Menopause
John L. Washington, MD FACOG

Strictly speaking, menopause is the stopping of the periods.  It is that time or day when one has her last menstrual period.  Commonly though, we talk about it as a span of months or years around the time, when social and bodily adjustments take place to accommodate the changes in the physiology.  There is a pre menopausal stage that is a longer and less well defined interval. Until recently pre-menopause has been largely ignored in the medical teaching and literature.  We will discuss here what happens in menopause, the whys and whats and what can be done to optimize one’s health and life during it.

Menopause is the stopping of the periods.  The supply of eggs that a woman is born with has been exhausted.  As the eggs and their surrounding follicle cells are the source of most of the female hormones, the estrogen level drops, sometimes suddenly and abruptly and sometimes by a slow decline.  If menopause occurs suddenly when the last egg is used menopause may be appreciated as a sudden and severe onset of hot flushes and night sweats.  If the onset is more subtle, with prolongation of the time between the menses and irregular periods, one may have a gradual decrease of the estrogen level and a more gradual onset of the hot flashes.  At first, they may only occur during the menstrual week.  They are at first infrequent, and gradually become more bothersome. They may come and go.  The first signs of menopause may occur many years before the periods actually stop.  Some women in their early thirties will complain of menopausal symptoms, hot flashes, generalized heat, vaginal dryness and fatigue, and wonder if they are going through menopause.  The answer is not simple. The periods are numbered even if we don’t know how many there are going to be.  Each period  takes one closer to menopause and each one may have a different pattern of hormone secretion.  The best and most responsive egg follicles are used first and they are the most proficient at hormone secretion.  As the less functional follicles are selected to develop, the hormone secretion may become erratic.  Thinking of it as being like a classroom sometimes helps.  The brain is like the teacher calling for volunteers to make estrogen.  At first there are a lot of good “A” students waving their hands to be called on.  When they are used up there are still a lot of “B” students that are slower but still produce.  When all the others are gone we are left with the losers sleeping in the back of the class.  It may take a lot of shouting on the part of the teacher to get them to wake up and make some estrogen and when they do produce, they may not do it very well. Finally the classroom is quiet and there is no one left to call on and the need for estrogen is unmet.  This is true menopause.

The early symptoms may be problems with the periods being irregular or too heavy.  We have covered most of this in the section “Problem Periods” and will not go over it again just now.  In short, treatment for  controlling the periods is usually accomplished by using hormones, either birth control pills or Provera in tablet or injectable form. Sometimes medicines are not successful or appropriate and surgery is necessary.

Later symptoms that are more specific to menopause are hot flashes and night sweats, depression or fatigue, vaginal dryness, osteoporosis, and other degenerative diseases.  Hot flashes seem to result from an increased level of FSH or LH, the hormones the brain uses to request estrogen from the ovary. When the brain's needs aren’t met, the level of the hormones is increased until they are many times higher than normal.  At these levels they cause a vascular instability, the hot flashes or flushes.  Some women just feel hot all of the time.  The most common time to experience flashes is at night and sleep interruption is the usual result.  Even if one doesn’t wake up completely there is usually enough stimulation to interrupt one’s rest.  As a result the peri-menopausal woman may not get a good night's sleep for years.  Hormone replacement, whether with pharmacological hormones in the approximate amounts that the body is used to or with plant sources to trick the brain into quieting down, are usually about 80% successful.  Most hot flashes can be suppressed but not all of them.  As a result the sleep improves and the fatigue that has been confused with depression and mental illness goes away.

Vaginal dryness is another estrogen deficiency symptom of menopause.  Most people will develop some degree of dryness.  In some women it is enough to make sexual relations difficult or impossible.  Some people are uncomfortable all of the time.  Estrogen supplementation usually will help though systemic estrogen, pill or patch, may not be enough. Some people need to have a “ booster dose” of estrogen applied directly to the vagina by a crème or a tablet or even a plastic “Est-ring” that is sold by one company.  Estrogen supplementation to the vaginal also helps the bladder and “bladder stem” or urethra.

