Menopausal Symptoms
& Treatment
Pharmacological treatments
Hormone replacement therapy
Hormone replacement therapy is the
administration of estrogen. Because estrogens increase the risk of cancer of
the uterus , usually are used together with a progestin , which reduces this
risk by making it similar to that of the general population. Women who have
been taken off the uterus can take estrogen alone .This therapy tends to
integrate the hormones that women in menopause do not produce more and so far
has been prescribed in the belief that it could protect against osteoporosis
and some important cardiovascular disease.
The risk of an increase in breast cancer ,
is already known, however, this was not considered to affect the possible
benefits if the therapy was used in the absence of contraindications and if the
women were followed closely by doctors and were willing to appropriate periodic
inspections.
A recent American study which was attended
by many women , however, has drastically reduced the usefulness of replacement
therapy in menopause.In women who have the uterus estrogen
should be used together with a progestin.
In particular, the main results of this
study indicate that among women who use hormone replacement therapy there are
more cases of breast cancer ( about 8 more each year for every 10,000 women) ,
heart disease ( about 7 more cases each every year 10,000 women) , stroke
(about 8 cases per 10,000 women per year ) and pulmonary embolism (about 8 cases
per 10,000 women per year ) compared with women who did not use it. The
increased risk is modest and does not justify any scaremongering , but the
study showed the opposite of what was expected : hormone therapy containing
estrogen and progesterone , while reducing fractures and colon cancer , as a
whole has more risks than benefits.
At the current state of knowledge ,
therefore, a long-term hormone replacement therapy is no longer recommended for
women who have the characteristics of those studied , namely, those in good
health , aged between 50 to 79 years who undergo hormone treatment as a
preventive measure : the majority of women, even if they do not incur side
effects, it does not get any real advantage . Are thus dropping the conditions
for prolonged treatment.
The results of this research does not apply
to the processing of short duration carried out to reduce the symptoms of
menopause , which normally constitute the main motivation to start hormone
replacement therapy , nor the processing operations performed in younger women
, for example, an early menopause : in these cases, the benefits may outweigh
the risks.
The use of estrogens to reduce the symptoms
that occur at the beginning of menopause ( the most common are hot flashes ,
night sweats , insomnia and vaginal dryness ) can be useful especially if the
disturbances are poorly tolerated .
A short treatment ( several months is
usually sufficient ) is not dangerous and, unless absolute contraindications ,
there is no reason to give it up. To improve gynecological disorders may also
be useful to be administered estrogen directly on the genitals (eg
Colpotrophine or Premarin vaginal cream or tablets ) that have an effect
limited to the area of application.
Similarly, in the case of early menopause (
natural or surgical ) therapy may be appropriate if there are no
contraindications, and undergoing the necessary checks , up to the average age
of menopause in our population ( 50-51 years). Estrogen taken by mouth are the
most documented. The progestin medroxyprogesterone ( Provera , Farlutal ) is
effective in the prevention of cancer of the uterus and to the continuous dose
of 2.5 mg (currently recommended for women who do not wish to menstruate ) that
the intermittent dose of 10 mg for 12 days a month .
The patches containing estradiol, which is
the natural product of the ovary, are preferable in young women in menopause ,
where therapy is required really " replacement " and in a few other
situations of medical interest .
In the choice of hormonal preparation the
woman has a decisive weight . Women taking estrogen combined with progestin
quote purposes only , that is, outside of cases of therapy or symptoms of early
menopause , should therefore seek advice from their doctor about the
advisability of discontinuing treatment . In the light of the latest data does
not appear in fact recommended to continue hormone replacement therapy over the
period necessary to reduce the symptoms , at least for those women who started
therapy after achieving a natural menopause . The same information must be
carefully considered valid for both oral estrogen than for those in patches ,
while in women without a uterus who take estrogen alone , the information
available is insufficient to give clear guidance.
The benefits that you wanted to pursue
hormone replacement therapy (especially the prevention of osteoporosis and
cardiovascular disease ) can be obtained with other measures, among which are
especially important lifestyle habits based on a correct and balanced varied
diet , with adequate calcium intake , smoking cessation and exercise. In cases
of particularly high risk , however, are available other drugs.
Phytoestrogens
Phytoestrogens are compounds found in many
plants. The most important are the isoflavones , found primarily in soybeans .
Possess an action similar to that of estrogen but weaker . Their use is
proposed in the treatment of menopausal symptoms , as an alternative
"natural" hormone replacement therapy . The interest in these compounds
is born from the observation that Oriental women whose diets rich in soy in
menopausal age have less typical symptoms of menopause , cardiovascular
disease, osteoporosis and hormone-dependent cancers than Western women . Since
soy is rich in phytoestrogens, have begun research to evaluate the potential
benefits of these substances in menopausal women .
The evidence to support the efficacy of
phytoestrogens taken as dietary supplementation , however, are scarce and
contradictory. Above all, it still remains to be determined whether the
positive effects observed are due to the phytoestrogens in itself , or the
combination with the other components of foods.
