WOMEN'S HEALTH: MENOPAUSE
THE "PAUSE"
WHAT IS MENOPAUSE AND PERIMENOPAUSE?
At approximately 40 years of age the frequency of ovulation begins to decrease. This starts a period of declining ovarian function called the PERIMENOPAUSE which may last a few months to several years. The total process of declining estrogen will last as long as 20 years. During this time, a woman will progress from decreased fertility through MENOPAUSE when menstruation actually ceases to manifestations of aging. Menopause in the US occurs between ages 43-55 with the average around 51.5 years.
Some eggs are still present in the ovaries but even prior to menopause these remaining eggs perform less well. Hence, older women have declining fertility and increasing irregularity of the menstrual cycles. Hot flashes and/or night sweats may also occur as signs of declining estrogen production. IS THIS AN ILLNESS? The answer is "NO" but can it be a problem for some women? YES! Menopause is a new phenomenon for women considering that in the year 1900 what was natural was to be a dead person! With a woman's life expectancy projected at 78+ years, we can expect to spend about one third of our life in the post menopause years.
After menopause, the ovaries do not produce significant amounts of estrogen but do produce increased amounts of the male hormone, testosterone. This is why an older women may notice some increased hair on the chin or upper lip and increased fat around the lower abdomen and waist. Estrogen doesn't totally disappear because the adrenal glands have a byproduct that is converted in body fat to a potent estrogen. Of course, the quantity of this estrogen is much less than that produced by the ovaries. However, because fat tissue is a major factory for this estrogen production, overweight women may have a higher estrogen effect than women who are underweight.
THE PROBLEMS OF TOO LITTLE ESTROGEN
Menstrual disturbances such as irregularity or heavy bleeding and vasomotor instability are encountered most frequently. Vasomotor instability results in hot flashes and night sweats. Hot flashes are wave-like sensations of heat that move up to the chest and the head and frequently are followed by heavy perspiration. Hot flashes may last a few seconds or 30-60 minutes. They are especially frequent and disturbing at night. Some women also describe feeling very warm all the time and this may be related to "extra padding" or insulation from weight gain. Weight gain occurs because our metabolism naturally slows as we age and we do not compensate with a decrease in calories consumed and increase our exercise.
Emotional changes are common during the perimenopause and may include anxiety, irritability, and depression. Recent studies suggest these changes may be due to sleep disruption due to hormonal fluctuations.
Atrophy of the vagina and the lower urinary tract often leads to specific problems as a result of this thinning and dryness of the tissue. Women may experience difficulty with intercourse, vaginal and vulvar itching, urinary frequency or burning.
Another major problem is the increased risk for wrist, spinal column, and hip fractures due to thinning of the bones with estrogen decline. Osteoporosis is a reduction in the quantity or density of bone and occurs as we age but really intensifies after menopause if estrogen is not supplemented. Approximately 25% of women over the age of 60 have compression fractures of the spine and results in women shrinking about 2 inches in height and forming the "Dowager's hump." Back pain is a common effect of osteoporosis. Eighty percent of all hip fractures in women are associated with osteoporosis and 17% of all hip fracture patients die within three months from pneumonia.
One of the most alarming health problems in women after menopause is the increased risk for heart attack and stroke. After the age of 60, one of every two women will DIE from a heart attack or stroke. This rapid increase in stroke and heart attack rates correlates with the loss of a protective effect of estrogen on the vascular system. Also, when women have their first heart attack they are more likely to die from that event than their male counterpart of the same age.
PROBLEMS OF TOO MUCH ESTROGEN
Long exposure to estrogen is associated with a greater risk of cancer of the lining of the uterus (endometrium) and of the breast. These two tissues respond throughout a woman's life by growing. It is not surprising then that a constant and unopposed stimulation may lead to uncontrolled growth (cancer). Contrary to previous beliefs, estrogen when given in small amounts after menopause does NOT cause blood clots, high blood pressure, or headaches.
BENEFITS OF ESTROGEN SUPPLEMENTATION AFTER MENOPAUSE
- Relief from vasomotor symptoms is prompt and usually easy to obtain.
- Improved emotional state may occur with sleep improvement if vasomotor symptoms resolve and sleep pattern/cycle is normalized.
- Urinary and vaginal symptoms improve or are prevented.
- THERE IS A 40+% REDUCTION IN OCCURENCE OF HEART ATTACK AND STROKE IF ESTROGEN IS SUPPLEMENTED AFTER MENOPAUSE. The most important effects of postmenopausal estrogen treatment are a reduction in the LDL-cholesterol levels (bad cholesterol) and an increase in the HDL-cholesterol levels.
- Osteoporosis is decreased with estrogen supplementation and bone density is further enhanced with adequate calcium intake and continuation of weight bearing exercise after menopause. ALSO, DO NOT SMOKE!
- Improved visual acuity, decreased eye dryness and protection against cataract formation occurs with estrogen supplementation.
- Estrogen protects against colon cancer and the risk reduction is greater with current users and increases with the duration of estrogen use.
- Estrogen decreases gingival inflammation, tooth loss and need for dentures.
- Recent studies are showing a risk reduction for Alzheimer's Disease of 50% in women who use estrogen for greater than seven years. There is a 25% risk reduction in those who use estrogen for less than seven years.
RISKS OF ESTROGEN SUPPLEMENTATION AFTER MENOPAUSE
- If a woman still has a uterus and only estrogen is prescribed there is an increased risk of endometrial cancer (lining of the uterus). Adding progestins to estrogen therapy actually lowers a woman's risk for endometrial cancer and this is commonly done by prescribing medroxyprogesterone (Provera).
- The risk for breast cancer in post-menopausal women on estrogen is really unknown. Over a hundred studies have been done to look at the relationship between hormones and breast cancer. After 100+ studies we do not have a definite answer which may actually be our answer! Smoking and the subsequent development of emphysema and lung cancer is only questioned by the tobacco companies but no cause and effect relationship has been established with estrogen and breast cancer. Any cancer is frightening but a woman's chance of dying from breast cancer after menopause is 4% as compared to 50% for heart attack or stroke.
Estrogen supplementation can take many forms and should be individualized for each woman. Estrogen supplementation may not be for everyone. Yes, there are many very healthy women who live well into their nineties without estrogen. Talk with your health care provider about what your risks and benefits may be with and without estrogen supplementation. Additional reading may be helpful and many books are available at your library or local bookstore. An especially helpful reference is Menopause, Naturally by Dr. Sadja Greenwood.
Written by: Pam DeVisser, FNP
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