Menopause - Women Health Information Page

What Is Menopause

Estrogen Dominance

Women who have suffered from PMS and women who have suffered from menopausal symptoms will recognize the hallmark symptoms of estrogen dominance:

• Weight gain
• Bloating
• Mood swings
• Irritability
•  Depression
• Tender breasts
• Headaches
• Fatigue

Controlling The Symptoms of Menopause

Natural progesterone is derived from wild Mexican yam and other plant sources. Natural progesterone is identical in molecular structure to the progesterone produced by the human body. Phyto-estrogens are estrogens that are also derived from plan sources and when used in combination with phyto-progesterone are effective and safe.

A woman suffering from estrogen dominance can still be lacking in estrogen. Just not as much as with progesterone. For many women the best results are attained by using a combination 2 in1 cream. That contains both natural progesterone and plant based estrogens. Thousands of women have experienced relief from their menopausal symptoms by using a high quality, natural, phyto-progesterone/estrogen cream. The body is rebalance within 72 hours. What is most important is to listen to your own body. Optimum dosage is based on managing your symptoms.

You’ve had that feeling before, remember? It came in the form of a blaring alarm clock the night before when you did more weeping than sleeping. Your mate’s suggestion? See a psychiatrist. Good advice, wrong medical field; gynecologist, internist or general practitioner is more like it.

Menopause affects women in many different ways. Some feel they’re about to faint or experience a heart attack, while others will become overly sensitive, highly depressed and cry for no reason. You no longer feel desirable. And any compliment from your mate could send you right over the edge. All in all, the tremendous hormonal fluctuations during this confusing time are uncomfortable and disturbing sensations.

If you’re over age 40, you’ve just entered the Outer Limits. It’s not your fault your dysfunctional ovaries are now controlling the horizontal and vertical lines of your normal behavior pattern. About 80% of all menopausal women suffer, some more than others. This imbalance is more severe in women who do not sweat, whose menopause was surgically induced, and who are also enduring external stress.

Your gynecologist or internist can prescribe estrogen and progesterone to help you endure this change of life. However, there are quite a few natural remedies that can help you get through this difficult time.

If you are not diabetic, high doses of Vitamin E can be effective. Diet supplements containing black cohosh, unicorn root and ginseng have helped some women. Licorice root works to balance hormone levels. Japanese women report that a daily menu of rice and soy helps them control their hot flashes. There are numerous herbal and homeopathic remedies on the market aimed at balancing hormone levels.

Keep in mind the store attendant is not a medical expert and is not interested in whether you are diabetic or asthmatic; some of these remedies, like ginseng, could do you more harm than good. Be sure to ask your doctor about the supplements before you purchase them.

Some women report that moderate exercise and an active sex life help them because both activities raise important endorphin levels. Others may turn to meditation and visualization to promote a more positive mood.

Recent studies show that hormone levels do, in fact, affect sleep. Doctors have been looking closely at melatonin, a hormone secreted by the pineal gland. If you are disturbed by night sweats, melatonin has been proven successful in treating insomnia and jet lag. However, this supplement can cause depression in some women, which may defeat the purpose.

Chamomile tea and St. John’s wort with Kava Kava also help menopause-related insomnia. Sage, which contains plant estrogens, reduces excessive sweating and also helps reduce the frequency of night sweats.

Another safe way to get a good night’s rest is pamper yourself with a soothing, hot bath before bedtime. Take calcium in your preferred form and listen to soft music or a mood enhancement audio tape.

Yes, the new millennium has given the “M” word a name. So it’s okay to talk about your symptoms with mature family members and compassionate friends. Your mate, in particular, needs to understand this menopausal passage in order to help you get through it.

Written by Sharon Raiford Bush

Title: The safest ways to stop hot flashes
Description: Hot flashes are a reaction of menopause. The pulse races, skin reddens and then drenching sweats occur. That's what 80% of menopausal women experience. There are alternatives to hormone replacement therapy.

The main reason that a woman starts to experience changes is due to two factors: estrogen and progesterone. As a woman grows older, the balance of these two important chemicals may be changed. After age 35 estrogen production decreased enough to produce changes in the body. These changes are what perimenopause is all about.

The changes may start with irregular periods in the woman’s thirties. These can include periods of longer duration, shorter duration, too much bleeding, less bleeding, or no bleeding at all. These changes will increase as the woman enters her forties. According to the book, Perimenopause: Changes in Women’s Health After 35, by Dr. James Huston & Dr. Darlene Lanka, it is important to alert your doctor when your period becomes irregular. A period cycle that is less than 20 days long can be an indicator for endometrium disorders. Excessive bleeding may cause anemia or other problems. Women who wish to have more control over their cycle may opt for hormone replacements at this point.

Hot flashes are experienced by 85 percent of American Women according to research done by Dr. Fredi Kronenburg (1990). He reported that 75% of the women who report having hot flashes experience them for 1-2 years. 20-50% experience them for 5 years, and 10% report an indefinite time for experiencing this symptom. Hot flashes occur when blood vessels dilate and bring large amounts of blood to the surface. This causes the skin to appear red. Essentially, everyone has a heat conservation system. When it is cold, blood vessels constrict near the surface to maintain vital organs. In a hot flash this system is thrown off kilter, and heat is released even though it is not necessary to get rid of it. Typically this hot flash will last 3 to 5 minutes, but recovery from the hot flash can take up to a half hour.

Hot flashes can be dealt with through replacing estrogen, exercise, and alternative remedies. Some studies suggest that women who are very slim are missing levels of estrogen that are stored in fat cells. For some people putting on a few pounds will assist them in avoiding hot flashes. It is important to avoid trigger situations. A large meal can direct a great deal of blood to the digestive system, and that can trigger a heat release reaction. Avoid environments where you will not be able to escape excessive heat. Hot weather, overheated rooms, a hot tub, too many bedclothes, and too much clothing can make hot flashes harder to deal with.

Mood swings can be drastic during this transitional period. Phone commercials on television can reduce a woman to tears. Touching pictures or memories can make a normally stoic woman collapse into hysterical weeping. It is difficult for a woman to feel out of control in terms of her emotions. Women may feel they are suffering from a mental illness or depression. It is important to rule these out of course, but it is very possible these variable moods are the result of hormonal changes again. A doctor can check progesterone levels to make sure these are not too low. This is determined by blood tests done at various points of a woman’s cycle. Low progesterone can cause irritability, anger, weepiness, and generally unstable behavior. A progesterone supplement can reduce symptoms significantly within the first month of treatment. The risks of cancer are greater for a person with progesterone deficiencies. This is a wonderful treatment that can help a woman feel like herself again.

If you are experiencing the symptoms discussed or other symptoms that might be related to your reproductive health. The option of alternative healing techniques can be a consideration. Some traditional medical doctors are more receptive to alternative treatment than others. Talk with your doctor, or find a doctor that is willing to explore these methods with you. Homeopathy is a method that uses medicine that is highly diluted, and said to encourage the body’s own healing powers. Herbal treatments such as Ginseng, and Black cohosh have been tested and the results show they can be very effective in helping women with estrogen deficiencies. Patients of acupuncture and acupressure report relief from specific symptoms. These alternatives are other routes to take when seeking relief from perimenopausal symptoms.

It is frightening to consider going through menopause when a woman is in her mid-thirties. Even referring to it as perimenopause does not lessen the blow of a woman aging. It is better to regard menopause as a process. The early stages of menopause include symptoms such as menstrual changes and moodiness, and the later stages may include hot flashes, vaginal dryness, and ultimately the last menstrual cycle. Just as puberty was a process of development. Perimenopause and menopause are the process of closing the door on a reproduction. The transitions are certain to bring some chaos as most change does, but utilizing some of the methods described can make this movement to later life more smooth and enjoyable.

Written by sally nulph

Title: Information on perimenopause
Description: Women experience symptoms of perimenopause long before menopause. It is important to know what to expect in terms of emotional changes, hormones, and general health options.

These relatively new clarifications of the mythic nature of women’s heart treatment show that heart disease is actually the biggest killer of American women, with over 240,000 dying annually. At least 21,000 of these women are under the age of 65. Women with a negative heart history in the family, and particularly if high blood pressure is present, need to take proactive steps such as quitting smoking, reaching and maintaining a normal weight, and engaging in a healthful program of exercise to minimize their risk of serious coronary consequences.

Women who are postmenopausal should discuss the use of estrogen-replacing hormones. While further studies are being done, current data shows that women who take estrogen are half as likely to suffer heart attacks or die from heart disease. But there are risks associated with hormone replacement, such as elevated probability of acquiring breast cancer. How does a woman decide what to do?

The Harvard Medical School’s Harvard Heart Letter recommends that a balance be achieved between risks and benefits, when women are deciding whether or not to take estrogen replacements. The major benefits of postmenopausal estrogen therapy are a reduction in the risk of heart disease and osteoporosis, as well as the symptomatic relief from postmenopausal symptoms like hot flashes and vaginal dryness.

The potential risks are increased chances of breast cancer and endometrial cancer (cancer of the uterus), although the latter risk seems to disappear if the woman takes progesterone along with the estrogen 12 or more days a month.

What do current studies show? Assessing the risk factors of almost 50,000 nurses in the Nurses’ Health Study verified that women taking estrogen replacements lowered their risk of coronary artery disease by half. A further “meta-analysis” by Harvard researchers who combined the results of 30 epidemiologic studies revealed that estrogen therapy reduced the risk of CAD by 44%--close enough to “half” to cause physicians to take notice.