In light of recent acquisitions ,
phytoestrogens could be seen as a safer alternative to hormone replacement
therapy but their greater safety in use has not yet been demonstrated, the
effects are not known after taking doses or for long periods high , and , in
particular , remains to be determined whether or not involve the risk of breast
cancer .
The treatment of menopause symptoms with
hormone replacement therapy is still a topic of discussion at both the
scientific as well as of women .
In the past years there has been an
emphasis on the first hormone replacement therapy and arrive at a "
demonization " of the same , creating alarmism in women who used it or who
wanted to start it .
Let's see some " points" that
have emerged from a recent publication of the North American Menopause Society
( NAMS ) .
My treatment ' effective for vasomotor symptoms of menopause ( hot
flashes ) is the therapy with estrogen or estrogen-progestin and this leads to
a better quality of life.
The duration of therapy is different for women who still have the uterus
and must be treated with estrogen-progestin compared with those who have
undergone a hysterectomy ( removal of the uterus ) and can only be treated with
estrogen.
The risk of breast cancer limits the estrogen-progestin therapy to 3-5
years.
For estrogen-only therapy , the risk-benefit ratio for breast cancer is
more favorable as it does not increase after 7 years of estrogen therapy .
Hormone replacement therapy is associated with a reduced risk of
fracture, but with a higher risk of ischemic stroke , venous thromboembolism
and ovarian cancer.
The combined estrogen -progestogen therapy , compared with that only
estrogen is associated with an increased risk of coronary heart disease.
The decision to use hormone replacement therapy should be assessed from
patient to patient according to its priorities related to quality of life and
the risk of thrombosis , stroke, cardiovascular disease and breast cancer .
The combined estrogen-progestogen therapy may ' be recommended in women
who have the uterus , as the progestin has a protective effect on the
endometrium , compared to the use of estrogen alone .
For women who complain only vaginal disorders ( dryness, dyspareunia )
is recommended the use of local vaginal estrogen use .
In healthy women aged under 60 years or under 10 years of menopause ,
use of hormone therapy does not increase the risk of cardiovascular disease.
Women who go through menopause at an early age and have no
contraindications to the use of hormone replacement therapy , can follow up to
51 years (average age of natural menopause ), or in addition , to control
menopausal symptoms.
There are insufficient data to support the use of hormone replacement
therapy in women who have survived breast cancer .
Compared to the use of oral estrogens with standard doses , the use of
estrogen transdermal ( patch ) or low-dose oral estrogen , has a lower risk of
thrombosis and stroke.
In conclusion , recent studies support the
use of hormone replacement therapy in menopausal women when the risk-benefit
ratio is favorable and must be assessed individually .
The studies recommend the use of hormone
replacement therapy to treat menopause-related symptoms and to prevent
osteoporosis in women at high risk of fracture.
What are the symptoms
of menopause and peri-menopause?
Experts say that
technically, the menopause is confirmed when a woman has not had a menstrual
period for one year. However, the symptoms and signs of menopause generally
appear well before that one-year period is over. They may include:
Irregular periods - this is usually the
first symptom; menstrual pattern changes. Some women may experience a period
every two to three weeks, while others will not have one for months at a time.
Lower fertility - during the
peri-menopausal stage of a woman's life, her estrogen levels will drop
significantly, lowering her chances of becoming pregnant.
Vaginal dryness - this may be accompanied
by itching and/or discomfort. It tends to happen during the peri-menopause.
Some women may experience dyspareunia (pain during sex). The term vaginal
atrophy refers to an inflammation of the vagina as a result of the thinning and
shrinking of the tissues, as well as decreased lubrication, caused by a lack of
estrogen. Approximately 30% of women experience vaginal atrophy symptoms during
the early post-menopausal period, while 47% do so during the later
post-menopausal period. There are cases of women who experience vaginal atrophy
more than a decade after their final period. The majority of post-menopausal
women are uncomfortable talking about vaginal dryness and pain and are
reluctant to seek medical help.
Hot flashes (UK term: hot flushes) - a
sudden feeling of heat in the upper body. It may start in the face, neck or
chest, and then spreads upwards or downwards (depending on where it started).
The skin on the face, neck or chest may redden and become patchy, and the woman
typically starts to sweat. The heart rate may suddenly increase (tachycardia),
or it may become irregular or stronger than usual (palpitations). Hot flashes
generally occur during the first year after a woman's final period.
Night sweats - if the hot flashes happen in
bed they are called night sweats. Most women say their hot flashes do not last
more than a few minutes.
Disturbed sleep - sleeping problems are
generally caused by night sweats, but not always. Sleep disturbance may be
caused by insomnia or anxiety. Difficulty falling asleep and staying asleep
increase as women go through menopause.
Urinary problems - women tend to be more
susceptible urinary tract infections, such as cystitis. Having to urinate may
also occur more frequently.