The imponderables of menopause are the conditions that may develop in menopausal women but  we don’t know what the risk is for the specific individual.  These are Heart Disease, Osteoporosis, Alzheimer’s and Colon Cancer and Macular degeneration and other diseases of degeneration..  The risks of these conditions can be estimated pretty well for a population but only roughly for an individual.  The general rule used to be  that estrogen supplementation in a postmenopausal woman will decrease the risk of each of these to perhaps, ½ of the risk of the untreated person.  Recent large poplulation studies, though possibly flawed, have cast doubt on these beliefs. 

As expected recent research studies have cast doubt on some of the most widely held ideas. There are questions about where estrogen is helpful in preventing heart disease. There is an increase in heart attacks in the first two years in women with established artery disease but probably a decrease after that.  There is also more doubt now about the relationship of estrogen to breast cancer but more concerns about medroxyprogesterone's role. There is a new worry about estrogen and ovarian cancer. All of these concerns are real but most practitioners still feel that there is an overall LOWER mortality rate in users of hormone replacement therapy than in non-users. Check out the ACOG web site, www.acog.org , for  press releases on HRT for the latest evaluation. 

A few years ago there was only one treatment for menopause and that was estrogen ( or if the person still has their uterus, estrogen and progesterone). This replaces the normal hormones that the body has stopped making.  We try to minimize breast tenderness and bleeding by keeping the hormone levels low.  This still is the most common, and in many ways the best, treatment.  It replaces the hormones that are missing with almost exact duplicates.  Usually, by adjusting the dose of the replacement hormones, bleeding and breast tenderness can be reduced to a minimum, but not always.  There is also the worry that hormones will cause breast cancer.  That has not been resolved.  There is an association, not evidence of cause, between taking hormones and diagnosis of breast cancer.  There is also evidence that women on hormones are less likely to die of breast cancer.  There is no evidence that taking estrogen shortens the survival of women in remission from breast cancer.  I don’t think that we have all of the answers yet. As of the  end of July 2002, life is just more confusing. There are two studies just released that may help to clarify some things. I have reviewed them in the web page on hormone replacement therapy. 

Recently there have become available several new types of medicines to replace some of the uses of estrogen in the menopausal woman.  Osteoporosis can be reduced with either bisphosphonates, like Fosamax,  Actonel, or Boniva, fake estrogens (SERM’s) like Tamoxifen or Evista, or synthetic calcitonin like Miacalcin.  These medicines improve the strength of osteoporotic bone almost as well as estrogen does.

Vaginal dryness improves with topical estrogen or with lubricating agents like KY—long-lasting, Replens or others. Most of these products are found over the counter.

Herbal remedies are a mixed bag.  Like all popular fads there is a lot of junk mixed up with the useful stuff.  Soy products may be useful.  Eating tofu or drinking soymilk will give relief of menopausal symptoms but the amount that you would have to consume is enormous.  Soy protein is better and can be obtained in capsule form.  Black cohosh has been tested and found in some studies to relieve hot flashes almost as well as estrogen.  Red clover is a powerful phyto-estrogen but may interfere with some medicines. Unfortunately there have been some well designed studies recenly that have cast doubt on the true value of most of the herbal preparations.  

Some people are not sucessful in treating their symptoms with standard hormone preparations. They may be helped with custom compounded hormone preparations or bio-identical, "boutique hormones." Some people can wear "off the rack' clothes, some people need tailoring to get a good fit. This may be an option if other things have not worked.

Calcium and magnesium are good for bones but will not be absorbed well into bone without estrogen or a bisphosphonate.  Exercise is good but will not take the place of estrogens or the other medicines on bone. Coral Calcium is probably just an expensive form of calcium and not worth the money.

The role of topical progesterone and testosterone in creme form is poorly defined.  Most of the studies are not very promising.

There is some evidence that testosterone, taken by mouth, in reasonable doses will restore libido in the menopausal woman.  I am going to devote a full page in the web to the libido problem in the near future.  I don't think I can do this important and vexing topic justice without a page of its own.  

I hope this brief rundown of menopausal symptoms and the medicines and products used to treat them is helpful. It is certainly not complete or exhaustive and is not intended to take the place of your own doctor's advice.  As always this is presented for your information only and is not intended as medical advice. I will appreciate any suggestions or corrections.  Thanks.