The Harvard Heart Letter finds this study particularly compelling because as many as one-third of all women 65 and over have coronary artery disease, and CAD is the leading cause of death in this group. Some experts speculate that women who take estrogen replacements tend to be healthier in ways that decrease their heart-disease risk, such as engaging in additional exercise, eating healthier diets, or seeing their physicians more frequently. Some of these factors could be responsible for the lowering of heart disease risk, yet there are clearly biologic reasons why estrogen should be good for the heart. For one thing, women on estrogen therapy continually have a significant increase in HDL, the good cholesterol, and a comparable decrease in the bad cholesterol, LDL.

Studies have also shown the positive effects of estrogen on the reactivity of blood vessels. That is, women who received injections or powerful oral doses of estrogen showed a significant dilatation of their blood vessels in response to certain stimuli, a factor that might be expected to protect the heart by providing increased blood flow. Also, it is thought that estrogen replacement may possibly decrease blood clotting, one of the factors thought to precipitate a heart attack. For example, estrogen users show lower levels of fibrinogen, a protein involved in blood clotting. Also, estrogen may improve the body’s response to insulin; since insulin resistance is another independent risk factor for heart disease, this is an added benefit. Some studies show that women taking estrogen report a lowered blood pressure, although this is not a definitive finding at this time.

Physicians are currently calling for more studies to look at the combination of progestin-estrogen therapies on heart health in women, since most studies thus far have focussed on estrogen replacement primarily. But another big plus factor for taking estrogen replacements is estrogen’s amazing ability to prevent bone loss density, and possibly even to increase bone density in many women. Since one in six women has a hip fracture during her lifetime, and many more have vertebral fractures, the increased bone density could be a major health factor overall. Recently, other medications that are not estrogens have become available to treat women with osteoporosis who should not take female hormones.

Exactly who are the women who should consider avoiding female hormones? Postmenopausal women who still retain their uterus and take estrogen therapy by itself have six times the likelihood of incurring endometrial cancer, a powerful warning. But when progestin is added to the prescribed dosage of estrogen, the risk seems to disappear. Thus, the concomitant use of progesterone with estrogen appears to protect against endometrial cancer.

Breast cancer risk however remains controversial. One study showed that women on some sort of estrogen therapy have a 40% increased risk of incurring breast cancer, and the risk appears to increase when the hormones have been taken for five or more years, putting women in the 60-65 year old range at particular risk. This factor remained solid, whether the treatment was for estrogen alone or estrogen in combination with progestin.

Another study is more reassuring, although the study involved a smaller number of participants. In it, researchers argued that there was no increased risk of breast cancer among women who took hormones for more than eight years. Probably the most significant factor for women considering hormone therapy is their personal histories. With a clear cut family history of breast cancer, which affects one women in nine over a lifetime and accounts for 45, 000 deaths of US women each year, women should consider the statistics soberly.

With no family history of breast cancer, whether or not heart disease history is present, women should probably be encouraged to consider estrogen replacement. With heart disease history in the family, women should probably be strongly encouraged toward hormone replacement in postmenopausal years.

The Women’s Health Initiative, a massive study which is looking at many aspects of female health, should prove enlightening. In one branch of the study 27,500 postmenopausal women will be treated either with estrogen alone, estrogen with progestin or with a placebo over a nine-year period. Investigators hope to more clearly define the role of hormone therapy as regards heart disease, osteoporosis, breast and endometrial cancer. Until results are in and fine-tuned, women should carefully consider the possibilities with their medical care providers and make the wisest choice available to them at this time.

Written by Eleanor Sullo

Title: Hormone replacement for women at menopause
Description: What's the latest scoop on hormone replacement therapy for menopause? The positives and negatives and possible side effects are considered

A: As you correctly point out, hormone replacement therapy (HRT) has long been recommended for women entering menopause. The benefits included relief from the symptoms of menopause including sweating, hot flushes, and mood swings. The prevention of osteoporosis and heart disease were two of the more compelling medical reasons behind the long-term benefits of this recommendation. Prevention of heart disease was a particularly compelling reason, as it remains the number one cause by far of death in women. Some women also believe that HRT delays the effects of aging and helps them to look younger longer. The “down” side includes risks for stroke, blood clots, and the development of breast and uterine cancers.

As physicians, we were asked to look at this in the context of risk vs. benefit ratios. For example, the benefits of a reduced risk of heart disease or a hip fracture were believed to outweigh the statistically much smaller risks of cancer and strokes. Try as I may, I’ve never been able to convert that argument into very convincing terms for my patients, especially in light of this new information.

A recent study has determined that HRT should not be initiated for the prevention of cardiovascular disease either in women with a previous history of heart disease or those who are currently disease free. There is some concern that HRT in women with heart disease may actually place them at an increase risk for a cardiac event. There is as well not enough information to recommend that women begin HRT for the purposes of the prevention of heart disease.

If you are on HRT, ask your doctor to review the benefits for which the medication was initiated. If the main reason is the prevention of heart disease, you may want to discontinue therapy and instead consider lifestyle changes and aggressive treatment for high blood pressure and elevated blood lipids. If you have a history of heart disease, blood thinning agents and other medications used to lower the risk of heart disease might be a less risky substitute.

There are other medications to slow the progression of osteoporosis such as raloxifine, alendronate, and calcitonin to name a few that are all augmented by the use of 1000-1200mg of daily supplemental calcium.

There is still an indication for short-term use (3-6months) for the management of the symptoms of menopause. There are a number of herbal substitutes that in my reading so far provide few if any of the benefits of HRT and may lead to a false sense of security for women using them.

Russell G. Robertson, MD

Keyword: Women's Health, estrogen, hormone replacement, HRT, menopause, hot flashes, heart disease, osteoporosis, breast cancer, uterine cancer, stroke, blood clots, hip fracture, cardiovascular disease

Perimenopause is the two to fifteen year span before menopause during which a woman experiences changes due to declining levels of estrogen and progesterone. For some women, the perimenopausal time can be more troubling than actual menopause.

Hormone Changes During Perimenopause

A woman may notice changes in her menstrual cycle several years before true menopause. The ovary has a finite number of eggs, and these begin to run out. The hypothalamus stimulates the pituitary to make more FSH in an attempt to cause the remaining eggs to mature. FSH and LH levels rise. Estrogen levels may vary. FSH levels can help determine whether a woman is entering menopause.

During perimenopause, ovulation occurs intermittently. If there is no ovulation, the progesterone does not increase and the estrogen production may continue. This may cause the uterus to build up a thicker lining. The menstrual period may occur irregularly and may be quite heavy. Other cycles may produce a light menstrual period. As perimenopause moves into menopause, the ovaries produce much less estrogen and progesterone and the menses cease.

Symptoms of Perimenopause

Hot flashes are experienced by up to two-thirds of perimenopausal women. They usually occur one to five years before the end of menstruation. These symptoms are more severe in women who have had their ovaries surgically removed. It is thought that low levels of estrogen cause the brain to release a surge of Gonadotropin-releasing hormone. This may be the cause of the hot flash. A woman suddenly feels hot and may perspire profusely. She may then have a cold chill. They are more common at night but can occur at any time of day. They last from a few seconds up to an hour.

Changes in menstrual cycles: Menses may be heavier, or lighter. There may be increased or decreased cramping. Eventually, menses lighten, become less frequent and then stop.

Increased PMS symptoms

Difficulty with memory and attention span: Some women report difficulty with concentrating or remembering specific words. A woman with attention deficit disorder may first come for treatment at this age because declining estrogen level has exacerbated her ability to concentrate.

Insomnia is a common complaint of women in perimenopause or menopause itself. Night sweats may disrupt sleep. Irritability and depression can impair sleep. Reduced sleep can lead to tiredness and irritability during the day.

Vaginal dryness: Before and after menopause, lowered estrogen levels cause the lining of the vagina to become drier and thinner. This may lead to painful intercourse and decreased interest in sexual relations.

Urinary leakage: Some urinary symptoms may be related to pelvic floor changes that occurred years ago during labor and delivery.  As the estrogen level drops, further changes can occur. Low estrogen levels may weaken the urethral sphincter that helps hold in urine. If the woman has gained weight, it may put more strain on the bladder.

Skin and hair changes

Dealing Actively With Your Midlife Changes

Healthy Lifestyle Changes: Regular exercise may decrease depression and irritability. Good muscle tone can also improve energy level and decrease aches and pains. Some forms of exercise may help decrease bone loss. Yoga or Tai Chi decrease stress and may reverse the decreased flexibility often associated with aging. Regular Tai Chi has been shown to decrease the incidence of hip fractures in older individuals. A diet high in complex carbohydrates, including multiple small meals may reduce irritability and improve one’s feeling of well-being.

Social support: Many women experience menopause as a time of increased freedom and new possibilities. As their own children grow up, they may have more time and flexibility. However, some women experience the empty nest as the loss of their central role in life. Loss of a spouse through death or divorce can increase isolation. The physical changes associated with hormonal fluctuations can be confusing. Menopause may cause some women to start to think about the finite nature of life. Supportive friends and family can help a woman understand and cope with life changes. Reading about menopause or talking to one’s doctor can help make the changes less mystifying. A return to spirituality can spur growth at this phase of life.

