Operational Obstetrics & Gynecology
Menopause occurs when the ovaries stop functioning and cease producing the female hormone, estrogen. This is a natural event in the life of all women, occurring, on average, at age 51 in North America, although there is considerable variation from person to person. Among those women who undergo surgical removal of the ovaries, menopause occurs immediately. Strict definitions have sometimes included such guidelines as 1 year without a period, accompanied by hot flashes.
The diagnosis of menopause is usually made on clinical grounds, but laboratory tests can be helpful in some patients. These would include a depressed serum estradiol (estrogen) level, resulting from ovarian failure. The pituitary gland, sensing the low levels of estrogen, responds by releasing steadily increasing amounts of ovary-stimulating hormones (gonadotropins), in the form of FSH (follicle stimulating hormone) and LH (luteinizing hormone). The typical laboratory profile of a menopausal women includes markedly elevated FSH and LH, with a low estradiol level.
The classical symptom of menopause is "hot flashes," an unpleasant sensation of sudden warmth and facial flushing, followed within minutes by profuse sweating. If this occurs at night, it is called a "night sweat," and can be so dramatic as to require the woman to change her clothing for comfort following the night sweat.
Other symptoms include vaginal dryness (and associated painful intercourse), sleeplessness, depression, memory loss, and decreased libido (sex drive). Not all menopausal women experience all of these symptoms. Women who do experience these symptoms may not experience them all at the same time.
Perhaps the most well-known of these is "osteoporosis," a loss of calcium from the bones, resulting in weakening of the bones and ultimately a risk of serious fractures.
The risk of cardiovascular disease rises after menopause. During their childbearing years, women enjoy a degree of relative protection against cardiovascular disease, in comparison to men. Following menopause, they lose this relative protection and their risk becomes similar to that of men of the same age, other risk factors being similar.
Many people think that menopause is a sudden event. They believe that once it occurs, a woman is "menopausal" and ovarian function will never return. While such a presentation may occur in some women, it is not the typical way for menopause to occur.
Usually, there is a period of several months to several years, during which a woman will go in and out of menopause. She will, at times, experience hot flashes and no menstrual flow for months, only to be followed by a brief resumption of ovarian function. She will feel much better and will notice that her hot flashes have gone away. She will likely believe that she is done with hot flashes, only to be surprised later when ovarian function again fails and she again experiences hot flashes.
This on-again, off-again presentation can be troublesome, both for the woman and her health care provider. During the episodes of hot flashes, laboratory tests for menopause (an elevated LH and FSH with a low estradiol level) will generally confirm the diagnosis. However, if repeated after the hot flashes have gone away and menstrual function has resumed, they will return to normal levels.
Philosophy of Management
One view of menopause is that it is a perfectly natural, predictable event in the life of every woman. The role of the health care provider should be to help the woman adjust to her menopausal state, using the least amount of medication for the shortest period of time, with the goal of being off of all medication.
The alternative view, is that menopause represents the premature failure of an important organ, with significant medical consequences. If a woman developed diabetes (failure of the pancreas), we wouldn't try to help her learn to live without insulin...we would give her as much insulin as she required to make her normal. If a woman developed hypothyroidism, we wouldn't try to help her learn to live without thyroid hormone...we'd give her as much thyroid hormone as it would take to make her normal again. In the presence of ovarian failure, we should try to replace the hormones (estrogen primarily) which are no longer being produced by the woman' ovaries.This is done with estrogen replacement therapy (ERT).
Benefits of Treatment
The benefits likely to accrue to the menopausal woman taking ERT include:
Risks of Treatment
The use of estrogen replacement therapy likely leads to a small but measurable increased risk of gallstones.
The use of estrogen alone, without balancing with progesterone, carries an increased risk of the development of endometrial hyperplasia and cancer of the uterus. If progesterone is used with the estrogen, this risk of cancer is actually less than that of the untreated population. In other words, using a combination of estrogen and progesterone protects against the development of uterine cancer.
More controversial is whether ERT increases the risk of breast cancer. Because of the limitations of the many scientific studies which have studied this issue, we really don't yet know whether ERT increases the risk of breast cancer, reduces the risk of breast cancer, or has no effect on the risk of breast cancer. It is probable that if ERT has any effect on the risk of breast cancer, it is a very small effect, not a large effect. If it had a big effect, that effect would have been obvious by now to most scientists looking at the issue.
Similarly controversial is whether women with a prior history of breast cancer should take estrogen. Strong feelings on both sides of the issue are plentiful. There is scientific merit to both sides, and this controversy is not likely to be resolved any time soon.
Alternatives to Estrogen Treatment
Regular, weight-bearing exercise, is known to have a beneficial effect on slowing the loss of calcium from the bones. The effect is small (much smaller than that of estrogen). Exercise also has beneficial effects on mood changes, libido, and reducing cardiovascular disease. Exercise generally has no effect on hot flashes, night sweats, or vaginal dryness.
Increased calcium intake has a beneficial effect on osteoporosis, but like exercise, the effect is very small, much smaller than the effect of estrogen. Typical recommendations for calcium intake are 1200 to 1500 mg per day of elemental calcium. This can be in the form of calcium tablets, but many antacid tablets contain similar amounts of calcium and may be less expensive for the patient. In theory, eating calcium-rich foods could also meet this need, but most people find it difficult to consistently eat enough calcium-rich foods to meet this requirement.
