Managing Menopause

Hormone Replacement Therapy (HRT)

To combat the symptoms associated with falling estrogen levels, doctors have turned to hormone replacement therapy (HRT). HRT is the administration of the female hormones estrogen and progesterone. Estrogen replacement therapy (ERT) refers to administration of estrogen alone. The hormones are usually given in pill form, though sometimes skin patches and vaginal creams (just estrogen) are used. ERT is thought to help prevent the devastating effects of heart disease and osteoporosis, conditions that are often difficult and expensive to treat once they appear. The cardiovascular effects of progesterone, however, are still unknown. Hormone treatment for menopause is still quite controversial. Its long-term safety and efficacy remain matters of great concern. There is not enough existing data for physicians to suggest that HRT is the right choice for all women. Several large studies are currently attempting to resolve the questions, though it will take several more years to reach any definitive answers.

In the 1940's when estrogen was first offered to menopausal women, it was given alone and in high doses. Today, after 50 years of trial and error, it is well known that estrogen stimulates growth of the inner lining of the uterus (endometrium) that sheds during menstruation. This growth may continue uncontrollably, resulting in cancer. Today, doctors typically prescribe a lower dose of estrogen. However, few doctors still prescribe estrogen alone to women who have a uterus. Most now prefer to add a synthetic form of progesterone called progestin to counteract estrogen's dangerous effect on the uterus. Progestin reduces the risk of cancer by causing monthly shedding of the endometrium. The obvious drawback to this approach is that menopausal women resume monthly bleeding. Once menopause arrives, most women enjoy the freedom of life without a period. Many are reluctant to begin their cycles again. In addition, there are other unpleasant side effects of progestin which often discourage women from continuing HRT. These include breast tenderness, bloating, abdominal cramping, anxiety, irritability, and depression.

Only about 15 percent of women who are eligible for hormone replacement therapy are now receiving it. This leaves 85 percent who either do not want or need it, or do not know about it.

The good news is that researchers are evaluating different schedules of low-dose estrogen and progestin to completely eliminate monthly bleeding. Currently most women receive what is called cyclic HRT. They may take estrogen continually and progestin for the first 12 days of each month. The use of a continuous combined dose, where estrogen and smaller amounts of progestin are taken every day, is also being studied. In theory, this use of progestin stems endometrial growth so no bleeding will occur. Unfortunately, it may take 6 months or more until bleeding finally stops. In many cases, monthly bleeding has been replaced by more bothersome irregular bleeding patterns. Obviously, further research is needed to evaluate and perfect this treatment. Various types of progestins in different dosages, preparations, and schedules are being studied in hopes of reducing its other unpleasant side effects while retaining the known advantages of estrogen.

Estrogen and Your Bones

HRT and ERT are successful methods of combatting osteoporosis. As previously discussed, estrogen halts bone loss but cannot necessarily rebuild bone. Long-term estrogen use (10 or more years) may be required to prevent postmenopausal bone loss. Why estrogen helps protect the skeleton is still unclear. We do know that estrogen helps bones absorb the calcium they need to stay strong. It also helps conserve the calcium stored in the bones by encouraging other cells to use dietary calcium more efficiently. For instance, muscles require calcium to contract. If there is not enough calcium circulating in the blood for muscles to use, calcium is "borrowed" from the bone. Calcium is also needed for blood clotting, sending nerve impulses, and secreting various hormones. Prolonged borrowing from bone calcium for these processes speeds bone loss. That's why it's important to consume adequate amounts of calcium in your diet.

Estrogen's Effect on Your Heart

The majority of past clinical studies have shown that women who use estrogen substantially reduce their risk of developing and dying from heart disease. One or two studies demonstrate conflicting evidence, but they are far outnumbered by the positive reports. Results from a 1991 study showed that after 15 years of estrogen replacement, risk of death by cardiovascular disease (CVD) was reduced by almost 50 percent and overall deaths were reduced by 40 percent. Some researchers credit this reduction to oral estrogen's ability to maintain high density lipoprotein (HDL) cholesterol and low density lipoprotein (LDL) cholesterol at their healthier, premenopausal levels, through its interaction with proteins in the liver. Others believe it is estrogen's direct effect on the blood vessels themselves (through receptors on the vessel walls) which creates this benefit. In the latter case, both oral estrogen and the skin patch would be effective. Studies are underway to determine which mechanism contributes most to a healthy heart.

Many doctors now believe that estrogen replacement benefits women at risk for heart disease. Risk factors for heart disease include a strong family history of CVD, high blood pressure, obesity, and smoking.

At any time of life, women who smoke are much more likely to develop heart disease or have a stroke than women who do not smoke. But after menopause, a smoker's risk climbs dramatically. Low estrogen levels and smoking are separate risk factors for CVD. When the two are combined, the risk is much higher than either one alone. Smoking also raises your risks for some types of cancer and for chronic lung disease, such as emphysema. Fortunately, quitting smoking--at any age--can cut the risk of disease almost immediately. Studies have shown that when older people quit, they increase their life expectancy. Their risk of heart disease goes down, their lungs function better, and blood circulation improves. So quitting smoking, whether before, during or after menopause, can have a definite impact on both the length and quality of your life.

Many women who have quit smoking say they found support in group counseling sessions. Local chapters of the American Cancer Society and the American Heart Association are good places to start looking for a smoking cessation group. Nicotine gum and nicotine patches prescribed by a doctor may also help.

While we know that estrogen users have a decreased risk of CVD, women with certain preexisting heart conditions are usually advised not to take HRT or ERT. These conditions include blood clots and recent heart attacks. Researchers hope to further investigate nonhormonal methods of preventing heart disease such as weight reduction or control, exercise, smoking cessation, and dietary modification. According to a 5-year study reported in 1988, weight gain (a common occurrence among many menopausal women) significantly raises blood pressure, total and LDL cholesterol, and fat levels. Together, these make up a dangerous recipe for heart disease. Several other studies also noted that having about one drink per day had a protective effect on the heart. Physicians advise caution in this area, however, as excess alcohol can increase risks for other serious problems.

While cardiovascular benefits associated with oral estrogen are fairly well-known, there is surprisingly little information on the cardiovascular effects of progestin combined with estrogen. Some studies suggest that progestins counteract the favorable effects of estrogen alone, while other studies show no such effect. This remains just one more gray area where questions outnumber reliable answers.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.