Menopause
Introduction: Menopause
occurs when the last period finishes and the ovaries no longer produce estrogen.
Due to low estrogen the pituitary gland produces more FSH and LH, which is used
to diagnose that the woman is in menopause. Most women enter into the age of menopause
around 50 or 51 in the US. At first, the follicular phase of the cycle is
getting shorter meaning that there is less estrogen production in the ovary. This
leads to shorter menstrual cycles. There are also more irregular menstrual cycles
as well. Finally after a last menstrual period her periods stop altogether.
Menopause
symptoms: Hot flashes are the most pronounced symptoms
that women complain about with menopause. The skin feels warm or hot, some women
perspire, occasionally profusely. Head and
neck region are most affected and the skin in that region might look reddish.
What causes hot flashes? The lack of estrogen in the circulation opens up the
skin vessels and the sweat glands are sweating easier. Postmenopausal women
are more sensitive to hot pepper, alcohol and large meals that will all make hot
flashes worse. They last for a few seconds or a few minutes and lead to a sensation
of heat from the chest upwards in the neck and head. Some women get reddish skin
discoloration and the skin feels warmer than in the skin of the lower body. When
the bedroom temperature is kept on the cool side women with hot flashes will have
50% less symptoms.
Without treatment the episodic hot flashes last
for between 1 and 5 years. There are also psychological symptoms ranging from
emotional lability, to irritability, trouble falling asleep to depression. Menopause
can cause heart palpitations without ECG changes; nausea, joint aches
and muscle pains are also part of the symptom complex. Because of the estrogen
reduction there are marked changes in the lower genital tract with thinning
of the vaginal wall and urethral mucosa, the labia and the clitoris. This leads
to painful sexual intercourse, causes vaginal infections and frequent bladder
infections. Some women have no hot flashes. They seem to have enough androgen
hormones from the remaining ovarian function as well as from the adrenal glands
so that estrogen can be formed in fat cells and skin, which prevents hot flashes.
Osteoporosis and menopause are clearly linked. White women are
at a higher risk than black women. Other risk factors are smoking, alcohol abuse,
lack of exercise and certain drugs (like prednisone and levothyroxine). About
25% of women have severe osteoporosis and fractures of bones are found in about
50% of them , if they do not take estrogen replacement and calcium supplements
and exercise. The typical osteoporosis fractures are compression fractures of
the spine, fractures of the hip, wrist fractures and ankle fractures. Finally,
heart disease and stroke become more common as the cardiovascular protective
effect of estrogen is no longer active as it was during the reproductive life
cycle.
Diagnostic tests: A menopause test is
a simple blood test where the FSH level is measured. This is the most important
single test, which when elevated, is sufficient proof that the woman is in menopause.
If the LH level is included in the test, this usually is equally elevated. If
there is suspicion for bone loss, a bone density test should be done by dosimetry
(DEXA scan) or other tests that your family doctor can order. If the patient's
test result is 1 standard deviation below the norm, the risk of sustaining a fracture
is 3-5 fold higher. If the bone density is 2 standard deviations below the expected
value, the risk of a fracture is 6-10 fold! Blood tests such as total cholesterol,
LDL and HDL cholesterol as well as triglycerides should also be done. Before hormone
replacement treatment is started, it is important to get baseline hormone tests,
best with saliva testing where a panel of 5 hormones are tested (estrogen. progesterone,
testosterone, DHEAS, cortisol). If your own physician is uncomfortable with bio-identical
hormone replacement, look for an A4M certified physician. The physician will likely
order more blood tests such as thyroid tests, IGF-1, CRP and others. The reason
is that many women in menopause can also be thyroid deficient, can be growth hormone
deficient and may have underlyng inflammatory diseases that have not yet been
diagnosed.
Menopause
Treatment: As often in other areas of medicine, the value of a
diet and exercise program should not be overlooked. Exercise like power
walking (minimum 1/2 hour 5 times per week) will strengthen the bones due
to small pulses of natural growth hormone that is released by the pituitary gland.
