Going Through The Change? Know the Facts

By Rhoda H. Cobin, MD, MACE

If you are “in the change” or menopausal, you are not alone. There are about 35 million women in the United States who are over age 50. Many of these women have reached menopause by then, or will soon after.

Symptoms of menopause include hot flashes, poor sleep, and vaginal dryness. Sex may not be as pleasurable, especially if there is pain during intercourse because of vaginal dryness.

Once your menstrual periods stop your body undergoes many changes because estrogen is no longer produced in the ovaries. Actually the ovaries begin to “slow down” even before your periods stop, so many menopausal symptoms begin even while women are still having periods.

It’s important to know that not every symptom is always related to a lack of estrogen. The time of menopause is also a time for many changes in women’s lives. Children are growing older, marital relationships change, work stresses may be difficult, and age itself changes the body. As women become middle-aged, other medical illnesses may develop. Women may be moody, irritable, depressed, and tired. They may notice differences in the quality of their hair and skin. Overall stamina might be reduced. Some of these symptoms may not be caused by menopause, but by aging itself, and by the effects of dealing with life changes. Despite all these processes, some symptoms seem to be clearly related to less estrogen, especially hot flashes, poor sleep, and vaginal dryness.

So what are women to do?

First, have a good discussion with your doctor. Let him or her know all of the symptoms that are bothering you and how your body has changed. It is important to be thorough. A complete physical exam and a set of blood tests can make certain that you are healthy and that your symptoms are not because of an illness.

Estrogen is the best and most effective treatment for symptoms that are a direct result of estrogen deficiency, such as hot flashes. Estrogen therapy is also excellent to prevent and treat osteoporosis [os-tee-oh-pore-OH-sis] (weakening of the bones that increases the risk of fractures), though there are other drugs available to fight this condition.

In clinical studies, estrogen use is linked with a lower risk of developing cancer of the colon. But estrogen may contribute to the risk of developing breast cancer, as reviewed below.

You should discuss with your doctor whether estrogen treatment is right for you. Not everyone should take estrogen, but for many women it can be a safe and effective therapy.

If you have not had a hysterectomy (removal of the uterus), estrogen treatment must be taken with another hormone called progesterone [pro-JESS-tur-ohn] because taking estrogen without progesterone can cause cancer in the uterus. If your uterus has been removed, taking estrogen alone is fine.

Smoking and hormone replacement therapy

Smoking increases the risk of blood clots and heart disease. Women who smoke are at even more risk of developing these problems if they take hormone replacement therapy (HRT) while continuing to smoke. Smoking raises the risk for the development of cancers of the lung, mouth, tongue, and bladder. All women should discuss with their doctors how to stop smoking.

How is HRT given?

Many preparations are available that contain estrogen, progesterone, or a combination of both. The American Association of Clinical Endocrinologists, along with other professional societies, endorses the use of only those preparations that are regulated by the FDA, to ensure that the proper drug at the proper dose is actually being taken. So-called “bioidentical” hormones offer no advantage to FDA-approved drugs and may be associated with inconsistent dosing. Bio-identical hormones have not been shown by scientific studies to have medical benefit. Also, some preparations have been found to contain irritating substances or no hormone at all.

Your doctor will recommend the best HRT program for you. He or she will determine whether a pill, a patch, or a vaginal preparation might be the safest and most effective form of treatment for you.

What if estrogen cannot be safely used?

Some women cannot safely take estrogen but have severe symptoms of menopause. For these women, a number of non-hormone containing medications may be tried to reduce some of the symptoms. But, these over-the-counter preparations, including herbal and soy remedies, should be used with caution since some may act like estrogen in your body. While that might be a good thing in some cases, in women where estrogen might be dangerous, these chemicals could also be dangerous.

You should discuss with your doctor the ingredients in all over-the-counter preparations you take or are thinking about taking.

HRT and blood clots

Fortunately, the risk of clots in the legs or clots that travel to the lungs (a very serious condition) is very rare, but the rate doubles in women who take estrogen. Though the risk is still very low overall, you shouldn’t take HRT if you have had blood clots, especially when you were pregnant or taking birth control pills. Also, even if there is a history of clots in your family and not yourself, you should mention this to your doctor. In some cases, there is a simple blood test to find out if you have inherited an increased risk of clots, and this might be an important factor in the decision to use estrogen.

Hormones and your heart

In general, if you are younger than age 60 and had your last period less than 10 years ago, the risk of heart disease is less if you took estrogen than if you didn’t. However, the risk of heart disease goes up as you age, so it’s generally best not to start estrogen treatment after age 60. Recent studies have suggested that taking estrogen early in menopause and before the age of 60 might actually help the heart. However, these studies are not definite and estrogen is not recommended as a prevention or treatment for heart disease at this time. More studies are being done to help us decide whether this recommendation will change in the future. Of course, women should have healthy lifestyles to reduce the risk of heart disease. This includes eating a heart-healthy diet, maintaining an ideal body weight, and exercising regularly. If your cholesterol is high, your doctor will likely recommend a “statin” drug. The use of hormone replacement will not interfere with the helpful effects of this drug.

Breast cancer and hormones

What about breast cancer? It’s the disease most women fear the most. Some studies have linked the use of postmenopausal HRT to cancer. When estrogen can be used alone (without progesterone), these studies do NOT show an increased risk of breast cancer. For those who need to take progesterone with estrogen because they have a uterus, there is a small increase in the risk of breast cancer. It is also possible that the kind of progesterone used may make a difference. It may also be true that taking estrogen, even with progesterone (using one of the progesterone agents which seem to have lower risk) for a short period, say, less than 10 years, may not pose a serious risk. Each woman, with her doctor, needs to decide if she is at high risk for the development of breast cancer. If you have already had breast cancer, have a strong family history of breast cancer, or have had other breast disease that your doctor tells you might later lead to cancer, estrogen should not be used. For other women, the small possible risk for the development of breast cancer should be weighed against 1) the improvement in symptoms, 2) the age of the woman, and 3) the number of years she might need to take hormones.

Stroke and dementia

HRT slightly increases the risk of having a stroke. This effect is more important in older women than in younger women. Dementia (impaired brain function) is something that worries all of us. Some early studies suggested that the use of HRT reduced the risk of developing dementia, while newer studies are not so clear. Certainly, women who are having severe hot flashes and are sleep deprived during menopause may develop difficulty in thinking clearly. Also, some develop emotional moodiness and trouble concentrating. This does not mean that dementia is developing. It is interesting that men who are sleep deprived have been shown to have the same emotional moodiness and trouble concentrating. And in the studies where HRT was started at an older age in women, there seemed to be higher risk of developing dementia.

The decision:

So should you take HRT? It certainly depends on whether you have symptoms related to estrogen deficiency. All of the currently available facts seem to point to the idea that there might be a window of time when HRT is most effective, and least likely to cause health risks. Your doctor will evaluate all of your factors to determine whether HRT can help your symptoms, improve your quality of life, and keep you healthy in your later years.

Dr. Rhoda H. Cobin was a member of the original board of AACE, a past president of AACE and of ACE. She has had a longstanding interest in reproductive endocrinology. For many years, she chaired the Reproductive Committee of AACE, overseeing many issues related to women’s health including PCOS, with an emphasis on cardiovascular and metabolic risk, issues related to amenorrhea, and menopause management. Dr. Cobin chaired the AACE Guidelines for the Management of Menopause, as well as the AACE position statement on Hormone Replacement Therapy and Cardiovascular Risk. Dr. Cobin is Clinical Professor of Medicine at the Mount Sinai School of Medicine in NYC and has practiced clinical endocrinology in New Jersey for over 30 years.