Hormone Replacement Therapy (HRT) Taking estrogen and progesterone can help some of the symptoms associated with approaching menopause. The decision to take hormones is an individual one. A woman considering HRT needs to consider the severity of her symptoms, her health history and her family history. She may also have personal preferences about taking medications. Estrogen is the hormone that seems to relieve many of the symptoms of approaching menopause. If a woman has already had her uterus removed, she may take estrogen by itself.  However, if a woman with an intact uterus takes estrogen without progesterone, the lining of the uterus may build up, and the woman may be at increased risk of uterine cancer. Thus HRT often requires a combination of estrogen and progesterone. The doses of estrogen and progesterone used for HRT are generally lower than the doses used for birth control pills. Often, women only need HRT for a limited number of years after menopause. There can be benefits and drawbacks to the use of HRT. Estrogen can relieve hot flashes, vaginal dryness, urinary problems, and sometimes insomnia. It can also promote a feeling of well-being. Some women feel that it improves memory and concentration. HRT can reduce the chance of osteoporosis. Estrogen may help prevent heart disease, but recent data has suggested that this effect may not be as dramatic as previously thought. For some women there may be drawbacks to HRT. Some studies have suggested a link between HRT and an increased incidence of breast cancer. Estrogen may elevate blood sugar, cause headaches, weight gain, or other side effects.

Psychological support: For some women, social support, healthy lifestyle changes and hormone replacement therapy are not enough. The death of loss of a spouse, heath changes and other stresses may cause stress. Depression and mood swings are more common during perimenopause than after menopause is well established. However, a woman with a history of anxiety or major depression may have a reoccurrence during either of these periods.  Counseling may help some women deal with losses. Counseling may also help a woman review her life and make decisions about new directions and interests. If a woman has a persistent depression or experiences sleep, appetite and energy changes, or has suicidal thoughts, she may want to consider a psychiatric consultation and antidepressant medication.

Passage through this life transition may leave one with a larger view of the rhythm and flow of life.

- By Gayatri Devi, M.D.

Menopause symptoms, due to estrogen deficits, include memory problems, trouble finding words, inability to pay attention, mood swings and irritability, in addition to the more well known symptoms.

These symptoms are often overlooked or left untreated but should be addressed. Treatment will not only result in symptom remission but may also, in my opinion, have preventive value.

Some common questions I have encountered in my practice about estrogen and memory loss include the following:

Q: Do I have Alzheimer's disease?

A: This unspoken fear is often the reason why women suffer in silence when they have cognitive symptoms of menopause. Scared about what they may find out, many women opt not to seek treatment. However, menopause related memory and cognitive disturbances are being increasingly described in scientific literature and are generally responsive to treatment. They should be addressed and treated, so that symptom resolution occurs.

Q: Does estrogen have an impact on functions of the mind?

A: Yes. Estrogen influences language skills, mood, attention, and a number of other functions in addition to memory.

Q: How does estrogen affect the mind?

A: Estrogen receptors are present in several regions of the brain, including those involved in memory (such as the hippocampus). When activated by estrogen, these receptors, in turn, activate processes that are beneficial to the brain. In addition, estrogen may, in effect, raise levels of certain chemicals (neurotransmitters) within the brain. These include the neurotransmitters acetylcholine (implicated in memory), serotonin (implicated in mood), noradrenaline (implicated in mood and other autonomic functions), and dopamine (implicated in motor coordination). Thus, estrogen facilitates networking between nerve cells, promoting their ability to "talk to" one another.

Q: Does this mean that my recent irritability, apathy, 'foggy' state of mind, trouble finding words, constantly losing my keys, inability to function at my job, etc. may be related to estrogen deficit?

A: Given estrogen's myriad role in brain processes, it should come as no surprise that it can influence many of the mind's functions. However, a careful history and a thorough examination are needed to sort through symptoms. You should plan to spend about an hour to an hour and a half with your physician to discuss the issues related to menopause, symptoms and treatment options.

Q: If estrogen replacement corrects my memory and other cognitive symptoms, do I need to do anything more?

A: Generally, if hormone replacement treats one's difficulties, your physician may decide that further work-up is not necessary.

Q: I am on hormone replacement and my symptoms persist. What next?

A: If your symptoms do not resolve with hormone replacement, you may need to discuss the dosage and type of hormone replacement you are on with your doctor. Sometimes, changing to another preparation is helpful. If problems still persist, you might want to seek further help from a physician who specializes in this area.

Q: What are other treatment options for my problems?

Estrogen related cognitive deficits may be differentiated from those associated with other conditions through a careful history, examination and testing. During this time in a woman's life, many problems coexist, including treatable causes (e.g.: depression, hypothyroidism). Focused neuropsychological testing is useful in this regard to delineate the nature of the problem. Testing will also establish a cognitive baseline for future comparison. Thus, treatment options will depend on the cause(s) of the memory loss.

Q: Ideally, what areas should be covered in neuropsychological testing?

A: As estrogen affects various cognitive functions, comprehensive testing should assess all aspects of language (reading, naming, understanding, word fluency), memory (both short and long term memory, visual and verbal memory), and other cognitive functions (problem solving skills, visuospatial skills, etc). Simple screening tools, such as the mini mental status examination, will most often remain normal in peri- and post-menopausal cognitive loss. A good neuropsychological battery of tests should establish a cognitive baseline for future comparison, answer the questions asked and allow monitoring of treatment response.

Q: Will my depression get better if I go on estrogen?

A: If the mood changes are related to estrogen deficiency, they usually will respond to hormone or estrogen treatment. If the mood changes persist, you need to discuss this with your physician.

Q: Is estrogen useful for preventing memory loss?

A: Various naturalistic studies have suggested a preventive role for hormone replacement with estrogen for memory loss. However, more rigorous trials to investigate this are now under way and need to be concluded before consensus recommendations can be made.

Q: I have heard that estrogen prevents Alzheimer's disease. Is this true?

A: The results of several naturalistic studies suggest that estrogen may reduce risk for Alzheimer's by up to 50% although other studies did not find this benefit. The more significant of these studies involved looking at risk in large populations (epidemiological studies). However, controlled clinical trials are needed to confirm this observation before a decision of estrogen's benefit in this regard can be reached.

Q: My friend's mother has Alzheimer's disease. Will estrogen or hormone replacement help in this case?

A: There is a body of evidence to suggest that estrogen or hormone supplementation helps to slow progression of Alzheimer's. Further work still needs to be done in this area. As of the present time, the opinions of experts vary in this regard.

Q: What about the naturally occurring estrogens found in substances like soy milk?

A: There is not enough data on the use of these naturally occurring hormones for treatment of cognitive symptoms of menopause.

Q: Why do I need hormone replacement? Isn't it the natural order of life that women go into menopause?

A: The average age of menopause is 52.3 years and has not changed much over the years. However, a century ago, life expectancy was much less for a woman than it is today. Today, the average woman will spend from a fourth to up to half of her life without the protective and beneficial effects of estrogen.

Q: What is the difference between hormone replacement and estrogen replacement therapy (HRT vs. ERT)?

A: Hormone replacement therapy is a combination of estrogen and progestogen and is generally given to women who have not undergone hysterectomies.

Q: If there is a family history of breast cancer, should I not take estrogen?

A: A family history of breast cancer does not preclude treatment with estrogen. Every person needs to be evaluated on an individual basis. Risk in each person varies and you will need to discuss this with your doctor.

Q: Does my risk for breast cancer increase if I am on estrogen?

A: The data in this area is conflicting. Some studies have noted an increased risk, while others have found an increase in certain types of breast cancer. You need to discuss this issue with your physician. Additionally, every woman on estrogen or hormone replacement should undergo periodic breast self examinations and mammograms as determined by her physician.

Q: What is the difference between a patch and an oral preparation?

A: Skin patches are often used when oral estrogen is not tolerated. Skin absorption bypasses the liver circulation and is more easily titrated.

Q: If my hormone levels are normal on testing, but I am having all these symptoms of menopause, what next?

A: Hormone levels fluctuate and may need to be rechecked if your symptoms are attributable to menopause (or estrogen deficit). You would need to discuss this with your physician.

Q: How does estrogen affect other organ systems?

A: Estrogen keeps bones healthy and prevents osteoporosis. It may also be helpful with cardiovascular diseases, although studies in this area are less unanimous.

Q: What are the risks of taking estrogen or hormone replacement therapy?

A: The most common concern for women deciding on estrogen or hormone replacement therapy is fear of increased risk for breast cancer. Several large, prospective studies have yielded varying results, including increased risk for certain kinds of breast cancer, although some studies found that the total risk for breast cancer of all kinds may not be increased. This is an area that you would need to discuss carefully with your physician. Other more common side effects include spotting, some bloating, breast tenderness and mood changes.

Q: Should I take estrogen or hormone replacement?

A: This is a question that every peri- and post- menopausal woman needs to discuss with her physician. Pros and cons of estrogen use in an individual woman vary.

Hot flashes, vaginal dryness and the onset of osteoporosis (the slow loss of calcium by bones) are physical side effects of menopause. Many emotional changes such as nervousness, fatigue or depression are also common. To ease the side effects of menopause, hormone replacement therapy (HRT) might be recommended by your doctor. Synthetic hormones are substituted for what your body no longer produces. HRT is not without risks and is not recommended for every woman.

Today, HRT differs greatly from the large doses of estrogen that were given to women until the 1970s. The lowest effective dose of estrogen is combined with progesterone. A large dose of progesterone may be given once a month, or a small dose of progesterone may be given daily.

Estrogen replacement therapy can be started during menopause if the woman is experiencing severe symptoms or if her ovaries have been removed.  

THE POSITIVE SIDE OF HORMONE REPLACEMENT THERAPY

• Hot flashes occur less often and are less severe.
• Vaginal dryness and discomfort are relieved.
• The progression of osteoporosis may be delayed.
• Depression and fatigue occur less often.
• The risk of heart disease and stroke are decreased.
• It protects against uterine cancer.
• It may reduce the risk of colorectal cancer.

THE NEGATIVE SIDE OF HORMONE REPLACEMENT THERAPY

• A menstrual cycle may occur.
• Use of estrogen by itself has been liked to cancer of the endometrium.
• Estrogen alone can cause swollen breasts, nausea, high blood pressure and fluid retention.

