Aging in women is associated with the menopausal transition. At the menopause a child-bearing woman has to cope with cessation of her periods and many changes both physical and mental. Before the menopause women are at a lower risk for heart attacks than men, after the menopause women have the same risk for heart attacks as men.

After the menopause, women lose bone (osteoporosis) and are prone to fractures of the hip, vertebrae, etc. Women at menopause become irritable, have mood swings and hot flashes. The list of problems developing at menopause goes on and on.

What is the menopause?

This is the time in a woman’s life when her period stops. It is a normal part of aging and begins years before the actual cessation of periods. At this time, the levels of hormones go up and down and cause problems such as hot flashes and vaginal dryness, among others.

Types of menopause

Natural – Occurs around 45-55 years in the average woman. A woman is said to have attained menopause when she has not seen her period for the duration of one year.

Surgical – This occurs when the ovaries are removed surgically, generally as a part of a hysterectomy.

Post radiation – When a woman undergoes radiation therapy for certain types of cancer it can cause the ovaries to stop functioning.

Natural menopause is gradual in onset, over a period of years, whereas surgical menopause is abrupt and almost overnight the woman is deprived of the hormone support provided by the ovaries.

Surgical menopause is far more severe in producing symptoms such as hot flashes, because of its abruptness.

Problems associated with the menopause

These are classified as major health problems and minor ones that are usually transient:

Major Problems

Osteoporosis

Cardiovascular disease

Strokes

Memory loss

Colorectal cancer

Relatively Minor

Problems

Hot flashes

Insomnia

Vaginal dryness

Reduced libido

Considering all the health problems associated with the menopause, physicians devised hormone replacement, whereby hormones – either estrogen alone or estrogen together with the other female hormone progesterone were administered to menopausal women.

The initial studies were very impressive and all analyses were in favour of the use of hormones. It was believed that with hormone replacement therapy (HRT) “maybe” women could retain their youth for a much longer period of time. Hormones were touted as a panacea for all age-related changes in women, from hot flashes, to loss of libido, to vaginal dryness, to aging of the skin, to heart disease and osteoporosis.

In July 2002, the Women’s Health Initiative (WHI) – a large multitiered, clinical trial first reported that hormone replacement therapy actually posed more health risks for women than benefits.

At this point we will digress and mention that hormone replacement may be given as estrogen alone (for patients who have had a hysterectomy) or as estrogen and progesterone – sequentially or combined (for patients who have an intact womb).

In women who were on the estrogen/progesterone combination

The WHI study found a greater risk for:

Heart disease

Breast cancer

Stroke

Blood clots

Dementia

The hormones also did not help sleeplessness, sexual satisfaction or general health. In fact the statistics on increased risk of breast cancer with estrogen replacement along with progesterone were so alarming that the WHI discontinued this arm of the study prematurely, because they could not justify exposing these women to the significant risk of developing breast cancer.

In the women who were on estrogen alone

The study found only a slightly increased risk of stroke.

Benefits of HRT according to the WHI

The two important benefits that were found in the WHI study, regardless of whether estrogen and progesterone were given or estrogen alone was used, were:

A decreased risk of osteoporosis related hip fractures.

A decreased risk of colorectal cancer.

Does age matter when considering HRT?

The majority of the women studied by the WHI study were older women. This is considered one of the flaws of the study by advocates of HRT.

The women included in the study were an average age of 63 years.

When women aged 50-59 years who took estrogen were studied, it was found that they had fewer heart attacks and deaths from heart disease than participants taking a placebo.

Therefore HRT in younger menopausal women may not have the terrifying implications that it does for older women.

To address the issues of younger women and HRT, a study called KEEPS (Kronos Early Estrogen Prevention Study) is under way, but it will take several years to complete.

Will you benefit from hormone replacement?

In spite of all the inherent health risks mentioned, HRT still has a role in treating menopausal symptoms especially when severe. Discuss your particular problems with your doctor.

You may need short term replacement,

To treat hot flashes – HRT is still the most effective treatment.

Local treatment – To treat vaginal dryness, itching, burning and discomfort with intercourse.

Long term treatment – It is recommended for osteoporosis prevention and treatment, if a patient is considered at risk for osteoporosis and other medications have been deemed unsuitable.

A word of caution

Women already on HRT, or considering it, should take the lowest effective dose and for the shortest amount of time needed to treat their symptoms.

Who should avoid HRT?

Women with breast cancer or a history of blood clots should not take HRT.

Does HRT help to prevent heart disease?

If you are considering HRT for preventing memory loss, heart disease, heart attacks or strokes, don’t take it, because it has been proven not to prevent these problems.

Are there alternatives to hormone replacement?

Healthy lifestyle changes may make a big difference in managing menopausal symptoms.

Don’t smoke

Remain physically active

Eat a low fat, high fibre diet

Manage high blood pressure

Keep cholesterol in check

Control diabetes

Avoid excess alcohol

Maintain a healthy weight

For osteoporosis prevention

The alternatives to be considered before considering hormones are:

Calcium and vitamin D

Weight-bearing exercise

Drugs such as Fosamax, Raloxifene and Calcitonin

Is there a role for alternative medicines in menopause?

Several herbal medicines are being researched. Black Cohosh and soya products, among others, are the subjects of ongoing research. Whether any of these help and whether they have any serious side effects are questions on which the jury is still out.

The most important measure for menopause management is not to think about it as a disease but as a period when the body undergoes changes. This is a time for women when a transition is occurring from the child-bearing years to those devoted to caring for a partner, maybe, grandchildren or other members of the family. Psychologically, this may be a difficult time due to retirement from the woman’s occupation.

This transition should not imply a decline in the health of the woman and she should try to remain physically active. If all general measures fail, HRT can be discussed with a physician and for an individual, short term or long term, the benefits may out weigh the risks; however, it should be an informed choice that is made.