Menopause occurs when a woman's ovaries no longer produce adequate amounts of estrogen. This causes irregular menstrual periods, which eventually stop all together. Hot flashes, insomnia, depression, mood swings, and other symptoms are common. There are also serious health problems that can occur as a result of low estrogen levels. The average age of menopause is 51 years, although the age can range from 40 to 55. A woman will generally enter menopause at about the same age as her mother or older sisters.

The average life expectancy of women is about 83 years. This means that most women will live more than 30 years after menopause. Consequently, there is the potential for serious adverse effects of menopause on a woman's quality of life as well as her risk of death. Replacing estrogen has been shown to prevent the development of serious health problems and to improve the quality of life.

HEALTH PROBLEMS AFTER MENOPAUSE

As a woman nears menopause, her estrogen levels decrease steadily. She may experience skipped menstrual periods, irregular bleeding, or a sudden cessation of menses. Eventually menstrual periods stop completely. Hot flashes are very common during this transition. Many women may also have insomnia, mood swings, depression, irritability, and decreased sexual desire. Although menopause may cause all of these problems, they can also be caused by other factors. However, if low estrogen is the cause, replacing estrogen will relieve the symptoms very effectively. A year or so after menopause, many women will experience vaginal dryness, atrophy, and irritation, which can lead to painful intercourse. This problem can also be prevented with estrogen.

The more serious health consequences of menopause occur over a long period of low estrogen levels. After menopause, the calcium in bones steadily decreases, and can lead to osteoporosis. This is the major cause of fractures in older women, and fractures can be devastating to one's health and well-being. In fact, 25% of patients die as a result of hip fractures. Replacing estrogen after menopause can prevent osteoporosis.

Heart disease is the most common cause of death in women. The risk of heart attack in a woman before menopause is very low. However, the risk increases quickly after menopause, and by the age of 60 the risk of heart attack in women is the same as it is in men. To illustrate the impact of heart disease on women, the following table shows the risk of death for a 50 year old caucasion woman from various causes.

Estrogen replacement significantly reduces the risk of death from heart disease.

BENEFITS OF HORMONE REPLACEMENT THERAPY

As discussed above, replacing estrogen after menopause effectively prevents many health problems. The immediate symptoms of hot flashes and alterations in mood are relieved. Vaginal dryness can be prevented, or if it has already occurred, it can be reversed. Estrogen can prevent osteoporosis and reduce the risk of heart disease, both of which can occur over a period of many years in the absence of adequate amounts of estrogen. The net result is a general improvement in the quality of life as well as a decreased risk of premature death.

RISKS OF HORMONE REPLACEMENT THERAPY

The most well-documented risk is in women who have a uterus (i.e. they have not had a hysterectomy) and they take estrogen alone. The usual method of hormone replacement therapy in a woman with a uterus is to take both an estrogen and a progestin, which is another female hormone. The effect of estrogen alone on the lining of the uterus, called the endometrium, is to stimulate its growth. Progestin blocks this effect. If estrogen is taken alone, there is an incresed risk of cancer of the endometrium. When taken together, the risk of endometrial cancer is no different than the general population, and the beneficial effects of estrogen are still gained.

A common side effect of hormone replacement therapy is vaginal bleeding. This may be in the form of a regular, monthly bleed, or it may be irregular. The incidence and type of bleeding depends on the manner in which the hormones are taken, but about one-fourth of women have some type of irregular bleeding. Fortunately, adjustments in dose and dosing regimen can often eliminate bleeding problems.

The most common concern among women is the issue of breast cancer. Many studies have tried to determine if estrogen increases the risk of breast cancer. Although some studies have shown a small increase in risk, most studies have shown no increased risk, or have shown a decreased risk. The conclusive answer is not yet available, but most experts believe that if there is any increased risk of breast cancer, it is small. For example, the incidence of breast cancer may be increased from 10 per 10,000 women per year, to 13 per 10,000 women per year.

FORMS OF HORMONE REPLACEMENT

There are many types of estrogen available. The synthetic estrogen that is used in birth control pills is relatively potent, and is not used for post-menopausal hormone replacement. Natural estrogens, which are less potent, are used. At this point, there is no evidence that any one type of natural estrogen is better than another for hormone replacement.

A progestin is another type of female hormone. Progesterone is a progestin, and is the natural hormone that is produced by a woman's ovaries. Usually a synthetic progestin is given with an estrogen, because natural progesterone is difficult and expensive to produce in a form that is easy to take.

These hormones can be taken in many different ways. Estrogen can be taken as a pill, or as a patch that is placed on the skin. There are weekly injections, monthly injections, and even implants that are replaced yearly. Usually the estrogen is taken continuously, but it may also be given for 21 to 25 days each month.

The progestin is usually taken as a pill. It can be taken every day in very small doses, or taken for 12 to 14 days each month in slightly higher doses. The daily regimen usually results in no vaginal bleeding, while taking progestin for 12 to 14 days a month usually causes a regular withdraw bleed.

Women who have had a hysterectomy do not need to take a progestin, and usually take estrogen every day.

DESIGNER ESTROGENS

There are new estrogenic drugs that affect only specific organs. They are called selective estrogen receptor modulators or SERMS. Evista, by Eli Lilly, stimulates bone and blood vessels, but avoids breast and endometrium.

CONCLUSION

Hormone replacement therapy is a valuable method to increase the health and well-being of women after menopause. While there are some risks involved, the potential benefits are many and profound.

There are many other things women should do to maintain good health. Calcium supplements and regular exercise are also important in preventing osteoporosis. A well-balanced diet, low in fat and high in fiber, is important for cardiovascular fitness as well as overall health. Smoking, excessive alcohol, a sedentary lifestyle, and other risky behavior, is detrimental to one's health and should be avoided.

The final decision to take hormone replacement is up to each individual woman. All women near or past menopause should discuss this issue with their doctors and learn as much as possible about the risks and benefits of this important preventive measure.