ESTROGEN THERAPY SHOULD NOT BE UNDERTAKEN IF YOU HAVE:

• cancer of the breast or uterus.
• estrogen-dependent ovarian cancer.
• a history of blood clots in the legs, pelvis or lungs.
• gallstones or gall bladder disease.
• large uterine fibroids.

Objectives

• Describe changes in androgens in aging, menopause, and following oophorectomy.
• Define patients who might be appropriate for testosterone therapy.
• Discuss alternative medical therapy versus prescription medical therapy.

WOMEN AND LIBIDO-IS THERE A ROLE FOR TESTOSTERONE?

Decreasing testosterone may be one of many possible causes of decreasing sexual desire; however, disorders of desire are complex and require careful, non-judgmental history taking. Testosterone replacement/supplementation may be appropriate in a small percentage of women who complain of decreased desire.3 Many women experiencing the clinical symptoms of androgen deficiency and low free testosterone levels respond well to testosterone replacement therapy.

Androgen Production

Menopause and Disorders of Desire

What is the nature of the patient's current sexual activity? Is there an identifiable event associated with loss of desire? How much disparity is there between the patient's desire and her partner's? It is the issues surrounding a woman's autoerotic behavior, her own sexual thoughts, dreams and fantasies, and masturbation, which define a woman's libido that need to be examined. Is the problem really lack of interest or is it anger, fear of rejection, or negative messages partners give to one another? Is the lack of desire selective? Is the underlying effort to remain sexually aloof a way to punish or control the partner? Have there been attempts to solve the problem?

It is important to determine if there is a surgical event connected to loss of desire. Women who can clearly define their sexual \drive through issues of fantasy and desire, and who can say there was a specific drop associated with a specific medical event, are very likely to respond to androgen therapy.8

There are a number of medical causes of decreased libido. These include acute and chronic illness, fatigue, malnutrition, alcohol, drugs, stroke, pituitary disease, renal disease, depression, and testosterone and estrogen deficiency. Traumatic deliveries can also result in chronic dyspareunia and incontinence, both affecting sexual relations and satisfaction.

Possible Medical Causes of Decreased Libido

• Illnesses Virtually any illness (genital or general; physical, emotional, or both): liver, renal, cardiac or hormonal disease, cystitis,
• anemia, hypertension, stroke, cancer, neurologic disease, colostomy, neostomy, bladder surgery, incontinence, herpes virus or
• HIV infection, gonorrhea, venereal warts.

• Medications Antihypertensives, antineoplastic drugs, some antidepressants, (including selective serotonin reuptake inhibitors),
• major or minor tranquilizers (depending on dose), diuretics, antihistamines.

• Treatments Major surgery (hysterectomy, mastectomy, cardiac bypass, organ transplant), dialysis, radiotherapy, chemotherapy.

In disorders of desire, 90 percent of it has to do with the relationship. However, 10 percent of it may be related to decreasing levels of testosterone. The biggest question to ask in evaluating disorder is whether the patient has had desire in the past, including autoerotic behavior and fantasies.

Androgen Therapy

For menopausal women who have never had much sexual desire, or who experience no change in libido, testosterone would probably not be the right therapy. But for those women who have felt sexual desire and wonder where it went, testosterone may be helpful.

During menopause, low estrogen levels lead to vulvar and vaginal atrophy,11 which can cause discomfort. This can have a dampening effect on libido, although lubricants can help. Estrogen replacement therapy can increase vulvar sensation and decrease dyspareunia, but it does not do anything for desire.12

Non-androgenic progestins in oral contraceptives, with the addition of ethinyl estradiol, can drive free testosterone to very low levels. This will eliminate the mid-cycle surge of androgens and accompanying surge of autoerotic and sex-seeking behavior in humans related to ovulation.

There is no convincing evidence that adding physiologic doses of androgens consistently enhances libido in menstruating women. Naturally menopausal women over 50 still produce a fair amount of androgens, for at least five to 10 years. For 35- to 60-year-old women who have had oophorectomies, there may be an increase in libido with the addition of androgens.13 Evidence that this is the case comes from a study, comparing estrogen-only, estrogen-testosterone, and placebo therapy in women who have had oopherectomies.14 The levels of testosterone used in the study were, however, superphysiologic, sometimes four to five times the average in males.Testosterone and estrogen combined may increase bone density more than estrogen alone.15 Recent studies have also shown estrogen-androgen therapy to contribute to the prevention of osteoporosis and reduce serum levels of total cholesterol, triglycerides, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol.16,17 Finally, there appears to be some connection between testosterone and an elevated sense of well being in some patients, although this is difficult to assess given the powerful placebo effect.18

For women who might be candidates, there are a number of androgen therapies available: combined oral conjugated estrogens, injectables, subcutaneous testosterone pellets, transdermal patches (in development), and creams and gels.

Androgens and Estrogens

Conjugated Estrogens and Methyltestosterone
1.25 mg conjugated estrogens/10 mg methyltestosterone
1x day for 21 days (7 days off)

Esterfied Estrogens and Methyltestosterone
0.625 to 2.5 mg esterfied estrogens and 1.25 to 5 mg methyltestosterone
1x day for 21 days (7 days off)

Fluoxymesterone and Ethinyl Estradiol
1 to 2 mg fluoxymesterone and 0.02 to 0.04 mg ethinyl estradiol
2x day for 21 days (7 days off)

Injection Dosages (not recommended or commonly used in the United States)

Testosterone Cypionate and Estradiol Cypionate
50 mg testosterone cypionate/2 mg estradiol cypionate
1x every 4 weeks

Testosterone Enanthate and Estradiol Valerate
90 mg testosterone enanthate/4 mg estradiol valerate
1x evey 4 weeks

Testosterone Enanthate Benzilic Acid Hydrazone, Estradiol Dienanthate, and Estradiol Benzoate
150 mg testosterone enenthate benzilic acid hydrazone/7.5 mg estradiol dienanthate/1 mg estradiol benzoate
1x every 4 to 8 weeks or less

Oral preparations are difficult to evaluate because their androgen delivery cannot be measured; only secondary effects can be measured. So it is hard to tell whether patients are receiving a lot or not enough testosterone. Transdermal preparations can vary in application effectiveness and dosing, but can achieve very high testosterone levels.

Androgen therapy does have side effects. These include hirsutism, increased facial oiliness, acne, deepening voice, hostility, weight gain, alopecia,19 elevated liver functions, lower HDL levels, and (rarely) epedicellular carcinoma.20 Finding the right balance that will help women with their libido without causing adverse side effects is very difficult. How much is too much or too little testosterone has yet to be determined.

Other potential indications for androgen therapy in women are currently being evaluated. These include use in women with premature ovarian failure, premenopausal androgen deficiency symptoms, postmenopausal and glucocorticosteroid-related bone loss, alleviation of wasting syndrome secondary to human immunodeficiency virus infection, and management of premenstrual syndrome  

WHAT IS PERIMENOPAUSE?

SIGNS OF PERIMENOPAUSE

• Menstrual cycles become shorter, longer, or unpredictable
• Flow becomes heavier or lighter
• Low blood sugar
• Fatigue several days before menstruation
• Weight gain
• Decreased sex drive
• Headaches - from mild to migraines with aura and visual distortions
• Dry and/or itchy vulva, clitoris
• Increased incidence of yeast infections

NATURAL SUPPLEMENTS

If you find yourself frequently light-headed, experiencing headaches or fatigue, stabilize your blood sugar by eating at regular intervals. Do not skip meals - especially breakfast.

Consider natural supplements. These are said to work wonders for many women, and do not have the side effects or high cost of medications. Add one supplement per month to your diet so you can observe its effects. By this sort of experimentation you can find out what combination really does or doesn't work for you.

DONG QUAI

PHYOTESTROGENS

AVENA SATIVA and SEX

BLACK COHOSH

RED CLOVER

OTHER SUPPLEMENTS

What is continuous hormone replacement therapy?

Are there different types of hormone replacement therapy?

In the past, women taking these two hormones would take estrogen for the first part of the cycle and progestin during the latter part of the cycle. But this form of hormone replacement therapy may cause bleeding every month, much like having a menstrual period. Many women quit taking the hormones because of this monthly bleeding.

Taking both of the hormones every day throughout the month seems to fix this problem for many women - most women taking continuous estrogen and progestin therapy quit having bleeding after three to six months.

How is continuous hormone replacement therapy taken?

Take both pills every day. You don't have to stop on certain days of the months. If you have bleeding, tell your doctor. The dose of progestin may need to be increased.

What are the benefits of hormone replacement therapy?

• It can reduce your risk of osteoporosis, a condition that causes the bones to become porous and thin and more likely to break.
• It can relieve symptoms of menopause, such as flushing, night sweats and vaginal dryness.
• It can decrease your risk of heart attacks.

What are the risks of hormone replacement therapy?

Progestin can cause tender breasts, fluid retention, swelling, moodiness and cramps. These side effects seem to be less for some women who take continuous hormone replacement therapy. Progestin may also reduce how well estrogen works to protect against heart disease. Studies are still being done on the use of progestin.

Generally, women who have had endometrial cancer, breast cancer, blood clots, stroke, unexplained vaginal bleeding or liver disease shouldn't take hormone replacement therapy.

Are there any signs of problems I should look for?

Yes. If you bleed after you haven't had any periods for several months, call your doctor. Also call your doctor if you notice any breast lumps or pain, or if you have any questions.  