Stopping smoking and quitting alcohol (large amounts) is definitely
beneficial. A zone diet program (Ref.1 and 12) or a similar
balanced diet (= low glycemic diet) has also been shown to free
suppressed cyclic AMP, which is beneficial in activating alternative estrogen
pathways. As mentioned above androgens can be metabolized in the skin and fat
cells and produce enough estrogen in some women to stop the hot flashes. Such
balanced diets play a major role in making this happen. If this is not
enough and hot flashes are still a problem, then bio-identical estrogen therapy
should be considered using nature identical estrogen cream from a compounding
pharmacy. Depending on what the hormone and blood tests showed, However,
there are some complications that have occurred with the use of SYNTHETIC hormones
and should be thought about. Synthetic hormones are molecules that resemble hormones,
but that have had some modification of atoms done or a side chain added that makes
them patentable (financially good for the company), but that disfigures their
structure so that not all of the information regarding the hormone can be read
by the hormone receptors of the tissues (bad for the postmenopausal women as this
is the reason for heart attacks, strokes and cancer). -
Some women
have precancerous conditions of the uterine lining or breast cancer and these
women should stay away from synthetic estrogen therapy. Others develop blood clots
(thrombophlebitis) easily and they too should stay away from synthetic hormone
replacement. -
Liver disease, such as cholestatic hepatitis, is
another reason not to take synthetic estrogens. -
There is a twofold
risk to develop uterine cancer on synthetic estrogen therapy, but with regular
Pap smears and yearly endometrial biopsies this can be followed closely. Even
when uterine cancer occurs, there is enough time to do a hysterectomy in most
cases before it spreads. With natural estrogen cream in combination with progesterone
cream where the hormone ratio in the saliva test is 200 to 1 progesterone versus
estrogen, NO cancer risk is observed (see Ref.16) due to the cancer prevention
effect of progesterone. -
In order to mimic what nature does, a
small amount of synthetic progesterone (Provera) was given cyclically in an attempt
to create a hormone cycle similar to the one that happened during the reproductive
cycles. It was thought that this would minimize or eliminate the uterine cancer
risk. However, the risk of heart attacks and strokes in postmenopausal women was
unacceptably high, so that this is now no longer the accepted treatment modality
by most physicians (due to the results of Ref. 17). We now know that this was
the effect of the misfit between the synthetic hormones (Provera and Premarin)
and the woman's hormone receptors. However, many studies in Europe have shown
that if we simply stick to the concept of using only bio-identical hormones as
replacement therapy there is no risk there. -
The risk of developing
breast cancer is about 1.6 fold higher with synthetic estrogen replacement compared
to when women do not use it. Yearly mammography is suggested as well as regular
monthly breast self examination. This way, should there be a suspicious breast
lump; this would be biopsied right away before it becomes an incurable problem.
Again, do not use synthetic estrogens, but bio-identical estrogen cream that is
balanced by also taking bio-identical progesterone cream to neutralize any cancer
risk (the ratio of hormone levels of estrogen to progesterone should be 1:200
or more), which prevents breast cancer development. -
Having said
all of this, hormone replacement with synthetic estrogens should be abandoned.
Many women feel that it is unnatural to interfere with nature and they prefer
to leave things alone. I sympathize with these women on the one hand; but I also
understand the women who want to prevent heart attacks, strokes and fractures
with bio-identical estrogen creams (balanced with other hormone creams to compensate
for those hormones that are missing). Those women who do bio-identical hormone
replacement will likely live 15 to 20 years more than those without any hormone
replacement. - There are benefits from the use of soy products. Isoflavones
contain or stimulate production of natural estrogen and this may be more for women
who want to keep it more natural.
To prevent osteoporosis,
the postmenopausal woman can also take elemental calcium, 400 IU
of Vit. D. In the past doctors recommended the use of biphosphonates (brand
name: Didrocal, Fosamax etc. ). However, in the meantime further research showed
that these chemicals may look good on tests, but do not on the long-term reduce
the risk for osteoporosis. This link
explains in detail why. There are only a few hormones that stimulate bone cells
to produce new bone and they are estrogen, progesterone, testosterone and calcitonin.
Your doctor can advise you how to benefit from that. But read the details of
osteoporosis treatment here first.
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