Menopause - Symptoms & Solutions

Before any treatment is started, doctors ask women about their medical and family history and perform a physical examination, including breast and pelvic examinations and measurement of blood pressure. Mammography is also performed. Blood tests may be performed, and bone density may be measured. The information thus obtained helps doctors determine the woman's risk of developing disorders after menopause. For women with a history of abnormal bleeding from the vagina, an endometrial biopsy may be performed to check signs of cancer. A small sample of tissue is removed from the lining of the uterus (endometrium) and is examined under a microscope.

Not consuming spicy foods, hot beverages, caffeine, and alcohol may help prevent hot flashes, because these substances can trigger hot flashes. Eating foods rich in B vitamins or vitamin E or foods rich in plant estrogens (phytoestrogens), such as tofu, soy milk, tempeh, and miso, may also help. Not smoking, avoiding stress, and exercising regularly may help improve sleep as well as relieve hot flashes. Wearing layers of clothing, which can be taken off when a woman feels hot and put on when she feels cold, can help her cope with hot flashes. Wearing clothing that breathes, such as cotton underwear and sleepwear, may enhance comfort.

Many of these measures - losing weight if needed, stopping smoking, and exercising regularly-plus decreasing the total amount of fat and cholesterol in the diet may be recommended to help lower cholesterol levels and thus reduce the risk of atherosclerosis.

If vaginal dryness makes sexual intercourse painful, an over-the-counter vaginal lubricant may help. Staying sexually active also helps by stimulating blood flow to the vagina and surrounding tissues and by keeping tissues flexible. Kegel exercises may help with bladder control. For these exercises, a woman tightens the pelvic muscles as if stopping urine flow.

Hormone Therapy For women who have a uterus, hormone therapy usually includes a progestin, such as medroxyprogesterone, as well as estrogen. A progestin, a drug similar to the hormone progesterone, is given with estrogen to reduce the risk of cancer of the uterine lining (endometrial cancer). A progestin without estrogen may be prescribed for women who have endometrial cancer or breast cancer. Progestins are available in synthetic and natural forms. The natural forms are identical to a woman's own progesterone.

Some Drugs Used to Treat Symptoms and Complications of Menopause
Type	Drug	Advantages	Disadvantages
Female Hormones
	Estrogen	Relieves hot flashes, night sweats, and vaginal dryness Helps prevent osteoporosis Has positive effects on cholesterol levels	Increases the risk of endometrial cancer if not taken with a progestin Increases the risk of blood clots Appears to increase the risk of breast cancer May increase the risk of atherosclerosis, heart attack, and stroke Increases triglyceride levels Modestly and temporarily increases the risk of developing gallstones
	A progestin, such as medroxyprogesterone	Reduces the risk of endometrial cancer associated with taking estrogen alone May help relieve hot flashes May help prevent osteoporosis	Does not relieve vaginal dryness May increase the risk of atherosclerosis In synthetic forms, may have negative effects on cholesterol levels
Selective estrogen receptor modulators (SERMs)
	Raloxifene	Prevents and treats osteoporosis Does not appear to increase the risk of endometrial cancer Inhibits the growth of breast tissue	Increases the risk of blood clots May mildly worsen hot flashes
Bisphosphonates
	Alendronate	Prevents and treats osteoporosis	Can irritate the lining of the esophagus if taken improperly
	Risedronate		Must be taken with a glass of water after awakening, followed by 30 minutes without consuming any food, liquid, or drug and without lying down
Antidepressants
		Relieve depression, anxiety, irritability, and insomnia May relieve hot flashes
Lipid-lowering drugs
		Prevent atherosclerosis (including coronary artery disease)
One type of antihypertensive drug
	Clonidine	Lessens hot flashes	Can cause side effects, such as drowsiness, dry mouth, fatigue, an abnormally slow heart rate, rebound high blood pressure when the drug is withdrawn, and sexual dysfunction
Male hormone
	Testosterone (used in combination with estrogen)	May increase sex drive and energy Prevents osteoporosis Improves mood	Decreases the HDL (good) cholesterol level In high doses, may have some masculinizing effects, such as facial hair growth Has not been studied extensively, so risks are unknown

A panel meeting in conjunction with a Conference on the Management of Menopause-Related Symptoms, convened by the National Institutes of Health (NIH), has issued a statement supporting the use of postmenopausal hormone therapy (HT) for the management of moderate to severe menopausal symptoms, such as hot flashes, night sweats, and vaginal dryness. Wyeth Pharmaceuticals, a division of Wyeth (NYSE:WYE), supports the panel’s statement on the treatment of menopausal symptoms and encourages women experiencing menopause to talk with their doctor to determine treatment options as appropriate, based on an individual woman’s treatment goals and personal health profile.

On March 23, 2005, a Conference of Menopausal Symptoms convened by The National Institute of Health supports the use of postmenopausal hormone therapy. “The panel agreed that hormone therapy remains the most consistently effective therapy for treating menopausal symptoms and is, by far, the most intensively studied,” said Dr. Gary Stiles, MD, Executive Vice President and Chief Medical Officer, Wyeth Pharmaceuticals.