Management of the climacteric

Options abound to relieve women's midlife symptoms

Douglas R. Morrissey, MD; Jeffrey T. Kirchner, DO

VOL 108 / NO 1 / JULY 2000 / POSTGRADUATE MEDICINE

CME learning objectives

• To become familiar with the main symptoms of the climacteric
• To identify currently available options, including alternative or complementary therapies, for treatment of symptoms of the climacteric
• To understand that counseling about lifestyle changes may allow women to forego both traditional and nontraditional therapies

The authors disclose no financial interests in this article.

This page is best viewed with a browser that supports tables

Sixth in a series of articles on women's health coordinated by Jeffrey T. Kirchner, DO, associate director, Family Practice Residency Program, department of family and community medicine, Lancaster General Hospital, Lancaster, Pennsylvania.

Preview: The transition out of the reproductive years can often be accompanied by uncomfortable and disruptive symptoms, one of the most common of which is hot flashes. Drs Morrissey and Kirchner describe this and other typical menopausal symptoms, as well as pharmacologic, hormonal, and lifestyle options that can bring relief and enable a smooth midlife passage.
Morrissey DR, Kirchner JT. Management of the climacteric: options abound to relieve women's midlife symptoms. Postgrad Med 2000;108(1):85-100

The term "climacteric" comes from the Greek word for rung of a ladder and refers to the period of passage out of the reproductive stage of life and into the nonreproductive phase. In women, it encompasses perimenopause, menopause, and the early postmenopausal years.

The climacteric can be accompanied by wide-ranging symptoms that are quite bothersome. However, physicians who understand the hormonal symptoms, who can differentiate these symptoms from age-related changes, and who are familiar with hormone replacement therapies, alternative therapies, and effective life-style modifications can help their patients gain relief.

Patterns of hormonal change

Perimenopause, or premenopause, is the period of years in which normal ovulatory cycles give way to cessation of menses. This time is marked by irregular menstrual cycles (1). Cycle length begins to increase (figure 1), and ovulation and fertility decrease. In the United States, average age at onset of perimenopause is 46 years (range, 39 to 51 years), and mean duration is about 5 years (range, 2 to 8 years).

Menopause is typically defined as the point, after the loss of ovarian activity, when permanent cessation of menstruation occurs (1). The average age at which this occurs is 51 years (range, 44 to 56 years). Cessation of menses before age 40 is considered secondary amenorrhea. Differential diagnosis of secondary amenorrhea includes premature ovarian failure, or early menopause, which occurs in 1% of women in the United States.

Women tend to experience menopause at the same age their mothers did. Risk factors for early menopause are higher socioeconomic class and smoking (2). Alcohol use, parity, and meat consumption have a dose-response relationship to later menopause (2).

Hormonal changes during perimenopause include a decrease in inhibin and an increase in follicle-stimulating hormone (FSH). Surprisingly, estradiol levels increase initially in response to rising FSH levels and then begin declining 6 to 12 months before menopause. After menopause, the ovaries no longer make significant amounts of estrogen. Instead, androstenedione from the adrenal glands and ovaries is converted to estrone, which is in turn converted to estradiol. Proportionally, estradiol levels decrease more than do estrone, testosterone, and androstenedione levels.

Hormone-related symptoms

Symptoms that are related to midlife hormonal changes include abnormal bleeding, vasomotor flushes (hot flashes), and urogenital discomfort. Treatment options include various hormonal, pharmacologic, herbal, and nutritional agents (tables 1 through 4) and lifestyle changes.

Table 1. Equivalent dosage and cost comparison of estrogen formulations
Formulation	Daily dose	Monthly cost*
Conjugated estrogens, natural (Premarin)	0.625 mg	$15
Conjugated estrogens, synthetic (Cenestin)	0.625 mg	$14
Estradiol, micronized (Estrace)	1.0 mg	$14 (brand) $10 (generic)
Estradiol, transdermal	50 micrograms	$24-33
Esterified estrogens (Estratab, Menest)	0.625 mg	$15 (brand) $8 (generic)
Estropipate (Ogen, Ortho-Est)	1.25 mg	$12-18 (brand) $13 (generic)
Ethinyl estradiol (Estinyl)	5.0 micrograms	$11**
*Average wholesale price plus $3.50 dispensing fee based on Pennsylvania Medical Society Professional Drug Education and Information Cost Cards. **Cost for 20 micrograms.

Table 2. Equivalent dosage and cost comparison of selected progestin formulations
Formulation	Daily dose	Cyclic dose	Monthly cost*
Medroxyprogesterone acetate	2.5 mg	5 mg	$9 (brand) $6 (generic)
Norethindrone (Micronor)	3.5 mg	7 mg	$38 (brand) $35 (generic)
Progesterone, micronized (Prometrium)	100 mg	200 mg	$18
*Average wholesale price plus $3.50 dispensing fee based on Pennsylvania Medical Society Professional Drug Education and Information Cost Cards.

Table 3. Cost of selected vaginal estrogen replacement formulations
Product (ingredient)	Monthly cost*
Estrace cream (estradiol, 0.1 mg/g)	$42
Estring ring (estradiol, 2 mg)	$26
Ogen cream (estropipate, 1.5 mg/g )	$51
Premarin cream (conjugated estrogens, 0.625 mg/g)	$50
*Average wholesale price plus $3.50 dispensing fee based on Pennsylvania Medical Society Professional Drug Education and Information Cost Cards.

Table 4. Dosage, common side effects, and costs of selected agents used in treatment of hot flashes
Agent	Dosage	Common side effects	Monthly cost
Conjugated estrogens, natural	0.625 mg qd	Nausea, breast tenderness, endometrial and breast cancer risk, headache	$15*
Medroxyprogesterone acetate	20 mg qd	Irregular bleeding, bloating, weight gain, depression	$26* (brand) $16* (generic)
Methyldopa (Aldomet)	500 mg bid	Sedation, headache, gastrointestinal upset	$47* (brand) $37* (generic)
Clonidine HCl (Catapres)	0.1-0.2 mg bid	Dry mouth, constipation, central nervous system depression	$45-67* (brand) $12-19* (generic)
Soy protein	60 g qd	Gastrointestinal upset	$15-30**
Black cohosh (Remifemin)	2 mg bid	Gastrointestinal upset	$10-15**
Tibolone***	2.5 mg qd	Nausea, edema, breast tenderness	NA
Veralipride***	100 mg qd	Galactorrhea, breast tension, gastrointestinal upset	NA
Bellergal-S	1 tablet bid	Dry mouth, dizziness, sleepiness	$40**
NA, not available. *Average wholesale price plus $3.50 dispensing fee based on Pennsylvania Medical Society Professional Drug Education and Information Cost Cards. **Average cost based on quotes from local retailers. ***Not currently available in the United States.

Abnormal uterine bleeding
Anovulation in the perimenopausal years leads to unopposed estrogen and dysfunctional uterine bleeding. However, abnormal bleeding may also be a sign of endometrial hyperplasia or cancer. Transvaginal ultrasound revealing an endometrial stripe of less than 5 mm is reassuring and essentially rules out cancer (3). An endometrial stripe greater than 4 mm necessitates endometrial sampling, preferably with in-office use of a Pipelle endometrial suction curette or similar device. Endocrine tumors, liver disease, obesity, hyperthyroidism, hypothyroidism, and ovarian tumors may also cause abnormal uterine bleeding and should be considered in the differential diagnosis.

Even if pathologic causes have been ruled out, dysfunctional uterine bleeding remains a sign of unopposed estrogen and, in general, should be treated. Treatment options include low-dose oral contraceptives and cyclical or continuous progestogen.

Hot flashes
Hot flashes, or flushes, begin with a sudden reddening of the skin of the head, neck, and chest accompanied by a feeling of intense body heat and conclude with perspiration that may be profuse. These episodes last for a few seconds to several minutes or, rarely, up to an hour. When they occur during sleep, often women say they have night sweats.

During a hot flash, skin temperature increases but core body temperature actually decreases. Hot flashes occur in 10% to 40% of premenopausal and 50% to 85% of postmenopausal women. Episodes occur daily in 15% to 20% of postmenopausal women. In most women, the episodes occur over a period of 1 to 2 years, but in 20% to 25% they continue for more than 5 years (1). Differential diagnostic considerations include pheochromocytoma, carcinoid, leukemias, pancreatic tumors, thyroid abnormalities, and psychosomatic disorders.

An elevated FSH level supports, but does not absolutely confirm, that symptoms are related to menopause. Measurement of the serum estrogen level is not generally useful for determining whether menopause is the cause of hot flashes.

Because hot flashes are not inherently dangerous, treatment is symptomatic only. Standard first-line treatment is hormone replacement therapy (HRT), usually taken orally or administered as a transdermal patch. Second-line therapy is a progestin. Oral medroxyprogesterone acetate at doses of 20 mg/day was found to reduce the frequency of hot flashes by 90% in one study (4) and by 74% in another (5). Depot medroxyprogesterone given at a dosage of 150 mg/week for 4 weeks (6) was found to relieve 90% of vasomotor symptoms and at a dosage of 100 to 150 mg/week for 12 weeks, relieved 100% of symptoms (7). Megestrol acetate, a synthetic derivative of natural progesterone, relieved at least 50% of symptoms in 75% of women when given at a dosage of 20 mg twice daily for 4 weeks (8). For all progestins, the side effects of irregular bleeding, bloating, weight gain, and depression can be limiting.

Third-line therapy should be based on comorbid conditions. For example, patients with hypertension may benefit from methyldopa (Aldomet) or clonidine hydrochloride (Catapres). Methyldopa, 250 to 500 mg twice daily, reduced the frequency of hot flashes by 65% compared with a 38% reduction with placebo (9). A single evening dose of 375 to 750 mg was not statistically better than placebo at reducing hot flash frequency (80% versus 65%) but was preferred over placebo by 63% of women (10).