Moodiness - this often goes hand-in-hand
with sleep disturbance. Experts say that most mood disturbances are triggered
by poor sleep.
Problems focusing and learning - Some women
may also have short-term memory problems, as well as finding it hard to
concentrate on something for long. Some women may not be able to learn as well
shortly before menopause compared to other stages in life.
More fat building up in the abdomen.
Hair loss (thinning hair).
Loss of breast size
If left untreated,
these symptoms will usually taper off gradually over a period of two to five
years. However, symptoms can persist for much longer. In some cases, vaginal
dryness, itching and discomfort can become chronic, and eventually get worse if
left untreated.
What causes the
menopause and peri-menopause?
The hormones estrogen
and progesterone regulate menstruation - more specifically, estrogen regulates
menstruation while progesterone is more involved with preparing the body for
pregnancy.
When the ovaries start
producing less of these two hormones, the peri-menopause will start. In fact,
by the time a woman is in her late 30s the ovaries start producing less
progesterone and estrogen. By the time she is in her 40s, the post-ovulation
spike in progesterone becomes less emphasized. A woman's fertility starts to
decline a long time before she may notice any menopausal or peri-menopausal
symptoms.
As time passes and the
ovaries produce less and less estrogen and progesterone, the ovaries eventually
shut down completely and the woman no longer has any more menstrual periods.
The vast majority of females experience a gradual change in menstrual activity,
while some go on normally until they suddenly stop.
Some women may
experience premature menopause - their ovaries fail earlier than they are
supposed to (before the age of 45). Ovarian failure can occur at any age - but
very rarely - and often the doctor and patient will never find out why. Some
who experience ovarian failure may still have periods and some degree of
fertility for a while. Premature menopause may be caused by:
Enzyme deficiencies
Down's syndrome
Turner's syndrome
Addison's disease
Hypothyroidism
Removal of the ovaries (bilateral
oophorectomy surgery)
Radiotherapy to the pelvic area
Chemotherapy
Hysterectomy surgery
(the uterus - womb - is surgically removed)
(the uterus - womb - is surgically removed)
Some infections - such as mumps or TB
(tuberculosis), malaria and varicella. However, in all cases risk of ovarian
failure is extremely small.
Genetic factors - scientists have been able
to identify genetic factors that influence the age at which natural menopause
occurs.
Being a twin - twins are more likely to
have a premature menopause.
How is menopause
diagnosed?
A GP (general
practitioner, primary care physician) should be able to diagnose menopause or
peri-menopause if he knows the age of the patient, has information about her
menstrual patterns, and receives feedback from her on her symptoms.
Apart from a blood
test which can measure levels of FSH (follicle-stimulating hormone), there is
no definitive test to diagnose menopause or peri-menopause. FSH blood levels
rise when a woman is in the menopause. However, as FSH levels tend to fluctuate
a lot during the menopause and peri-menopause, the test may provide a little
data, and is not that helpful for a diagnosis. Under certain circumstance a
doctor may order a blood test to determine the level of estradiol (estrogen).
As hypothyroidism (underactive thyroid) can cause menopause-like symptoms, a
blood test to determine the woman's level of thyroid-stimulating hormone may be
recommended.
What are the treatment
options for menopause or peri-menopause?
Only about 10% of
women seek medical advice during the menopause. Many women require no
treatment. However, if symptoms are affecting the woman's daily life she should
see her doctor. The kind of treatment the patient should have depends on her
symptoms, her medical history, as well as her own preferences. Available treatments
include:
Paroxetine approved by the FDA for the
treatment of hot flashes - on June 28th, 2013, the US Food and Drug
Administration (FDA) approved the medication Brisdelle (paroxetine) for the
treatment of hot flashes caused by menopause, the first non-hormonal treatment
to be FDA-approved for hot flashes linked to menopause.
HRT (hormone replacement therapy) or HT
(hormone therapy)
This is very effective for many of the symptoms that occur during the menopause, including vaginal dryness, vaginal itching, vaginal discomfort, urinary problems, bone-density loss, hot flashes and night sweats. HRT tops up the woman's levels of estrogen. However, as with many treatments, HRT has its risks and benefits:
This is very effective for many of the symptoms that occur during the menopause, including vaginal dryness, vaginal itching, vaginal discomfort, urinary problems, bone-density loss, hot flashes and night sweats. HRT tops up the woman's levels of estrogen. However, as with many treatments, HRT has its risks and benefits:
Benefits of HRT
Effectively treats many troublesome
menopausal symptoms.
Helps prevent osteoporosis.
Lowers colorectal cancer risk (cancer
of the colon or rectum)
Risks of HRT
Raises breast cancer risk
Raises ovary cancer risk
Raises uterine cancer risk (cancer of
the womb)
Raises coronary heart disease risk
Raises stroke risk
HRT slightly accelerates loss of brain
tissue in areas important for thinking and memory among women aged 65 and over.
