Menopause
Definition
Note to readers from
the Brookside Associates:
Although this page faithfully
reproduces the original Operational Medicine 2001, there is a
better (updated, with pictures) version of it in
Military 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.
Symptoms
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.
Associated Medical Problems
Following the loss of a regular supply of estrogen, a number of medical problems can
gradually arise.
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.
Clinical Presentation
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:
- Substantially reduced risk of osteoporosis
- Reduced risk of cardiovascular disease
- Improved memory
- Reduction or elimination of hot flashes and night sweats
- Reduction or elimination of sleeplessness and depression
- Reduction or elimination of vaginal dryness
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,
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.
Standard Treatment
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.
Conjugated estrogens, for example,
are usually used in a 0.625 mg pill, but also come in a smaller (0.3 mg) and larger (0.9,
1.25, 2.5 mg) pill. Start with a standard dose of estrogen (0.625 mg) and then you may adjust
the dose higher (if she continues to experience hot flashes), or lower (if she experiences
significant, persistent estrogen side-effects). If laboratory facilities are available, a
good target range for serum estradiol levels among
menopausal women on ERT would be about 50-100.
Progesterone also comes in different doses. If progesterone is to be taken continuously, a dose of 2.5 mg
per day is generally sufficient to protect against endometrial hyperplasia. If taken for
shorter periods of time (cyclic therapy), then the dose needs to be higher to achieve a
similar effect on the uterus. If taken 10 days per month (the shortest recommended time)
then a full 10 mg each day is indicated.
Continuous treatment often consists of:
OR
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:
OR
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.
Birth Control Pills
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.
Risk of Pregnancy
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.
Follow-up
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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