October 25, 2010

Menopause and Hormonal Treatment
By Carolyn Gutierrez
For The Record
Vol. 22 No. 19 P. 24

Once viewed as being a “disease,” menopause has shed that label but now faces questions about how its symptoms should be addressed, if at all.

Over the years, the public’s perception of menopause and hormonal therapy has been riddled with controversy, misinformation, and confusion to the point that many women are at a loss as to how to approach this midlife change in their bodies.

Natural menopause (which on average occurs between the ages of 48 and 52) begins when a woman has gone through one year without a period. Alan Altman, MD, a gynecologist specializing in menopause and sexual dysfunction and featured in the documentary Hot Flash Havoc, says, “Menopause is not a disease. It’s a natural transition in a woman’s lifetime. Basically, if you’re lucky, you live long enough to have your menopause, so there’s nothing unnatural about it or diseased about it. What’s very ‘unnatural’ is the relatively recent extension of life expectancy in this country for women into their mid-80s, and that means that women will be outliving their ovaries by three to five decades. That means that women are going to be living way beyond their ovarian function, and there’s a cost to that.”

 In the years leading up to menopause, subtle hormonal changes begin occurring in a woman’s body. Known as perimenopause, this biological transformation can start anytime from a woman’s mid-30s to early 40s.

Dee-Dee Shiller, DO, a gynecologist and director of the Women’s Wellness Center at Northwest Hospital in suburban Baltimore, notes that women beginning perimenopause “may have a change in menstrual cycles. There will be either shorter cycles—where they may have had a 30-day cycle, it’ll go to 25 to 26 or even 21 days—or they may skip periods as well. They may also start to get hot flashes at that time because they’re starting to get that drop in their estrogen level. But until they have that full year without a period, they’re not considered menopausal.”

Due to the low estrogen levels in the circulatory system and subsequently the brain, menopausal women may experience symptoms such as vaginal dryness, fatigue, weight gain, mood changes such as anxiety or depression, and, in some cases, sleep disorders and a decreased libido. However, the most ubiquitous effect of menopause is a hot flash.
Anatomy of a Hot Flash

According to James A. Simon, MD, CCD, FACOG, clinical professor of obstetrics and gynecology at the George Washington University School of Medicine in Washington, D.C., the reduction of estrogen at menopause affects the temperature control center in the brain, in particular the thermoneutral zone—the range of ambient temperatures in which thermoregulation in the body is achieved.

“When the hormones go down,” Simon says, “the thermoneutral zone where you feel comfortable gets narrower. So when your body temperature gets just a little bit too hot, you start to sweat, and if your body temperature gets just a little bit too cold, you start to shiver.”

But not all women get hot flashes during menopause. As Shiller points out, “There are studies that show that some cultures actually have less hot flashes overall. The question is, are they actually having less hot flashes or are they just having less reaction to the hot flashes—are they less sensitive to them? It may be diet related as well.”

Hormonal Treatment
Perhaps the most controversial topic pertaining to menopause is the use of hormones for treatment purposes. As early as the 1930s, estrogen was given to women to treat hot flashes. In the 1960s, a polarizing gynecologist named Robert A. Wilson created a stir in the media when he published a book titled Feminine Forever. Wilson described menopausal women as decrepit, nonsexual beings whose lives were essentially over at midlife. He considered menopause to be a “crippling disease” that made women dull and unattractive. Wilson’s push for estrogen therapy was seemingly not for the women’s sake but for their husbands; he maintained menopausal women taking estrogen would be “more pleasant to live with.”

During the sexual revolution, the discussion of linking a menopausal woman’s self-worth and identity with hormone use became a loaded one. Were women “retaining” their “youth” and sexuality via hormones for themselves or for their spouses?

In the 1970s, studies were conducted linking estrogen to endometrial cancer, but it was discovered that adding a progestogen to estrogen seemed to reduce this risk.

In the 1990s, after decades of use for hot flashes and other menopause symptoms, researchers and clinicians began looking at hormones for not only improving a menopausal woman’s quality of life but also for disease prevention—in particular, heart disease and osteoporosis. Hormone therapy was in high demand and became the gold standard for menopause treatment. Yet conflicting data regarding its benefits and risks continued to confound women, culminating with the results of the Women’s Health Initiative (WHI) study in 2002.

WHI Controversy
On July 9, 2002, federal health officials announced the suspension of the $725 million WHI study due to data showing that hormones increased a menopausal woman’s risk of heart attack by 29%. Women on hormone therapy were outraged and terrified, many of them flushing their hormones down the toilet.

“All of a sudden,” says Altman, “women were told that these things that their doctors and nurse practitioners were prescribing for them were poison. Women stopped trusting their clinicians. Millions of women stopped [taking hormones] immediately—the worst thing you can do with hormones is stop immediately. You begin withdrawal symptoms that are worse than the symptoms you started with.”

Physicians like Altman, who strongly believes in the benefits of hormone therapy, had to convince their patients to take another look at the data. Because of the media frenzy surrounding the WHI, “it’s taken a lot of effort for us to educate the public about this,” Altman says.

