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Menopause:
When a woman stops her periods due to menopause, her ovaries stop producing two female hormones, estrogen and progesterone. This usually occurs between the ages of 45 and 55 with an average age of 51.
Common symptoms associated with menopause include hot flashes, night sweats, vaginal dryness, and sometimes heart palpitations, anxiety attacks, short-term memory loss, and difficulty concentrating. This is also a time in a woman’s life when there is more rapid bone-thinning as well as a worsening of cholesterol levels.
During peri-menopause, which may last for several years before periods stop, there are intermittent deficiencies in estrogen and progesterone, and menopausal symptoms may come and go.
Some women have relatively minor menopausal symptoms which they consider to be little more than an annoyance, while other women experience great disruptions in their lives due to these symptoms. The effects can be particularly severe when sleep deprivation occurs due to night sweats or insomnia. Symptoms tend to be more severe when the ovaries are removed surgically before the menopause compared to when the menopause occurs naturally.
Hormone replacement therapy:
Hormone replacement therapy typically consists of estrogen alone if a woman has had a hysterectomy and a combination of estrogen and progesterone if the uterus is still present. Testosterone replacement is less frequently prescribed.
Pros:
First, and foremost, are the beneficial effects of estrogen on hot flashes, night sweats, insomnia, and vaginal dryness.
These symptoms can sometimes be managed by life-style changes, such as reducing caffeine and stopping smoking, or by supplements such as black cohosh or soy. For many women, though, these measures are not adequate, and for them estrogen provides the greatest relief, allowing them to return to their normal life style.
The beneficial effect of estrogen on bones has been well established, and it can be very helpful in treating or preventing osteoporosis.
Benefits for the cardiovascular system have been suggested in the past, but more recently questioned. Until more evidence is available, this should not be considered one of the benefits of estrogen.
Observational studies suggest that estrogen may also help prevent aging problems such as Alzheimer’s and macular degeneration, and may reduce the risk of colon cancer by 30-50%. These studies are only suggestive, not conclusive, and many observational findings are disproved when larger groups are studied, or when randomized trials are conducted. The recent Women’s Health Initiative study, sponsored by the National Institutes of Health, and published in JAMA
(Journal of the American Medical Association) is by far the largest randomized trial to confirm the reduced risk of colon cancer in women on hormone replacement therapy.
The Nurses' Health Study at Brigham and Women's Hospital www.nurseshealthstudy.org and other large studies have suggested that women on HRT have a 30 to 40 percent lower rate of death compared to those who are not on the therapy. What is not known is if these women live longer because they are on the therapy or if it is because women who use HRT, in general, tend to take better care of themselves and are simply healthier to begin with. In the Women’s Health Initiative study mentioned above there was no difference in the survival rate between women who used hormone replacement and those who used a placebo for roughly 5 years.
Cons:
As with all medical treatments the benefits must be weighed against the potential side effects.
Whenever estrogen goes up in a woman, there is an increase in the chance of developing phlebitis (blood clots in the legs). This is seen in pregnancy and with birth control pills, and similarly, may be seen when menopausal women use estrogen replacement therapy.
Gall stones are also more commonly seen with pregnancy, birth control pills, and hormone replacement therapy.
Women are often concerned about risks for cancer that they have heard about with estrogen. The biggest increase in risk is of cancer of the uterus if estrogen is taken alone. For this reason, if a woman has not had a hysterectomy she is usually given estrogen in combination with progesterone as the progesterone eliminates the increase in risk of uterine cancer (just as progesterone does when produced naturally in women before menopause).
Many published studies have shown an association between HRT and breast cancer. A report from the Nurses' Health Study showed that a woman's risk of breast cancer increases with long-term use (greater than 5 years) of estrogen and is highest for older women (over age 65) who take estrogen. In the Women’s Health Initiative the increased risk was seen after 4 years of estrogen use. During that study women taking placebo developed breast cancer at a rate of 0.30% per year, while in women on hormone replacement the rate was 0.38% per year.
There is less data available regarding other cancers, but a recent study suggests that estrogen replacement may increase the risk of ovarian cancer, and, as mentioned above, it may decrease the risk of colon cancer.
In two studies, the Women’s Health Initiative study mentioned above, and HERS (Heart and Estrogen/Progestin Replacement Study – JAMA Aug 19, 1998), it appears that there is an increased risk of coronary heart disease in the first year or two after women start a particular continuous combined hormone replacement therapy regimen (Prempro). It is not clear whether this risk pertains to all women, or to a subgroup of women with preexisting risk factors for heart disease.
In the Women’s Health Initiative study, researchers decided that after 5 years the risks to women in the study outweighed the benefits, and the trial was halted at that point. Two thirds of the women in this trial were over age 60 at the start of the trial, with a mean age of 63. It is not clear that the relationship between risks and benefits is the same for women starting estrogen many years earlier when they first become menopausal. The risks/benefit ratio may also be different in women on hormone replacement regimens other than Prempro.
The Bottom Line: Menopausal symptoms, and their severity, vary from one woman to another. Risks and benefits seen in large studies may not be equally applicable to all women due to differences in personal and family medical history. An informed decision about whether to use hormone replacement therapy can be accomplished best by discussing your personal situation with a medical professional who is familiar with hormone replacement therapy and its alternatives. At Coastal Connecticut Research we are participating with major pharmaceutical companies in an effort to provide women with more options for therapy in this area, and with more information on which to base a decision. We are happy to help you decide whether to use hormone replacement, and we can offer clinical trials comparing existing HRT options or investigating new HRT combinations. For additional information, please follow the links to our HRT trials.
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