Use of clonidine has had variable results. A standard gynecology textbook states that transdermal clonidine is more effective than the oral form (11). However, studies (12-24) suggest that oral clonidine is just as good or possibly better. In the largest trials, the oral formulation was effective, with reductions of 43% to 88% in hot flash frequency (12,14), but transdermal clonidine was unimpressive, with only a 20% reduction in frequency (23). In the latter study, only 31% of women given clonidine reported that they were feeling better, compared with 24% given placebo (23). Side effects of clonidine include dry mouth, constipation, and central nervous system depression.

Fourth-line therapies for hot flashes include proven alternative therapies, such as soy protein and black cohosh. In a trial of 104 women (25), 60 g of isolated soy protein per day reduced the number of hot flashes by 45%, versus 30% with placebo. However, 25% of the women dropped out of the study because of gastrointestinal side effects. In another study (26), hot flashes decreased in 23 (40%) of 58 women who received dietary supplementation with soy flour and in 8 (25%) of 30 who consumed wheat flour. Another trial compared soy protein at 20 g/day in a single dose or 10 g twice a day with placebo (27). Soy was no more effective than placebo for controlling night sweats, and hot flash severity was improved over placebo in only the twice-a-day group. These data collectively suggest that a dose higher than 20 g daily should be used.

Black cohosh is an herbal supplement that contains phytoestrogens. A review of eight clinical trials (28) concluded that black cohosh is safe and effective for treating hot flashes. All eight studies used the brand Remifemin as drops or tablets. Patients took 40 drops or two 2-mg tablets twice a day. However, these forms of black cohosh may not be readily available. For example, one national retailer carries Remifemin only as 20-mg tablets (cost, $15/month). Another national retailer does not offer Remifemin but has a different brand available as 500-micrograms tablets. Herbal products are not regulated by the US Food and Drug Administration and may vary in strength.

Fifth-line therapy should be guided by a concept called "the trial of one," in which harmless but unproven therapies are given a trial on a patient-by-patient basis. The physician and patient can experiment with successive agents until relief is found. This strategy is appropriate for hot flashes because many safe treatments are available. Moreover, there may be a 20% to 50% response to placebos.

Vitamin E is commonly prescribed for hot flashes. A MEDLINE search identified only one randomized, controlled trial of this therapy (29). In it, vitamin E (800 IU/day) resulted in only one less hot flash per day. Furthermore, patient preference for vitamin E over placebo (32% versus 29%) was not statistically significant. However, vitamin E is low in cost and may provide some additional cardiovascular benefits (30).

Dong quai is popularly considered an estrogenic herb. However, a study to detect its estrogenic effect on endometrial thickness, vaginal maturation, and vasomotor flushes found no difference from placebo (31). Other agents that have been reported to relieve hot flashes include vitamins B and C, zinc, ginseng, bee pollen, angus castus, red sage, fenugreek, gotu kola, sarsaparilla, licorice root, wild yam root, and beth root (32).

Bellergal-S (a combination of belladonna, ergotamine, and phenobarbital) has been used for many years for treatment of hot flashes but has generally gone out of favor. In one older study (33), this formulation reduced symptom severity scores by 66%, versus 22% with placebo. A more recent study (34) found Bellergal-S to be ineffective. More important, Bellergal-S has many contraindications for use. Ergotrates are contraindicated in patients with peripheral vascular disease, coronary vascular disease, hypertension, and impaired hepatic or renal function. Belladonna is contraindicated in patients with glaucoma, asthma, and obstructive uropathy. Phenobarbital sodium (Bellatal, Luminal Sodium, Solfoton) is sedating and potentially addictive and should not be used for long periods of time (32). It may be useful at bedtime for hot flashes that disturb sleep.

A final but very important approach is to counsel women about lifestyle changes that can attenuate hot flash severity. Patients can be told to keep a diary of triggers or avoid such inducers as hot weather, warm rooms, alcohol, caffeine, and hot or spicy foods. They should wear layered clothing, preferably made of cool, breathable, natural material, such as cotton. Regular exercise has also been reported to help (32).

Urogenital discomfort
Dysuria is a result of mucosal thinning of the bladder and urethra and is common in postmenopausal women. It responds very well to HRT. Dysuria can also signify a urinary tract infection, and this diagnosis should routinely be ruled out. A 1993 study by Raz and colleagues (35) found that recurrent urinary tract infections were effectively prevented (0.5 versus 5.9 episodes per year) by postmenopausal treatment with intravaginal estriol.

Women with urge, stress, or mixed urinary incontinence may improve with HRT, but the current evidence is contradictory. In a study of 629 postmenopausal women (36), both urge and stress incontinence improved with topical estriol. A smaller, placebo-controlled study of oral conjugated estrogens (37) found no significant benefit. Many investigators have suggested that topical estrogen therapy is more effective than oral therapy for this condition.

Dyspareunia results when estrogen deficiency reduces vaginal lubricating fluid and vaginal elasticity. Consistent sexual activity helps prevent this decline. Vaginal lubrication with nonprescription formulations (eg, K-Y, Replens) is also effective. Oral, transdermal, and topical estrogens are all effective for dyspareunia, as noted by Speroff and colleagues (1).

If systemic estrogen is contraindicated, vaginal creams should probably be avoided, since they are rapidly absorbed by atrophic epithelium (38). The estradiol ring (Estring), however, does not produce significant levels of serum estradiol. It is less expensive, more convenient (lasting 3 months), and better tolerated (having 78% compliance at 1 year) (39). After the vaginal epithelium has been restored with use of the ring for 3 to 6 months, it is acceptable to switch to a vaginal cream that can be used two to three times per week.

Estrogen replacement does not effectively treat all urogenital disorders. Opinions differ about which conditions deserve a trial of estrogen therapy. However, in general, conditions such as cystocele, rectocele, uterine prolapse, and vulvar dystrophy are not caused by estrogen deficiency and thus do not respond to estrogen replacement (1).

Other estrogen-deficiency disorders
Hirsutism is usually a consequence of a decreased estrogen-androgen ratio. In perimenopause, this should be evaluated and treated as in premenopause. In postmenopausal women, HRT increases the levels of estrogen and sex hormone-binding globulin. The sex hormone-binding globulin decreases the free testosterone level. As a consequence, the estrogen-androgen ratio will increase and growth of new hair will decrease. Electrolysis, waxing, or bleaching may be necessary to treat established hairs, even if HRT prevents new growth. Adrenal and ovarian tumors are a possible concern in women with persistent hirsutism or other signs of virilization.

Skin loses collagen content and thickness with age and estrogen deprivation. This leads to tissue sagging and wrinkles. Topical estrogen cream improves facial wrinkles (40), and oral HRT is associated with a lower prevalence of skin wrinkling and dryness (41). Unfortunately, this benefit is offset by smoking, which can be another reason to encourage patients to quit smoking (41).

Central (android) obesity is a consequence of estrogen deficiency. In midlife, women tend to gain weight whether they are menopausal or not. However, after menopause, this weight is distributed more in the abdomen than in the thighs and hips. HRT effectively prevents this redistribution of body fat (42) but does not prevent weight gain itself (43).

Decreased libido is common in menopause. Although this symptom does not seem to respond to HRT, many studies have suggested a benefit from androgen replacement. Multiple studies of parenteral administration of androgen, which were recently reviewed (44), have shown increases in various sexual parameters. A study comparing use of daily doses of combined esterified estrogens and methyltestosterone (45) (1.25 mg and 2.5 mg, respectively) with use of esterified estrogens alone or placebo showed increased sexual sensation and desire in the estrogen-androgen group relative to those receiving the other treatments. However, the review suggests choosing parenteral formulations over oral forms to avoid negative hepatic and lipid side effects. The investigators also suggest measuring testosterone levels before considering replacement and limiting doses to physiologic levels (44). It is important to discuss with patients other possible causes of diminished libido, including depression, dyspareunia, alcohol, and use of psychotropic medicines.

Insomnia is a common complaint of postmenopausal women. Hot flashes often contribute to this problem; however, hot flashes are not the sole explanation, since HRT improves sleep in women who have insomnia without hot flashes (46). Behavioral therapy and use of a pharmacologic adjunct such as Bellergal-S, a sedative-hypnotic, an antihistamine, or a low-dose tricyclic anti-depressant may also be prescribed.

Nonhormonal midlife changes

Several common problems of the climacteric do not seem to be due to estrogen deficiency and do not respond to HRT. Weight gain, as previously mentioned, is a function of age, diet, and exercise, not estrogen deprivation (43). Fatigue, nervousness, headaches, irritability, joint and muscle pain, dizziness, and palpitations are common in both men and women in midlife and are probably not attributable to hormonal changes (1).

Menopause is not associated with an increased risk of depression. On the contrary, depression is less common among middle-aged women (1). Therefore, if a woman in the climacteric has any of these nonhormonal symptoms, a cause should be sought from among the common changes of midlife other than menopause (eg, the loss of a parent, a change of employment, a child leaving for college or moving out of the house).

Despite these facts, mood symptoms do improve with HRT (47). Most authorities attribute this to relief from hot flashes. However, such relief with use of veralipride did not result in the same improvement in quality of life that resulted from HRT (48). In fact, a group of asymptomatic women showed improvement on the Beck Depression Inventory after starting HRT (49). Therefore, if a woman is not receiving HRT for other reasons, it seems prudent to suggest HRT for persistent, nonhormonal emotional symptoms that are not attributable to other causes.

