The term menopause refers to a woman’s final menstrual flow. The average age of menopause in the United States is between 49 and 50 years old. Since a 50 year old woman may expect to live 30 additional years, an American woman experiencing menopause faces health decisions that will affect a significant portion of her life.

The principle hormonal change at menopause is a drop in estrogen production by the ovaries. Estrogen production by the ovaries continues to decline as a woman passes through the menopause. A woman’s body maintains some estrogen production as the result of conversion into estrogen of male hormone, which is produced in the adrenal gland. Since male hormone of adrenal origin is converted into estrogen by fat tissue, slender women tend to be more estrogen deficient than their heavier peers. As a result of estrogen deficiency, a woman may experience hot flashes or thinning and dryness in the vaginal area. What she will not feel are changes in her bones, heart and blood which may hold serious consequences for her health.

Symptoms

Hot Flashes

Eighty percent of women passing through menopause will experience hot flashes. Hot flashes are sudden feelings of warmth affecting the head and upper body. They may be accompanied by reddening of the affected area, rapid heart beat and feelings of anxiety. Flashes are most common at night or in warm environments. These flashes (or flushes) may continue for between a few months and many years.

Although changes in diet and activity may modify hot flashes, the only proven effective means to eliminate them is (natural or pharmaceutical) estrogen replacement therapy. The use of hormones other than estrogen (such as progesterone) may be partially successful. The use of sedatives to attenuate hot flashes is both unsuccessful and undesirable.

Atrophy

Atrophy of the genitalia is manifested by a thinning of both the vulva and the lining of the vagina. Vagina secretions may change in character. The thinned walls of the vagina are less resistant to irritation; discharge or pain may result. Physical changes in the genitalia may affect sexual response. Pain on entry and penetration may reflect either lack of lubrication or thinning of tissue caused by estrogen deficiency.

Water soluble lubricants are one means to compensate missing lubrication. Alternatively, small amounts of estrogen replacement will maintain lubrication and prevent serious atrophic changes. For the purpose of relieving symptoms of atrophy, estrogen may be administered as a pill, skin patel or vaginal cream or rings.

Osteoporosis

A serious consequence of estrogen deficiency in the menopause is loss of calcium from the bone. As a result of calcium loss, bone becomes brittle and subject to fracture. Although calcium is rapidly lost from bone within the first five years of the menopause, the fill effect of calcium loss may not be seen for 10 or 20 years. The resulting condition, called osteoporosis, can lead to fracture of the hip or spine in older women.

Moderate doses of estrogen will prevent the loss of calcium from bone and significantly reduce the risk of fractures of the hip and spine. An alternative approach to preventing osteoporosis is to consume more dietary calcium. Although, adequate dietary calcium is not a substitute for estrogen, it will partially counteract the rapid loss of calcium seen after menopause. The daily requirement for calcium in a post menopausal woman is 1.5 grams. This amount of calcium can be found in one and a half quarts of skim milk, five cups of yogurt, three cups of turnip greens, or one and a half quarts of chocolate fudge.

Calcium pills may substitute for dietary calcium. Calcium carbonate pills (for example, calcium from oyster shells or Tums) are 40 percent calcium. Thus, 4000 mg. (or eight 500 mg. pills) of calcium carbonate constitutes the daily requirement for a menopausal woman. The average cost of such replacement is fifteen dollars per month. Alternative forms of calcium are calcium gluconate (9% calcium), calcium lactate (13% calcium) and calcium citrate (20%). These preparations are of similar cost but require the ingestion of many more pills per day. Certain women must be cautions about taking large amounts of calcium. A history of kidney stone and the use of drugs which block the cellular uptake of calcium may be contraindications to calcium.

Some foods inhibit the adsorption of calcium. One offender is phosphate – found in soda pop. On the other hand, dairy products contain substances that improve the adsorption of calcium and makes them excellent sources of calcium. Calcium pills are better adsorbed when taken with citrus juice or with food. Whatever its source, dietary calcium is a critical nutrient for post menopausal women.

Physical activity which involves weight bearing has also been shown to retard the loss of calcium from bone. The advisability of a program of jogging, walking or other exercise must be considered within the context of a woman’s skeletal, muscular and cardiovascular health.

