House Calls runs every other Thursday. Today’s column is written by Christopher B. Cutter, a physician at Sutter Coast Community Clinic.
Few things are as certain as the eventual onset of menopause in a middle-aged woman.
At the average age of 51.2 years, the quarter million primordial eggs that she was born with will be gone. As a result of that, she will abruptly stop producing estradiol and progesterone, whose waxing and waning presence had been in her life since just prior to puberty.
If she is lucky, she may feel just fine. Otherwise, she may join the millions of women who start to suffer with prolonged hot flashes and other body changes that often become a real challenge.
The most common symptom of menopause by far is the hot flash (or flush). It is uncomfortable, unpredictable, and disturbs day-to-day activities as well as causing sleep deprivation. The flashes may begin many months before the actual drop in hormone levels and some women may even be told it is all in their head.
Other symptoms are less common, but definitely get the attention of the person who has to deal with it. These include ringing in the ears, palpitations (irregular heart beat), anxiety attacks, crying jags, depression (sometimes quite severe), pruritus (itching skin), intimacy issues (loss of libido), irritability and fatigue.
What about physical changes? Her bone density will start to drop rapidly and immediately and osteoporosis is likely if not treated. Her beautiful hair may start to thin and fall excessively. Her skin may look less youthful and acne can develop. Intimate physical relations can become uncomfortable and urinary problems she hadn’t ever pictured for herself may become an issue.
We should not forget that this event is also felt to be one of the reasons why a woman begins at this time to have heart attacks at the same rate as men. Medical studies have shown that the natural production of estrogen is of great benefit to the heart and blood vessels. Other studies showed that the premature removal of the ovaries (usually from surgery), results in a significantly higher overall death rate in women, mostly from cardiovascular diseases (stokes and heart attacks).
When dealing with women who present with these symptoms, it is comforting to know that there are many options for treatment. The most direct way is to carefully replace the missing estrogen (estradiol), and if she has a uterus, the progesterone. For women that absolutely should not be on hormones (those with diagnosed breast cancer, recent blood clots or certain types of strokes), we can help with non-hormonal medicines that have been found to reduce some of the symptoms.
But weren’t there some studies a few years ago that showed that hormones are bad for you?
This is the most common question that women ask and it is a very important one. The main study that was done was called the Women’s Health Initiative and it was closed prematurely in 2002 after it was shown that the women using Premarin and Provera had a higher than expected rate of stroke, myocardial infarction, breast cancer and even dementia in some cases. (Little attention was brought to the benefit seen with decreased fractures and colon cancers). Subsequently, these results have been analyzed over and over by impartial reviewers and some very important conclusions and lesson were learned.
One of the reasons there were increased poor outcomes was because the women in this study were, on average 18 years past their menopause. They were much older than women who are normally started on hormone therapy, and therefore at much higher risk for every complication. The other thing was that almost none of these women had significant menopausal symptoms! Because this was to be a blinded study, the women were excluded if they had hot flashes. Therefore, the vast majority were women who would not have opted for treatment in the first place.
Subsequent studies have shown that it is the asymptomatic woman who often has the most side effects from treatment. Another often ignored fact was that all of the adverse heart events occurred during the first few years of treatment, and after five years of use there was a powerful reduction in heart attack risk.
The other fact that was often ignored was that there were two groups to the study, and the second group was treated with Premarin only — no synthetic progestin. That group actually had less breast cancer than placebo, had no increase heart attacks and only a very small increase in strokes.
In my practice, I found that blood clots (deep vein thrombosis), combined with their traveling to the lungs (pulmonary embolus) is one of most concerning side-effects of hormone therapy. This risk is actually much higher with birth control pills than with standard doses of menopausal hormones. The risk goes up if the woman smokes.
Fortunately, recent research has shown that if the estrogen dose is given through the skin (rather than by mouth) the risk of these clotting problems is greatly reduced if not eliminated. This is great news, since we now have access to estradiol in both the patch and gel formations that we can adjust to each patients needs.
Lastly, there is growing research that the use of natural progesterone — not the synthetic form — is a much safer progestin and can be safely given by mouth. It is readily available through pharmacies, but does cost more.
Many vaginal estrogens are now available and these are felt to be very safe because of the extremely low dose required to get a beneficial effect on those tissues. This can bring relief to women suffering from dryness and bladder problems with minimal worries about safety.
The important message that women should take home here is that if you are suffering with menopausal symptoms that are disrupting your life, you have every reason to bring these concerns to your provider and discuss available options. Hormone therapy is still a very viable, safe alternative for women who want and need it, and medical science has shown us new ways to make it even safer.