"I was 45 when I first started having night sweats. I'd wake up in the middle of the night, and even though the air conditioner was running full blast, I'd be covered in sweat. Those night sweats — and the other symptoms I began to notice — suddenly made me feel old. One day, I'm a young woman in her prime, and the next day, I'm worrying about whether or not I'm prepared for retirement, and thinking about 'getting my affairs in order.' It was a classic overreaction."
"I didn’t really worry about menopause. It’s just one of those things that all women go through. Sure, I was bothered by some symptoms. But they were manageable — they didn’t slow me down."
"No longer having periods or needing to think about birth control was a welcome change!"
These women are talking about their experiences with menopause – what many women refer to as the "change of life" that signals the end of a woman's reproductive years. While menopause used to mean withdrawal from active life for many women, this is not true today. Yet, some women still worry about what will happen and what they should do when menopause arrives. Women may experience a wide range of feelings, from anxiety and discomfort, to release and relief. Most adapt to the changes and continue to live well and remain healthy through these transitions.
"Today, women entering menopause are healthier, feel younger than their years, and lead more active lives..."
Most of today's women will live 25 to 30 years — one-third of their lives — after menopause. An understanding of the body's changes during this phase of life can ease the transition, and equally important, better prepare you to safeguard your health during your later years. There are many different considerations a woman needs to take as she approaches menopause. Specific treatment for menopausal symptoms will be determined by your doctor based on:
- Your age, overall health, and medical history
- Current symptoms
- Your tolerance for specific medications, procedures, or therapies
- Your opinion or preference
Today, women entering menopause are healthier, feel younger than their years, and lead more active lives and careers than previous generations. Despite the problems menopause may bring, the years afterward are the most productive and satisfying for many women.
It’s Not All a Bad Rap: Positive Aspects of ET/HT
by Joe R. Childress, MD
Many people consider estrogen therapy and hormone therapy to be toxic and, at best, of no medical benefit; however, definite benefits exist for many women.
Decisions about use of ET/HT – and access those benefits – should be based on evidence, and patients should be counseled on an individual basis each year concerning the risks and benefits.
Significant information became available via the Women’s Health Ini-tiative, which used conjugated equine estrogen (0.625mg) in its studies. The progestin was medroxyprogesterone acetate (2.5mg).
And, while most women enter menopause at age 50 to 51, the mean age used by the WHI for starting estrogen plus progestin was 63.3 years and the mean age of women starting estrogen-only was 63.6 years.
The WHI in 2004 reported that invasive breast cancer was diagnosed at a 23% lower rate in women who used estrogen for 6.8 years, as compared to women assigned to placebo. Although this reduction in breast cancer was not statistically significant, the findings are reassuring that estrogen does not increase the risk of breast cancer in post-menopausal women aged 50 to 79 years with previous hysterectomy.
The absolute risk of breast cancer was low in both the treatment and the control arms of the study. Invasive breast cancer was diagnosed at a rate of 26 cases per 10,000 women per year in the estrogen arm and 33 cases per 10,000 women per year in the placebo arm. The risk reduction amounted to 0.7 fewer invasive breast cancer events per 1,000 patients per year.
The reduction in breast cancer was confined to ductal carcinomas, and no significant effect was seen with lobular cancer. In addition, no effect was observed on in situ disease. The reduction in breast cancer also was confined to women who had no prior exposure to hormones.
In contrast, the 2002 WHI estrogen and progestin study reported an increased risk of breast cancer in women using HT for 5.6 years. The risk was reported as 0.8 additional cases per 1,000 women per year in women aged 50 to 79. There was no increased risk in women who had never before used hormone therapy.
Additionally, younger women have less risk for breast cancer than older women. Values for risk that are based on the incidence of breast cancer in an older population will overestimate the risk in a younger, newly menopausal population – and 66% of the women in the HT study were 60 to 79 years of age.
The association between breast cancer and HT/ET is weak. Linking the finding of an increased risk of breast cancer in the WHI estrogen-progestin arm with an implication of causality would be inappropriate. Likewise, linking the finding of a decreased risk of breast cancer in the WHI estrogen-only arm with protection would be inappropriate.
Obesity and family history have higher relative risks for breast cancer than estrogen-progestin. Considerable evidence supports the concept that HT promotes the growth of pre-existing breast cancer. The etiology of breast cancer appears to be multifactorial.
Osteopinia and Osteoporosis
The most dramatic and rapid bone loss leading to low bone mineral density occurs during the first five to seven years of menopause or in the fifth decade of a woman’s life. It is not rational to wait to initiate therapy until the sixth or seventh decade.
Women who enter menopause at an early age – either naturally or surgically – are at an extremely high risk for osteoporosis. Prevention of post-menopausal fractures was demonstrated in both the estrogen-progestin and estrogen-only arms of the WHI, and both vertebral and hip fractures diminished unequivocally.