A particular woman’s likelihood of developing osteoporosis is difficult to assess. White race, slender physique, early menopause, cigarette smoking and family history of osteoporosis are known risk factors. Measurement of bone density by radiographic means, for example, a dexa scan, can be used to evaluate a particular woman’s bone density.

In order to absorb calcium it is very important to have adequate vitamin D.  Post menopausal women should consider taking vitamin D supplement (800-1000 units/day).

Cardiovascular Disease

It has long been recognized that middle aged men have a higher incidence of heart attacks and strokes than comparable aged women. We now know that it is estrogen that gives women this protective edge. The way estrogen protects may be through changes in cholesterol as well as effects on blood cells and blood vessel walls. Unfortunately, recent evidence shows that estrogen replacement therapy does not reduce the overall incidence of cardiovascular disease. Although estrogen may help cholesterol and blood vessel walls, it increases the tendency of blood to clot, thereby increasing the risk of heart attack and stroke.  It appears that estrogen therapy will decrease the incidence of heart disease when started immediately after menopause; estrogen may increase the risk of heart attack and stroke if a woman starts it after having gone more than 7-10 years after menopause without estrogen.

The most important thing a woman can do to decrease her chances of heart attack is to stop cigarette smoking. Low cholesterol diet and regular exercise are also very important.

Treatment

Estrogen replacement therapy is an effective way to addressing the major symptoms of the menopause – hot flashes and genital atrophy. It may prevent osteoporosis. Estrogen replacement may also prevent aging changes in the breast and skins. Many estrogen takers report improvements in their psychological outlook.

Risks and Complications of Estrogen Therapy

Potential complications of estrogen replacement therapy must be recognized. If estrogen is administered on a daily basis, without the accompanying use of progesterone to prevent overstimulation of the uterus, the chance that a woman will develop cancer in the lining of her uterus is increased. However, if progesterone is administered to a woman receiving estrogen, her chance of developing cancer in the lining of her uterus is not increased. Progesterone is not essential if the uterus has been removed, i.e. after hysterectomy.

We expect some women taking cyclic regimens of estrogen to experience menstrual – like bleeding at predictable times of their hormone cycles. On the other hand, unexpected bleeding may be a sign that the lining of the uterus is overgrowing. Tissue sampling of the lining of the uterus – an endometrial biopsy – and/or visualization of the uterine lining by ultrasound are often done to evaluate abnormal bleeding.

There is concern that estrogen replacement therapy may increase the chance that a woman will develop breast cancer. While progesterone protects the lining of the uterus from overgrowth, it does not appear to exert a protective influence on breast tissue. In fact, progesterone may increase the risk of breast cancer. Recent studies suggest that when estrogen is taken without progesterone, the incidence of breast cancer is not increased. Estrogen replacement may offer some protection against colon cancer. All menopausal women, whether they receive estrogen replacement or not, should regularly be screened by PAP test, breast exam, mammography and pelvic exam.

Contraindications

The most common reason for a patient not to receive estrogen is history of stroke, phlebitis or another condition associated in intravascular clotting. Estrogen in high dose is known to increase the coagulability of blood. A small number of women are sensitive to estrogen in the low doses used for estrogen replacement. These women often have a history of phlebitis (inflammation of blood vessel walls) while pregnant or taking birth control pills. Women with risk factors for breast cancer or with close family members (mom, sister, daughter) with breast cancer usually avoid estrogen.

Estrogen should not be given to women whose liver function is impaired. The administration of estrogen to women with high blood pressure requires special care. Women with usually high levels of triglycerides (a kind of fat molecule) in their blood may be better off not taking estrogen. No woman experiencing vaginal bleeding should be administered estrogen without a concerted effort to diagnose the cause of that bleeding. Estrogen therapy is known to accelerate the development of gallbladder stones, although it does not ultimately increase the number of women who will experience difficulties with their gallbladders. Estrogen must be administered with care to women with a history of migraine. Women who experience increased migraine or new headaches are usually advised to discontinue their estrogen. However, for other women estrogen may reduce the incidence or severity of migraine.