In the WHI study, the average age of the women was 63. Only 3.5% of the women in the study were aged 50 to 54, the time when most menopausal women consider taking hormones. When the data were released to the media, a sweeping generalization was made about the dangers of hormones to all women, regardless of age. While the data did indicate a heart attack risk for the older women, researchers eventually showed that hormones were protective for the younger age groups of menopausal women.

“There appears to be a little bit of a double-edged sword to the use of estrogen,” says Simon. “It’s good for you if you start near menopause, but it may actually make things worse if you start many years from menopause.”

According to Altman, the initial WHI results were misleading. “Based on the decades of observational studies before WHI, also based on WHI itself, and based on studies that have come out after WHI, there is no doubt that if you start the appropriate hormone at the appropriate time (and we believe that to be within five to eight years of your final period), you will cut your future risk of heart attack by 35% … and will cut your future risk of dying from any cause at all—total mortality—by a statistically significant 40%,” he says.

Altman also maintains that hormones given to the proper age group have been proven to protect the bones, skin, mucous membranes, immune system, and blood vessels. As for the relationship between breast cancer and hormone therapy, he says the jury is still out.

“If you look back to the smoking and lung cancer [studies], every single study that was done looking at smoking and lung cancer showed a major statistically significant increased risk of lung cancer if you smoked. That was what we called consensus—total consensus in the studies [and] in the literature. With breast cancer and hormones there is no consensus,” Altman says. “Some studies show slight increase; some studies show slight decrease; some studies show no change. The benefits outweigh the risks.”

In their July executive summary on postmenopausal hormone therapy, researchers from the Endocrine Society examining the data from the WHI study concerning the risk of breast cancer concluded that “no single estimate of absolute risk can be provided for an individual woman because risk varies with time of initiation [of hormone therapy] relative to final menses, duration of use, and body mass index, and possibly with type of progestogen and family history of breast cancer.”

Depression and Decreased Libido
Estrogen may also play an important role in treating depression in menopausal women. “We know that estrogen, when it decreases, leads to changes in the brain that predispose women at risk for depression with depressive symptoms,” Simon says. “That’s fairly well established. It’s also clear that women with menopause can have a decrease in their interest in sex, whether they have a partner or not. Those effects seem to be related to the neurotransmitters in the dopamine pathway in the brain and then the serotonergic pathway in the brain. When estrogen goes down, the amount of serotonin in the brain goes down, and depressive symptoms can kick in. When we decrease estrogen, norepinephrine—another neurotransmitter—and dopamine go down, and women have less interest in sex. So the key here is that estrogen has a very important effect on neurotransmitters in the brain—those brain hormones that conduct all the business of the brain—and when estrogen goes down, the amount of those brain hormones changes and some of the brain hormones are related to interest in sex, some of them have an effect on mood and depression, and still others have an effect on cognitive function.” When taken early enough, hormones are believed to be protective against short-term memory loss and even Alzheimer’s disease.

According to Altman, the most beneficial hormone combination is “a nonoral estrogen, which means patch, gel, vaginal ring, cream (if it’s FDA approved) plus a natural progesterone.” Many clinicians prefer the transdermal delivery of estrogen because it bypasses initial processing by the liver. Doing so is thought to minimize the risk of any possible cardiovascular side effects. In addition, clinicians are able to prescribe lower dosages when the hormones are absorbed directly into the bloodstream.

Other Treatment Options
As an osteopath, Shiller’s main focus tends to be holistic, meaning she looks at “the whole picture” of the menopausal patient. Many of them, she believes, do not need intervention. “One of the things I start with for someone who’s just having mild symptoms is some lifestyle changes,” she says. “Stress reduction and meditation, regular exercise, [and] decreasing the amount of spicy food, alcohol, and caffeine that they consume. These things can help systematic hot flashes. Other alternatives to hormonal therapy include medications such as Effexor and clonidine, a blood pressure medicine. The herbal remedies aren’t really proven in the literature to be helpful … but the things that they could try would be black cohosh, soy-based products, etc.

“I look at the patient’s overall well-being. I look at their age, I look at what their symptoms are, and then we decide together, based on family history and cardiovascular risks, if they are a good candidate for hormones. I also try to put them on hormones for as short a time as possible. My target is usually between five and 10 years. Our goal is the shortest amount of time at the lowest dose for the results that we need.”

An active lifestyle that includes wholesome food choices, exercise, and a healthy sex life (which can benefit vaginal and bladder tissues) can improve the quality of life for those entering menopause. Studies have shown that exercise has had a positive impact on women’s mood during midlife.

“In my experience,” Shiller notes, “patients just want to know what they’re going to go through. They’re interested in educating themselves. The days of being scared to death about what you might go through, whether it be physiologic or not, are over. Women are very interested in knowing. They come to my office asking ‘What can I expect?’ and ‘How can I go through it gracefully?’ And just like everybody went through puberty, everybody will go through menopause. And just like most girls do not need intervention when they go through puberty, most women don’t need intervention when they go through menopause. I think that’s kind of a good way to look at it.”

Education about what to expect during menopause and available treatment options are paramount for women of all ages.

“People need to be educated so they can make better decisions with their healthcare provider,” says Altman, “and that takes time.”

— Carolyn Gutierrez is a freelance writer based in New York City.