Conclusion

A crucial role of the primary care physician is to counsel and educate perimenopausal patients about the diverse and often bothersome changes that can accompany the climacteric. For most of these patients, standard therapy remains HRT. The benefits of HRT extend to protection against osteoporosis and coronary disease. However, many women have medical contraindications or are simply averse to using HRT. Fortunately, for these patients there is a growing armamentarium of new estrogen products and alternative therapies that are effective for relief of symptoms associated with the climacteric.

References

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26. Murkies AL, Lombard C, Strauss BJ, et al. Dietary flour supplementation decreases post-menopausal hot flushes: effect of soy and wheat. Maturitas 1995;21(3):189-95
27. Washburn S, Burke GL, Morgan T, et al. Effect of soy protein supplementation on serum lipoproteins, blood pressure, and menopausal symptoms in perimenopausal women. Menopause 1999;6(1):7-13
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29. Barton DL, Loprinzi CL, Quella SK, et al. Prospective evaluation of vitamin E for hot flashes in breast cancer survivors. J Clin Oncol 1998;16(2):495-500
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31. Hirata JD, Swiersz LM, Zell B, et al. Does dong quai have estrogenic effects in postmenopausal women? A double-blind, placebo-controlled trial. Fertil Steril 1997;68(6):981-6
32. Hendrix SL. Nonestrogen management of menopausal symptoms. Endocrin Metab Clin North Am 1997;26(2):379-90
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34. Bergmans MG, Merkus JM, Corbey RS, et al. Effect of Bellergal Retard on climacteric complaints: a double-blind, placebo-controlled study. Maturitas 1987;9(3):227-34
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37. Fantl JA, Bump RC, Robinson D, et al. Efficacy of estrogen supplementation in the treatment of urinary incontinence. Obstet Gynecol 1996;88(5):745-9
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39. Henriksson L, Stjernquist M, Boquist L, et al. A one-year multicenter study of efficacy and safety of a continuous, low-dose, estradiol-releasing vaginal ring (Estring) in postmenopausal women with symptoms and signs of urogenital aging. Am J Obstet Gynecol 1996;174(1 Pt 1):85-92
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41. Dunn LB, Damesyn M, Moore AA, et al. Does estrogen prevent skin aging? Results from the First National Health and Nutrition Examination Survey. Arch Dermatol 1997;133(3):339-42
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Dr Morrissey is a third-year resident and Dr Kirchner, coordinator of this series, is associate director, Family Practice Residency Program, department of family and community medicine, Lancaster General Hospital, Lancaster, Pennsylvania. Correspondence: Jeffrey T. Kirchner, DO, Department of Family and Community Medicine, Lancaster General Hospital, 555 N Duke St, PO Box 3555, Lancaster, PA 17604-3555. E-mail: jtkirchn@lha.org.

A Natural Passage through Menopause

The current medical view of menopause is that menopause is a disease rather than a normal physiological process. The medical response to the disease is to treat it with drugs. The most popular estrogen drug in the United States is Premarin which contains estrogens derived from the urine of pregnant mares. Other popular estrogen drugs are Estrace and Estraderm.

Reports of increases in endometrial cancer (cancer of the lining of the uterus) being linked to estrogen began surfacing as early as 1961. In 1975 and 1976 three studies reported such strong links between estrogen and endometrial cancer that the FDA (Food and Drug Administration) issued a recommendation that pharmaceutical companies place warnings on estrogen package inserts. In response to these studies, doctors began prescribing a progestin (synthetic form of progesterone) called Provera as an adjunct to Premarin to help prevent estrogen-induced uterine cancer. Progesterone, when occurring naturally, counteracts the tumor-stimulating effects of estrogen in the body; it does not, however, reduce the risk of estrogen-induced breast or ovarian cancers.

In addition to the increased cancer risks, estrogen and progestin drugs have well-documented side effects such as weight gain, thrombosis (abnormal blood clot formation), nausea, headaches, irritability, fluid retention, increased risk of gallstones, fibroid tumors and adult-onset asthma.

Why would women consider taking these drugs?

Despite their unpleasant and sometimes dangerous side effects, HRT (hormone replacement therapy) can produce true anti-aging effects such as smoother, firmer skin, better muscle tone, reduced genital atrophy and vaginal dryness and relief from menopausal symptoms such as hot flashes, dizziness and mood swings. HRT has been reported to slow the loss of bone density, help prevent osteopororis, improve memory and the ability to concentrate and support the immune system.

Another supposed benefit of HRT is reduced risk of heart disease and strokes. New research, however, is showing that HRT may not be effective in preventing heart disease. According to Ellen Kahmi, Ph.D., R.N and co-author of Cycles of Life: Herbs and Energetics for Women, in a recent interview on WebMD a study called HERS (the Heart Estrogen/Progestin Study), 2,763 women with heart disease were found after four years of HRT to have just as many heart attacks as women not on hormones. During the first year of treatment, more women had heart attacks and other cardiovascular problems than those who were given the placebo. The American College of Cardiology (ACC) discussed at a meeting in March that HRT again showed no protective effect for heart disease. On the other hand, HRT is related to a slight increased risk in deep vein thrombosis and clots in the lungs as well as clots in the cardiovascular system.

Is there another, more natural way to achieve the benefits of HRT without the risks?

Recent studies show that changes in diet, regular exercise and supplementation with certain vitamins and plant-derived estrogens or phytoestrogens can relieve the symptoms of menopause and protect your heart and bones without the side effects of synthetic hormones.

Diet

Adhering to a low-fat, high fiber diet with at least 5 to 9 daily servings of fruits and vegetables while limiting animal protein is one of your best defenses against heart disease, stroke, cancer, diabetes, arthritis and cataracts.

While you should reduce the amount of saturated fat in your diet, “good fats” such as the Omega 3’s found in flaxseed, flaxseed oil and cold water fish are highly beneficial. Eating several servings a week of tuna, salmon, sardines, herring or mackerel can reduce cholesterol and the risk of heart disease and stroke, relieve the pain associated with inflamed arthritic joints and even combat depression.

Animal protein, especially red meat, is high in phosphorous as are carbonated drinks such as colas and other sodas. Phosphorous can cause the excretion of calcium from your bones. Try to limit the intake of animal protein and eliminate sodas if at all possible.

For Asian and Latin women, menopause is a relative nonevent, both physically and emotionally. This smooth transition from one age to another is due partly to a culture that values the experience that comes with age rather than fearing it. Researchers attribute the lack of physical symptoms in Asian and Latin women, however, to a diet consisting largely of legumes such as lentils, soy, and chickpeas that are rich in phytoestrogens. Phytoestrogens are plant hormones that are accepted by our bodies because they closely mimic human hormones. They are classified into groups - the flavones, flavanones, flavonols, chalcones, lignans, and isoflavones.

The most common types of phytoestrogens are flavones and lignans, the most potent are the isoflavones. Lignans and flavones are found in most cereals and fruits and vegetables. Isoflavones, however, are only found in legumes such as soy, lentils, chickpeas, and beans. Most American women will have modest levels of lignans and flavones in their blood but very low levels of isoflavones.

Adding soy to your diet can relieve many of the symptoms associated with menopause. Soybeans are rich in isoflavones and phytosterols. Consuming 300 mg. of soy isoflavones would be roughly equivalent to taking a .45 mg. tablet of Premarin. There is one big difference however, while synthetic hormone replacement has been linked to increasing cancer, studies have shown that Japanese women who eat an average of 30-50 grams of soy a day (150-200 mg of isoflavones) enjoy a relatively low rate of hormone-related cancers.

Soy products have been attributed to reducing the risk of breast cancer, lowering cholesterol and protecting the heart. Studies have also shown that the phytoestrogens in soy can help increase bone density and bone mineral content. If you wish to incorporate soy into your diet, you are not limited to soy beans. Soy milk, tempeh, tofu and soy cheese are all rich sources of isoflavones.

Exercise

The most important effect of regular exercise, especially weight bearing exercises such as strength training and walking, is the increased mineralization of your bones. A study was devised to measure the effectiveness of exercise on bone density. A group of postmenopausal women were given a program of exercise comprising of a fast, one-hour walk three times a week alternating with a one hour series of back extensions and posture exercises two times a week. At the end of the study, the women who followed the exercise program while taking medications to combat osteoporosis showed a 4.4 percent increase in spinal bone density as opposed to the women on medication alone who experienced a bone density increase of only 1.6 percent.

Regular exercise has also been shown to reduce the frequency and severity of hot flashes, improve circulation, reduce blood cholesterol levels and relieve stress.

Menopause 101

With record number of baby boomers now reaching mid-life, menopause has become the news hot flash of the 1990’s. Yet much of what we hear or read about menopause is alarmist, misleading or downright confusing.  Dr. Donnica explains that menopause is a transitional time characterized by the end of the menstrual cycle-and the beginning of the final third of a woman’s life. She also discusses what menopause is, what its consequences are, and what is available to treat them.

Each day, 4,000 women in the United States and Canada reach menopause, which is simply the end of a woman's menstrual cycle. During the perimenopausal period (up to 10 years before menopause), the ovaries decrease production of the "female hormones" estrogen and progesterone, the hormones which allow a woman to become pregnant and to menstruate.  Yet these hormones also affect many other functions in a woman’s body such as the circulatory system, urogenitary system, nervous system, skeletal system, memory, sexuality, skin, vision, and teeth.

The average age for menopause in American women is 51. However, when menopause begins and the length of time it lasts varies for every woman. Menopause means more than just losing your periods.  This is a syndrome with clinical symptoms as well as long term consequences.  Estrogen loss can have wide-ranging effects--from menopausal symptoms (such as hot flashes) to increased risk of heart disease and osteoporosis, which can be life threatening.  Because most women will live a third of their life after menopause, it is important to be aware of the symptoms, systemic effects, and available treatment options associated with estrogen loss. 