A window of opportunity to prevent osteoporosis exists when women enter menopause. Although ET/HT also prevents fractures when initiated many years after menopause, prevention of bone loss and preservation of bone architecture is better than treatment after significant loss. Also, the effects of estrogen in osteoporosis prevention are lost when estrogen is discontinued, after which rapid bone loss ensues and fracture rates increase.
Vertebral compression fractures are the most common fragility fractures due to osteoporosis. Postmenopausal women with a vertebral fracture have a two-fold increase in the risk for a hip fracture, which can result in significant morbidity and mortality. Only about 33% of patients regain their pre-fracture level of function, and an estimated 20% of women who suffer a hip fracture die in the year following as a consequence of the fracture.
Estrogen/hormone therapy is equivalent to bisphosphonates in its effect on bone density, and estrogen is less expensive. Women need estrogen, vitamin D, calcium, and weight-bearing exercise working in concert in order to prevent bone loss.
Coronary Heart Disease
The unified hypothesis, published in 2005, predicts that hormone therapy initiated at the time of menopause should produce a decrease in coronary heart disease over time, and therapy begun years after menopause should produce an increase in CHD events shortly after therapy is begun, followed later by benefit. The findings of the WHI tend to support the window of opportunity concept. In the WHI estrogen-alone centrally adjudicated data reported in February 2006, only women using ET who were 20 or more years distant from menopause had a statistically significant increased CHD risk. Women who were between the ages of 50 and 59 at the start of the study, however, demonstrated a statically significant (34%) lower risk for CHD.
Also, in subgroup analysis the WHI report for HT showed greater risk with initiation of therapy at longer intervals since menopause: RR=0.89 for <10 years since menopause; RR=1.22 for 10 to19 years; and RR=1.71 for 20+ years. The findings of the Nurses’ Health Study support the possibility that timing of HT initiation in relation to either menopause onset or age influence coronary risk.
In the Nurses’ Health Study, the large majority of women started HT near menopause, and they reported a 30% lower risk of CHD for women using ET or HT compared with postmenopausal women who never used hormones. If initiated at the onset of menopause before significant coronary artery disease, there continues to be reason to believe that ET/HT will have a beneficial role in CHD prevention.
Quality of Life
Estrogen or estrogen and a progestin are the most effective treatments for hot flashes and night sweats. Hot flashes occur with varying intensity in approximately 85% of menopausal women. Most hot flashes resolve within about four years, but about 10% of women will continue to have symptoms that interfere with their quality of life. Women who experienced hot flashes were excluded from the WHI study; therefore, the WHI cannot address the most common reason for women starting ET/HT.
Estrogen is effective for treatment of vaginal dryness and vaginal atrophy and consequently promotes sexual functioning in postmenopausal women. Estrogen also is effective in relieving dryness, itching, burning, and dyspareunia, regardless of the route of administration. Although numerous factors can result in low sexual desire, estrogen deficiency resulting from menopause can have a significant impact on a woman’s sexual functioning. Thinning of the vaginal epithelium, vaginal dryness, and loss of vaginal smooth muscle all are associated with estrogen deficiency. Furthermore, estrogen helps to prevent sexual pain disorders. Maximum benefit of treatment for quality of life requires early onset of therapy.
Thromboembolic Disease, Stroke
The risk of venous thromboembolism in the estrogen plus progestin WHI was 1.8 additional cases per 1,000 women per year, and in the estrogen-only study the risk of VTE was 0.7 additional cases per 1,000 women per year. The risk was higher in the first year of exposure, and deceased with increasing duration of use. Women with factor V Leiden and with a history of VTE should not use ET/HT due to a greater risk of thrombosis. Women who are obese and older have a greater risk of thrombosis.
The risk of stroke was increased with HT and with ET. The increased risk in the estrogen-only study was 1.2 additional cases per 1,000 women per year. Women in the estrogen-only arm also had a greater incidence of hypertension and diabetes mellitus, both known risk factors for stroke, than did women in the estrogen-progestin arm.
Not all postmenopausal women are candidates for ET/HT. Many women are frightened by the WHI findings, and have elected to stop ET or HT. Meanwhile, information about the use of hormones in postmenopausal women continues to accumulate. Currently strong evidence supports the use of ET and HT for prevention of osteoporosis, for prevention of vaginal atrophy, and for prevention and treatment of hot flashes and night sweats.
Dr. Childress earned his med-ical degree from UTHSCSA in 1974, and completed both his internship and residency in obstetrics and gynecology with the Bexar County Hospital District. He began a private practice in San Antonio in 1978 and joined the Institute For Women’s Health in 2004.