Other estrogen-like medications may be useful during menopause. Often called "SERM's" (selective estrogen receptor modulators), they act in some respects like estrogen and in other respects, they do not. One of the most well-known of these, Fosamax is highly effective at blocking the loss of calcium from the bones, and can rebuild bone. It has no other apparent estrogenic effects. While this makes for few side-effects, it will not relieve hot flashes, night sweats, or the mood changes which often accompany menopause. Nor will it protect against cardiovascular disease.
Several other non-hormonal medications, such as Bellergal-S, and Peridin-C have been used to treat menopausal symptoms. These reportedly act by stabilizing smooth muscle, blocking the vasodilatation associated with hot flashes. Bellergal-S also contains a mild hypnotic, which may promote sleep at night. Some women may obtain symptomatic relief with these medications while others will not. They do not provide any protection against osteoporosis or cardiovascular disease.
Usual treatment consists of a combination of estrogen and progesterone. This may be taken either continuously, without letup, or in a cyclical fashion.
There are different doses of both estrogen and progesterone.
Continuous treatment often consists of:
About 80% of women taking continuous ERT in this way will have no bleeding at all. The 20% who do have some bleeding will need careful gynecologic follow-up (assessment of the endometrium) to rule out significant pathology as an underlying cause of the bleeding. Eventually, most of this bleeding will stop, but there will still be some women who continue to have irregular bleeding on this regimen. They are usually moved to the cyclic form of ERT so that the bleeding will at least be predictable.
Cyclic treatment often consists of:
With cyclic therapy, about 1/3 of the women will have monthly menstrual cycles, about 1/3 will initially have monthly menstrual cycles which will later disappear, and about 1/3 will continue to have monthly cycles no matter how long they stay on the ERT.
For women in the peri-menopausal time (the few years leading up to menopause and the first few years after menopause), birth control pills are sometimes used as ERT.
These are particularly useful in women who are experiencing several months of ovarian dysfunction (menopausal symptoms), followed by resumption of normal function. The back and forth instability can be annoying and lead to considerable medical intervention. For these women, starting BCPs usually relieves their menopausal symptoms and provides very normal, regular, predictable menstrual flows each month. While the BCPs are not ideally suited to long-term ERT (too much progestin), they can be safely used in this age group for a number of years until the woman is past the "peri-menopausal" time.
When using BCPs for this purpose, the usual contraindications for BCPs apply.
A common question women in the peri-menopausal state often have is when to stop using birth control methods. The answer is complicated.
A woman who is truly menopausal should not need birth control. However, because of the tendency to go in and out of menopause for a while before menopause is firmly established, pregnancy remains an issue. A woman might have skipped 4 periods and had intense hot flashes before once again ovulating. If she were to have unprotected intercourse, a pregnancy could possibly occur. For this reason, traditional recommendations have been that after one year of no menstrual flow, accompanied by hot flashes, in a woman of menopausal age, contraception need not be employed. This guideline may not be very useful in the current atmosphere of aggressive medical management of menopause.
Spontaneous pregnancies (without infertility treatments) after age 50 are very rare. The risk of spontaneous pregnancy after age 50 is about the same as the risk of pregnancy occurring in a 22 year old who is using condoms for contraception, and less than the risk if she were using a diaphragm. For women seeking a higher degree of protection, other contraceptive techniques may be used until age 55. Spontaneous pregnancy after age 55 is essentially nil.
Libido (Sex Drive)
Interest in sex (libido, sex drive) varies from individual to individual, and within the same person from time to time. Menopause has no consistent, predictable influence on sex drive. Some women may find an increase in libido, possibly related to freedom from fear of pregnancy. Others notice no change. Others may experience a lack of interest in sex.
Loss of interest in sex may occur for several reasons. The emotional and psychological changes associated with menopause (depression, mood swings) may influence it. Loss of sleep due to night sweats can adversely influence sex drive. Other factors (children leaving the home, marital discord) may play a role. To the extent that ERT corrects an underlying hormonal abnormality and eliminates menopausal symptoms, this loss of libido may be corrected.
Other menopausal women may experience diminished sex drive to to changes in testosterone levels. Male hormone, testosterone, is normally produced in small quantities by women. About 1/3 comes from the ovaries and the rest comes from other organs in the body. As ovarian function ceases during menopause, not only do female hormones (estrogens) fall, but also male hormone levels drop. The fall in male hormone levels is not as dramatic, because they only fall by about 1/3. For some women, this drop proves to be insignificant, but for others, even this small drop can have significant effects on them. Among these effects are loss of libido.
For women who experience a loss of libido, it is useful to explore the many reasons for this. It may also prove useful to give a therapeutic trial of small amounts of testosterone. One convenient product, Estratest, contains both conjugated estrogens and a small amount of methyl testosterone. It can be substituted for the usual estrogen component of ERT and the patient reassessed in a month or two to see if it will be helpful.
Some women with a loss of libido are comfortable with their new circumstance and prefer no intervention.
Any women taking ERT who experience abnormal bleeding will need to be evaluated carefully for the presence of significant endometrial pathology. Various techniques used to accomplish this evaluation may include endometrial biopsy, D&C, hysteroscopy, and fluid-enhanced ultrasound.
Because of the theoretical potential for estrogen to stimulate breast cancer cells, women taking ERT are very good candidates for regular mammography (annually after age 50). Likewise, annual pelvic and breast exams are indicated in these women.
Some providers make good use of bone density scans to determine the relative strength of a woman's bones. These tests may indicate women who might benefit from the use of ERT but who would otherwise be disinclined to take it. The test may also be used to follow the progress of women with known osteoporosis, assisting the provider in determining the extent of therapy and its effects.
It is unknown whether the benefits of ERT continue indefinitely, so any recommendation of how long a woman should take ERT is speculative. Many women take ERT through their mid-70s.
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