible means of preventing osteoporosis, then a program of estrogen, progestin, exercise, and nutritional support is the best option. It should be stressed that a program of exercise and nutritional therapy without estrogen *will* retard the rate of bone loss and is an option for those unwilling to take estrogens. -- Atrophic Vaginitis The dryness, discomfort, and difficulty of sexual relations caused by diminishing estrogen levels in the menopause can be a serious quality of life problem for many women. As stated above, sexually active women seem to have less trouble with this than celibate women. The atrophy of the vagina and vulva responds well to estrogen-containing creams as well as to estrogen pills, and though absorption into the blood stream does occur with topical application, certainly the risks are much reduced compared to long term oral replacement therapy. Use of the estrogen creams, directly applied to the vaginal and vulvar mucosa (lining), restores turgor and reverses the menopausal changes outlined above. However, because the risk of topical estrogens is not completely known, prudence requires the use of estrogen creams for short periods in response to severe symptoms. Milder symptoms, such as mild dryness with intercourse, often respond well to common water-soluble vaginal lubricants. SO WHAT'S A WOMEN TO DO? Given the list of potentially serious adverse effects of estrogen replacement therapy, extreme care must be exercised in deciding to embark on a course of long term treatment. Certainly, disabling symptoms should be treated. Certainly the dose should be as low as possible, and the duration of treatment as brief as possible. For those who elect long term treatment for prevention of osteoporosis, a progestin drug should also be part of the regimen. Patients must clearly understand the relative risks and benefits and make their own decisions. Patients who undergo estrogen therapy require careful monitoring. Because endometrial cancer is usually asymptomatic in the early stages, and because postmenopausal uterine bleeding is both a clue that uterine cancer may be present, and because a common side-effect of estrogen therapy is bleeding, for all these reasons women who take estrogens postmenopausally often require repeated uterine scrapings (D+C, Dilation and Curettage) both to monitor for the development of endometrial cancer and to rule it out when symptoms of bleeding occur. Indeed, a risk of estrogen replacement therapy is the potential increase in frequency of endometrial biopsy and D+C procedures. Women unwilling to follow what is often a rigorous follow-up regimen are not good candidates for chronic estrogen replacement therapy. Page 6 ----------------------------------------------------------------- OK, that's it for now. I think we've covered the basics. Of course I'd be more than happy to answer any further questions as best I can. ...alex.... ----------------------------------------------------------------- FINIS Page 7