THE HEALTH GAZETTE

Menopause usually occurs around the age of fifty years old. It varies from forty-five to fifty-five years of age. You can best estimate when you will go through menopause if you know when your mother went through "the change." This is just an estimate, but surprisingly correlates quite well with when you can expect to go through menopause. Menopause occurs secondary to failure of the ovaries to produce estrogen and progestin which are the female hormones. This is a gradual process occasionally taking two to three years. Symptoms vary from only the cessation periods to a multitude of annoying symptoms. The most common symptoms are sweating, hot flashes, fatigue, vaginal drying, pain with intercourse, low sex drive and depression. Usually these symptoms will eventually resolve even without taking hormones. Taking estrogen will definitely stop these symptoms.

I will discuss some of the pros and cons of taking estrogen and/or progestin. First I will discuss some of the long-term problems that occur with the loss of estrogen at menopause. The bones lose calcium and become thin and brittle. This markedly increases the risk of bone fractures. More than 120,000 elderly women fracture their hips each year and about 15% will die from complications of the hip fracture. The process in which the bones become weak and brittle is called osteoporosis. Collapse of the vertebrae in elderly women can occur because of the thin, weak bones. This is responsible for the loss of height as well as the "stooped-over" appearance known as a "Dowager's hump." Much of the bone loss occurs in the first five to ten years after menopause. Estrogen replacement therapy stops this rapid bone loss and reduces hip fractures by 25% and spine fractures by about 50%. Unfortunately the process of osteoporosis is not reversible with estrogen replacement therapy. That makes it important to start hormones early after going through "the change" before the process has already resulted in weak bones. Preliminary studies suggest that estrogen replacement therapy may reduce the risk of Alzheimer's disease by up to 40%.

Another long-term problem is the change in cholesterol that occurs with the loss of hormones. The total cholesterol will increase and the good cholesterol, which is called the high density lipoprotein (HDL) cholesterol will decrease. Both of these changes result in a higher likelihood of developing coronary artery disease and subsequently having a heart attack. Estrogen replacement therapy prevents these changes and will reduce the risk of dying from a heart attack by about 35%. This is really the most significant advantage to taking hormones after going through menopause.

Unfortunately there are some potential risks from taking Estrogen. Taking estrogen (Premarin) without progestin (Provera) will increase the risk of endometrial cancer by up to eight fold. This is why we recommend taking progestin with the estrogen. Studies have shown that the combination of Premarin and Provera does not result in an increased risk of endometrial cancer. In women who have had a hysterectomy, it is not necessary to take Provera since they do not have a uterus and therefore are not susceptible to endometrial cancer. The addition of progestin to the estrogen will slightly decrease the beneficial effect that estrogen has on lowering cholesterol.

Another risk of taking estrogen is the increased chance of developing breast cancer. There is a lot of disagreement as to whether there is truly an increased risk of breast cancer, but a general consensus is that the risk is increased by about 25% if estrogen is taken for ten to twenty years.

As you can see, there are risks as well as benefits from taking estrogen replacement therapy. Several studies have actually looked at the life expectancy in women taking estrogen versus those that don't take estrogen. In about all situations, the life expectancy is increased if you take estrogen. This is mainly because of the lower risk of heart attacks when you take estrogen. The prevention of osteoporosis can potentially save lives. One study showed that taking estrogen after menopause was associated with an increased life expectancy of up to 2.3 years. Heart attacks are the leading cause of death overall in females. The annual death rate from heart disease in females in the United States is 359,000. Anything that will reduce deaths from heart attacks by 35% will save a lot of lives.

On the other hand if you have a markedly positive family history of breast cancer then the decision whether or not to take estrogen becomes more difficult.

Methods for Taking Hormones

There are three ways to take estrogen replacement therapy.

If you have an intact uterus (you have not had a hysterectomy):

1. Take Premarin .625 mg. on the 1st through the 25th of each month and Provera 10 mg. on the 13th through the 25th of each month. This is the standard method, but many women don't like the idea of continuing to have monthly periods. Periods will usually occur the last several days of the month. The periods may decrease in time, but the majority of women will continue to have some bleeding on a monthly basis.

2. The Premarin (.625 mg.) can be taken on a continuous basis, with the Provera taken in a lower dose (2.5 mg.), but taken continuously. This method will usually result in temporary vaginal spotting. After four to six months you will no longer have periods and you also do not have an increased risk of developing endometrial cancer. The advantage of this method is that over approximately a six-month period, the vaginal spotting will stop completely in most women.

3. You may choose to take estrogen without the addition of progestin. In this case there is usually no vaginal spotting, but the risk of developing endometrial cancer (cancer of the uterus) is increased eight fold. For that reason you will need to have an endometrial biopsy once a year. By having the yearly biopsy, the development of endometrial cancer can be detected very early when it is usually curable. If you have had a hysterectomy, then you need only to take estrogen. This is actually a good situation because there are less side effects of this method and you enjoy the maximum benefit of improving cholesterol without having any risk of developing endometrial cancer.

There are several forms of estrogen that can be taken. They are probably of equal efficacy. The exception is the patches which may not provide all the beneficial effects of oral estrogen. They are certainly better than not taking any estrogen at all and are sometimes better tolerated than oral estrogen. The patches don't seem to provide the same degree of beneficial effect on the cholesterol as does oral estrogen.

About 5% to 10% of women who take estrogen alone will experience side effects such as bloating, headaches and breast tenderness. However, in most women the symptoms are mild and will resolve after a few months of therapy. The addition of progestin to estrogen therapy may occasionally have some undesirable side effects. The most common are bloating, weight gain, irritability and rarely, depression. These symptoms may also improve with time. For the first three to six months, vaginal spotting will occur in 30% to 50% of women taking continuous estrogen and progestin. This bleeding will generally stop permanently in about 95% of women within a six-month period.

Other ways to help prevent osteoporosis are to walk or perform other weight bearing exercises on a regular basis. Regular exercise will also help reduce your chance of having a heart attack by 40%. You should also take between 1,000 and 1,500 mg. of calcium daily. Calcium comes in many forms that are equally effective, but Tums are probably the least expensive and provide 200 mg. of calcium per tablet. One eight-ounce glass of skim milk provides approximately 300 mg. of calcium.

In conclusion, I would like to say that taking hormones is a decision that each woman will have to make on an individual basis. I hope this discussion will help you in making this decision and I would be glad to discuss this important issue with you.

1. Archer DF. Hormone Replacement Therapy and Uterine Bleeding. Menopausal Medicine; April 1993 pp 1-3.

2. Berg AO. Clinical Guidelines and Primary Care. JABFP, March-April 1993; Vol 6 No. 2 : pp 153-58.

3. American College of Physicians. Guidelines for counseling postmenopausal women about preventive hormone therapy. Ann Intern Med 1992; 117:1038-41.

4. Zubialde JP, Lawler F, Clemenson N. Estimated Gains in Life Expectancy with Use of Postmenopausal Estrogen Therapy: A Decision Analysis. J Fam Prac 1993; 36:271-289.

5. Rickert B. Estrogen Replacement: Making Informed Choices. Office Nurse June 1993, pp 8-12.

6. Johnson R. Estrogoen/Alzheimer's link found. Medical Tribute for the Family Physician Dec 9,1993, pp 1 and pp 8.

The information provided above is offered as a community service about health-care issues and is not a substitute for individual consultation. Advice on individual problems should be obtained from your personal physician. This information is based on research by the author and represents his interpretation of the literature.