The term "menopausal" usually refers to the year preceding the end of menstruation and the five years following.  "Postmenopausal" refers to the time thereafter.  "Perimenopause" is the 2-10 year time period preceding menopause; it is this period we are now learning more about.  "Premature menopause" is defined as menopause occurring for whatever reason before age 40.  It is also called "premature ovarian failure".

An important definitional distinction here is that women who have had a hysterectomy (surgical removal of the uterus) but whose ovaries function normally won’t have periods, but they are not "in menopause."  They will go into menopause naturally when their ovaries cease functioning.  Many women who have a hysterectomy also have their ovaries removed (ovariectomy or oophorectomy) at the same time; it’s important to find out which category you are in if you have had either type of surgery.

Interestingly, up to a third of women report no disruptive menopausal symptoms; in others the symptoms may last several years, usually between ages 40 and 55.   The most common symptom is that menstrual periods appear less and less frequently, or, in some cases, "irregularly irregular" until they stop altogether.  Many women have the typical symptoms of menopause: hot flashes, night sweats, irritability, moodiness, sleep disturbances, vaginal dryness, decreased libido, and hair coarseness/loss

Learning Center - Menopause Overview

An Ending and a Beginning
In the history of the world, menopause is a relatively recent condition — before the twentieth century most women did not live long enough to experience this biological change. Advancements in medical science during the last 100 years have increased life expectancy, so that menopause is now a normal life event for women. In fact, it is estimated that by the year 2020, there will be over 45 million women older than age 55. While menopause signals the end of fertility, it also marks the beginning of a time when growth and transformation are possible.

What is Menopause?
Menopause is the result of a gradual biological process (a phase called perimenopause) when the ovaries decrease production of female sex hormones, most notably estrogen, and menstruation eventually stops. Menopause may occur as the natural result of aging or may be induced as a result of surgical or medical intervention.

• Begins sometime in the decade before menopause (late 30s to early 40s).
• Menstrual cycles may become irregular and menstrual flow may become unusually light or heavy.
• Irregular hormone levels may be associated with symptoms such as hot flashes, breast tenderness, night sweats, fatigue, and concentration and memory changes.

• Identified as the last normal period in a woman’s life.
• Menopause is reached when a woman has not experienced a menstrual period for one full year.
• The average age of menopause in the United States is 51 years, 4 months.

• Hereditary factors
• Whether or not a woman smokes
• Whether any medical procedures, such as a oophorectomy (removal of both ovaries), have been performed

• Irregular bleeding before the last period
• Hot flashes
• Changes in sexual desire
• Weight gain
• Mood swings
• Reported memory loss and concentration changes
• Secondary insomnia
• Vaginal dryness
• Incontinence
• Hair loss or growth of facial hair

• Estrogen replenishment for osteoporosis
• Regular exercise that includes weight training and weight-bearing exercise
• A healthy diet with adequate calcium intake
• A no-smoking lifestyle

Each is more useful with a good working partnership with your clinician.

Knowledge is Power
As menopausal women make up more of our society — "Baby Boomers" are reaching middle age — information, treatments and support for women are increasing. It is vital for you to be knowledgeable about your risks, and all the options available to make informed decisions about your long-term health.

If you reach midlife understanding the process during menopause, you may experience the transition with less anxiety, allowing you to make effective decisions in partnership with your clinician.

Hormone replacement for women at menopause

Charlotte Libov, M.D., physician advocate for women’s heart health, explores the myths concerning women and heart disease which were promulgated in medical schools throughout most of the past century. First, women are NOT largely "immune" to heart disease. Second, if a woman DOES suffer a heart attack, she may not be elderly, as previously assumed.

These relatively new clarifications of the mythic nature of women’s heart treatment show that heart disease is actually the biggest killer of American women, with over 240,000 dying annually. At least 21,000 of these women are under the age of 65. Women with a negative heart history in the family, and particularly if high blood pressure is present, need to take proactive steps such as quitting smoking, reaching and maintaining a normal weight, and engaging in a healthful program of exercise to minimize their risk of serious coronary consequences.

Women who are postmenopausal should discuss the use of estrogen-replacing hormones. While further studies are being done, current data shows that women who take estrogen are half as likely to suffer heart attacks or die from heart disease. But there are risks associated with hormone replacement, such as elevated probability of acquiring breast cancer. How does a woman decide what to do?

The Harvard Medical School’s Harvard Heart Letter recommends that a balance be achieved between risks and benefits, when women are deciding whether or not to take estrogen replacements. The major benefits of postmenopausal estrogen therapy are a reduction in the risk of heart disease and osteoporosis, as well as the symptomatic relief from postmenopausal symptoms like hot flashes and vaginal dryness.

The potential risks are increased chances of breast cancer and endometrial cancer (cancer of the uterus), although the latter risk seems to disappear if the woman takes progesterone along with the estrogen 12 or more days a month.

What do current studies show? Assessing the risk factors of almost 50,000 nurses in the Nurses’ Health Study verified that women taking estrogen replacements lowered their risk of coronary artery disease by half. A further “meta-analysis” by Harvard researchers who combined the results of 30 epidemiologic studies revealed that estrogen therapy reduced the risk of CAD by 44%--close enough to “half” to cause physicians to take notice.

The Harvard Heart Letter finds this study particularly compelling because as many as one-third of all women 65 and over have coronary artery disease, and CAD is the leading cause of death in this group. Some experts speculate that women who take estrogen replacements tend to be healthier in ways that decrease their heart-disease risk, such as engaging in additional exercise, eating healthier diets, or seeing their physicians more frequently. Some of these factors could be responsible for the lowering of heart disease risk, yet there are clearly biologic reasons why estrogen should be good for the heart. For one thing, women on estrogen therapy continually have a significant increase in HDL, the good cholesterol, and a comparable decrease in the bad cholesterol, LDL.

Studies have also shown the positive effects of estrogen on the reactivity of blood vessels. That is, women who received injections or powerful oral doses of estrogen showed a significant dilatation of their blood vessels in response to certain stimuli, a factor that might be expected to protect the heart by providing increased blood flow. Also, it is thought that estrogen replacement may possibly decrease blood clotting, one of the factors thought to precipitate a heart attack. For example, estrogen users show lower levels of fibrinogen, a protein involved in blood clotting. Also, estrogen may improve the body’s response to insulin; since insulin resistance is another independent risk factor for heart disease, this is an added benefit. Some studies show that women taking estrogen report a lowered blood pressure, although this is not a definitive finding at this time.

Physicians are currently calling for more studies to look at the combination of progestin-estrogen therapies on heart health in women, since most studies thus far have focussed on estrogen replacement primarily. But another big plus factor for taking estrogen replacements is estrogen’s amazing ability to prevent bone loss density, and possibly even to increase bone density in many women. Since one in six women has a hip fracture during her lifetime, and many more have vertebral fractures, the increased bone density could be a major health factor overall. Recently, other medications that are not estrogens have become available to treat women with osteoporosis who should not take female hormones.

Exactly who are the women who should consider avoiding female hormones? Postmenopausal women who still retain their uterus and take estrogen therapy by itself have six times the likelihood of incurring endometrial cancer, a powerful warning. But when progestin is added to the prescribed dosage of estrogen, the risk seems to disappear. Thus, the concomitant use of progesterone with estrogen appears to protect against endometrial cancer.

Breast cancer risk however remains controversial. One study showed that women on some sort of estrogen therapy have a 40% increased risk of incurring breast cancer, and the risk appears to increase when the hormones have been taken for five or more years, putting women in the 60-65 year old range at particular risk. This factor remained solid, whether the treatment was for estrogen alone or estrogen in combination with progestin.

Another study is more reassuring, although the study involved a smaller number of participants. In it, researchers argued that there was no increased risk of breast cancer among women who took hormones for more than eight years. Probably the most significant factor for women considering hormone therapy is their personal histories. With a clear cut family history of breast cancer, which affects one women in nine over a lifetime and accounts for 45, 000 deaths of US women each year, women should consider the statistics soberly.

With no family history of breast cancer, whether or not heart disease history is present, women should probably be encouraged to consider estrogen replacement. With heart disease history in the family, women should probably be strongly encouraged toward hormone replacement in postmenopausal years.

The Women’s Health Initiative, a massive study which is looking at many aspects of female health, should prove enlightening. In one branch of the study 27,500 postmenopausal women will be treated either with estrogen alone, estrogen with progestin or with a placebo over a nine-year period. Investigators hope to more clearly define the role of hormone therapy as regards heart disease, osteoporosis, breast and endometrial cancer. Until results are in and fine-tuned, women should carefully consider the possibilities with their medical care providers and make the wisest choice available to them at this time.

Written by Eleanor Sullo

Title: Hormone replacement for women at menopause
Description: What's the latest scoop on hormone replacement therapy for menopause? The positives and negatives and possible side effects are considered.

Continuous Hormone Replacement Therapy After Menopause

What is continuous hormone replacement therapy?

Continuous hormone replacement therapy involves taking hormones every day after menopause, when the ovaries stop making enough of the female hormones estrogen and progesterone, or after surgery to remove the ovaries.

Are there different types of hormone replacement therapy?

Yes. There are different types of hormone replacement therapy. One type involves taking estrogen alone, but hormone replacement therapy with estrogen alone can increase the risk of cancer of the uterus (womb) and endometrium (lining of the uterus). Adding progestin, a synthetic form of progesterone, to your treatment seems to keep the risk of these two cancers down.

In the past, women taking these two hormones would take estrogen for the first part of the cycle and progestin during the latter part of the cycle. But this form of hormone replacement therapy may c