Menopause

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[edit] Menopause

Introduction:

Menopause occurs when the last period finishes and the ovaries no longer produce estrogen. Due to the lack of estrogen the pituitary gland produces more FSH and LH, which is used to diagnose that the woman is in menopause. Most women enter into the age of menopause around 50 or 51 in the US. Menopause occurs over a period of time, which mirrors the declining estrogen hormones.

At first, the follicular phase of the cycle is getting shorter meaning that there is less estrogen production in the ovary. This leads to shorter menstrual cycles. There are also more irregular menstrual cycles as well. Finally after a last menstrual period periods stop altogether.

Menopause symptoms:

Hot flashes are the most pronounced symptoms that women complain about with menopause. The skin feels warm or hot, some women perspire, occasionally profusely. Head and neck region are most affected and the skin in that region might look reddish. What causes hot flashes? The lack of estrogen in the circulation opens up the skin vessels and the sweat glands are sweating easier.

Postmenopausal women are more sensitive to hot pepper, alcohol and large meals that will all make hot flashes worse. They last for a few seconds or a few minutes and lead to a sensation of heat from the chest upwards in the neck and head. Some women get reddish skin discoloration and the skin feels warmer than in the skin of the lower body. When the bedroom temperature is kept on the cool side women with hot flashes will have 50% less symptoms. Without treatment the episodic hot flashes last for between 1 and 5 years. There are also psychological symptoms ranging from emotional lability, to irritability, trouble falling asleep to depression. Menopause can cause heart palpitations without ECG changes; nausea, joint aches and muscle pains are also part of the symptom complex. Because of the estrogen reduction there are marked changes in the lower genital tract with thinning of the vaginal wall and urethral mucosa, the labia and the clitoris. This leads to painful sexual intercourse, causes vaginal infections and frequent bladder infections.

Some women have no hot flashes. They seem to have enough androgen hormones from the remaining ovarian function as well as from the adrenal glands so that estrogen can be formed in fat cells and skin, which prevents hot flashes.

Osteoporosis and menopause are clearly linked. As this image shows women have problems with brittle bones a lot earlier leading to an increased fracture risk than men do. White women are at a higher risk than black women. Other risk factors are smoking, alcohol abuse, lack of exercise and certain drugs (like prednisone and levothyroxine). About 25% of women have severe osteoporosis and fractures of bones are found in about 50% of them , if they do not take estrogen replacement and calcium supplements and exercise. The typical osteoporosis fractures are compression fractures of the spine, fractures of the hip, wrist fractures and ankle fractures.

Finally, cardiovascular disease and strokes become more common as the cardiovascular protective effect of estrogen is no longer active as it was during the reproductive life cycle.

Diagnostic tests:

A menopause test is a simple blood test where the FSH level is measured. This is the most important single test, which when elevated, is sufficient proof that the woman is in menopause. If the LH level is included in the test, this usually is equally elevated. If there is suspicion for bone loss, a bone density test should be done by dosimetry or other tests that your family doctor can order. If the patient's test result is 1 standard deviation below the norm, the risk of sustaining a fracture is 3-5 fold higher. If the bone density is 2 standard deviations below the expected value, the risk of a fracture is 6-10 fold! Blood tests such as total cholesterol, LDL and HDL cholesterol as well as triglycerides should also be done.

Menopause Treatment:

As often in other areas of medicine, the value of a diet and exercise program should not be overlooked. Exercise like power walking (minimum 1/2 hour 5 times per week) will strengthen the bones due to small pulses of natural growth hormone that is released by the pituitary gland. Stopping smoking and quitting alcohol (large amounts) is definitely beneficial.

A zone diet program (Ref.1 and 12) or a similar balanced diet (= low glycemic diet) has also been shown to free suppressed cyclic AMP, which is beneficial in activating alternative estrogen pathways. As mentioned above androgens can be metabolized in the skin and fat cells and produce enough estrogen in some women to stop the hot flashes. Such balanced diets play a major role in making this happen.

If this is not enough and hot flashes are still a problem, then low dose estrogen therapy should be considered following the slogan: "Go slow and low...". Recently there have been several trials that showed that the equivalent of 0.625 mg of Premarine per day has beneficial effects on reducing strokes, heart attacks and osteoporosis provided it was taken long enough. Once it is decided that estrogen replacement therapy would be the way to go in a particular patient, it should be taken for 5 or 10 years, perhaps even up to 15 years. This gives the maximum benefit to the postmenopausal woman. However, there are some complications that can occur and should be thought about:

Some women have precancerous conditions of the uterine lining or breast cancer and these women should stay away from estrogen therapy. Others develop thrombophlebitis easily and they ,too, should stay away from hormone replacement.
Liver disease, such as cholestatic hepatitis, is another reason not to take estrogen.
There is a twofold risk to develop uterine cancer on estrogen therapy, but with regular Pap smears and yearly endometrial biopsies this can be followed closely. Even when uterine cancer occurs, there is enough time to do a hysterectomy in most cases before it spreads.
In order to mimic what nature does, a small amount of progesterone was given cyclically to create a hormone cycle similar to the one that happened during the reproductive cycles. It was thought that this would minimize or eliminate the uterine cancer risk. However, the risk of heart attacks and strokes in postmenopausal women is unacceptably high, so that this is now no longer the accepted treatment modality by most physicians. Discuss this with your physician.
The risk of developing breast cancer is about 1.6 fold higher than without estrogen replacement. Yearly mammography is suggested as well as regular monthly breast self examination. This way, should there be a suspicious breast lump, this would be biopsied right away before it becomes an incurable problem.
Having said all of this, hormones (estrogen replacement) are not for everybody. Many women feel that it is unnatural to interfere with nature and they prefer to leave things alone. I sympathize with these women on the one hand; but I also understand the women who want to prevent heart attacks, strokes and fractures.
There are benefits from the use of soy products. Isoflavones contain or stimulate production of natural estrogen and this may be more for women who want to keep it more natural.

To prevent osteoporosis, the postmenopausal woman can also take elemental calcium, 400 IU of Vit. D and biphosphonates (brand name: Didrocal). Your family doctor can advise you further.

References:

1. B. Sears: "The age-free zone". Regan Books, Harper Collins, 2000.

2. R.A. Vogel: Clin Cardiol 20(1997): 426-432.

3. The Merck Manual, 7^th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 8: Thyroid disorders.

4. The Merck Manual, 7^th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 7:Pituitary disorders.

5. J Levron et al.: Fertil Steril 2000 Nov;74(5):925-929.

6. AJ Patwardhan et. al.: Neurology 2000 Jun 27;54(12):2218-2223.

7. ME Flett et al.: Br J Surg 1999 Oct;86(10):1280-1283.