Menopause

Menopause
Menopause is the normal process of the ovary ceasing to produce eggs for reproduction. As a consequence, in the absence of developing egg follicles where estrogen was previously produced, the female body attempts to adapt to the decreasing levels of estrogen. Sometimes this can be a minimally uncomfortable condition; at other times it can be very uncomfortable with numerous symptoms; the most common of which is hot flashes. Menstrual periods can change during this shutting down process, either becoming longer or shorter, flow can become heavier or lighter, and the interval between periods can become longer or shorter. Eventually the periods cease as the body enters the actual phase of menopause. If one considers the life cycles of a woman, about one-third of her life is spent in pre-puberty and puberty, one-third is spent in reproductive years, and one-third is spent in menopause. This is how the life clock is set, though certainly there are variables such as illness or surgery (hysterectomy or removal of ovaries) which accordingly can change it.
There is estrogen receptors located throughout the body. When these receptors are not joined with estrogen, they act in different ways on their various organ systems. Certainly there are large concentrations of estrogen receptors in the genital structures of the female anatomy. With declining levels of estrogen there can be a decrease in the vaginal wall thickness, and onset of vaginal dryness. This can cause problems with intercourse which is very distressing. There can be changes in the bladder and urethra which cause leakage of urine or increased urinary infections. A very common phenomenon is vasomotor instability, or hot flashes. This no doubt arises from unfilled estrogen receptors in the blood vessels. A menopausal woman can go from comfortable to drenching sweat in a few moments. This condition is especially improved with systemic dosages of estrogen. There are other medicines which seem to help. Some are the SSRI or SNRI antidepressants. Clonidine, which is normally used for blood pressure, can help. Gabapentin, a seizure medicine can help; there was another seizure medicine called veralipride which was effective, but has been removed from use due to adverse side effects. There are other general health measures which a woman can do to prevent hot flashes. One is to avoid all caffeine, concentrated sugars, stimulants, and alcohol which seem to aggravate the condition. (Smoking makes hot flashes worse, and on the average brings on menopause a year younger in smokers than in non-smokers). One hour of aerobic exercise per day can help with vasomotor instability. One way to make hot flashes more comfortable is to suggest that a woman dress in layers of breathable fabric materials, so she can shed extra clothing when she starts to have a hot flash. In view of the worries about systemic estrogens which came out after the Woman's Health Index studies, there is some renewed interest in herbs and phytoestrogens like black cohash and ginseng. The jury is still out on the effectiveness of herbs to help this problem.
Other estrogen receptors are in the skin. Menopause can cause thinning, dryness, decreased skin tone, and wrinkling of the skin. The hair can become thinner and more brittle. The central nervous system can show sleep disorders leading to chronic fatigue, headache, mood swings, nervousness, and irritability. Once again, anywhere there are estrogen receptors there can be a change in system function. One example which is very important is bone. Menopausal women have progressive decrease in bone density and strength, and are more prone to certain fractures, especially in the vertebrae, hips, and wrists.
There are three types of estrogen that we are talking about. Estrone is produced during menopause, to a degree by other organs such as the liver, the adrenals, and fat cells. Estradiol is the estrogen normally produced by the ovarian follicles, and is stronger than estrone. Estriol is the estrogen primarily produced during pregnancy. Systemic estrogen supplementation used to come from conjugated estrogens found in horse urine, but these are now essentially replaced by more human specific estrogens. What might be expected from giving estrogen to a menopausal woman? It seems to be safest if started within three years after menopause onset. Women with heart disease, history of stroke or thromboembolism, or breast cancer are excluded right off the bat. Its use has to be evaluated yearly in reference risk to benefit ratio. But if a woman meets these criteria, she might expect relief from hot flashes, some reversal of vaginal atrophy, positive skin and hair changes, and stronger bones. As mentioned, the WHI (Women's Health Initiative) found that the addition of progesterone to the estrogen caused increased risk in several areas, including heart and vascular. Starting estrogen after age 65 seemed to lead to increased dementia and other complications.
So, in summary, it might be said that we live in a culture where youth and secondary sexual characteristics are highly promoted and valued. Entry into a new and different life phase is a bit daunting, and certainly brings on sadness and a sense of uncertainty. Work with your doctor to make it as comfortable as possible. Have a thorough physical exam to be sure that other medical problems such as thyroid or diabetes are not adding to the symptomatology. Discuss the benefits and risks of hormone replacement. There are other medicines to increase bone strength and integrity, and other medicines for hot flashes. Take care of yourself: exercise regularly, keep your weight down, and remember that caffeine and alcohol can make hot flashes worse. As they say, “this is something you're going through,” and there are many things that can make the passage more comfortable.

John Drew Laurusonis, M.D.
Doctors Medical Center