While the NIH conference focused on menopausal symptoms, another important health issue for women is postmenopausal bone loss – an asymptomatic condition that can lead to the development of osteoporosis. Up to 20 percent of a woman’s expected lifetime bone loss can occur in the years immediately following menopause. Only HT has been proven both to relieve menopausal symptoms and to prevent postmenopausal osteoporosis.

Wyeth is the pharmaceutical company that financed the research on Premarin and Prempro.

With more than 60 years of science and clinical experience, there is an extensive catalogue of data documenting the benefits and risks of the PREMARIN® (conjugated estrogens) Family of Products. Products are available in multiple strengths, including four low doses options: PREMARIN® (conjugated estrogens tablets, USP) 0.3 mg, PREMARIN 0.45 mg, PREMPRO™ (conjugated estrogens/medroxyprogesterone acetate tablets) 0.3 mg/1.5 mg, and PREMPRO 0.45 mg/1.5 mg.

“Medicine and science continue to evolve, and Wyeth is committed to offering menopausal women and their health care providers innovative, well-studied products to meet individual treatment goals and risks,” said Dr. Stiles.

What is the most important information you should know about PREMARIN (estrogens) or PREMPRO (a combination of estrogens and a progestin)?

Do not use estrogens with or without progestins to prevent heart disease, heart attacks, strokes, or dementia. Using estrogens with or without progestins may increase your chances of getting heart attacks, strokes, breast cancer, and blood clots. Using estrogens, with or without progestins, may increase your risk of dementia, based on a study of women age 65 years or older. You and your health care provider should talk regularly about whether you still need treatment with estrogens.

At the moment, the best advice experts can give is for women to discuss the benefits and risks of HRT with their physicians and make informed choices.

Brand Names and Common Daily Dosages of HRT for Post-Menopausal Women
Estrogen	Progesterone
Premarin, 0.625-1.25 mg Estrace, 1.0-2.0 mg Ogen, 0.625-1.25 mg Estraderm, 0.05-0.1mg patches Climara, 0.05-0.1 mg patches Vivelle, 0.0375-0.1 mg patches	Provera, 2.5-10mg Cycrin, Curretab, Amen 10mg Micronized ("natural") Progesterone 100mg, 200mg Norethindrone 0.5-1.0mg po qd
Combination Estrogen and Progesterone
Prempro (0.625mg Premarin + 2.5 Provera) Premphase (0.625mg Premarin + 5.0mg Provera 14 days of the month)(called Premique in UK; Provelle in Australia) Estratest (esterified estrogen and methyltestosterone)
Source: Hormone Replacement Therapy & Menopause by Ann Brown, MD, Duke University Medical Center. (2)

Side effects of hormone replacement therapy (HRT) vary from individual to individual but may include:

Since estrogen has been linked to an increased risk of endometrial cancer (cancer of the lining of the uterus), there is a concern that HRT may increase the risk of a recurrence of endometrial cancer in women who have a history of the cancer. Physicians typically prescribe progestin with estrogen to counteract the risk of endometrial cancer.

There are also conflicting studies that show that HRT may increase the risk of blood clots in the veins. Generally, patients who have suffered from phlebitis (the inflammation of a vein, often along with the formation of a blood clot) from either the veins close to the skin (inflammation of varicose veins) or in the deep veins of the leg are not at greater risk of blood clotting. However, if previous blood clotting was associated with estrogen use or a "high-estrogen" state (i.e., pregnancy), it is likely that HRT may cause increased blood clotting.

The Women's Health Initiative was launched in 1991 to study combination HRT (estrogen plus progestin) and estrogen-only HRT. All together, its studies have involved 161,808 healthy post-menopausal women. The following summarizes the study's findings as of 2003.

Compared with women taking a placebo (an inactive pill), women who took estrogen plus progestin experienced:

The study results also show that for every 10,000 women per year taking estrogen with progestin, there would be:

Compared with women taking a placebo (an inactive pill), women taking estrogen alone experienced:

HRT is a tradeoff between the proven benefits of relieving menopausal symptoms and preventing diseases such as osteoporosis versus the possibility of increasing the risk of breast cancer. If a woman is at high risk of osteoporosis (due to age, family history, small build, etc.) and has a relatively low risk of breast cancer, then HRT may be an easy choice. If a woman is already at high risk of breast cancer due to genetic factors, family history, etc. then the decision to take HRT may be more complicated.

To further add to the confusion, the combined estrogen/progestin arm of the Women's Health Initiative (WHI)-a large clinical trial that was studying HRT, heart disease, osteoporosis, breast cancer, and colon cancer in 63,000 American women between the ages of 50 and 79-was halted in by the National Institutes of Health (NIH) in 2002. Researchers felt that the elevated risk of breast cancer, as well as higher than normal rates of heart attack, stroke, and blood clots, outweighed the benefits that HRT may provide against hip fractures and colon cancer. The arm of the WHI that studied estrogen alone (with progestin) did not find an increase in heath-related problems among women who took estrogen. That arm of the study will continue.

At the moment, the best advice experts can give is for women to discuss the benefits and risks of HRT with their physicians and make informed choices.

Heart disease is the leading cause of death in post-menopausal women. Since a woman's risk of heart disease increases significantly at menopause, when her body stops producing estrogen, researchers have long been interested in determining whether HRT can help protect women against heart disease.

Past studies have provided hope that HRT can reduce heart disease risk. For example, studies have also shown that HRT may prevent the spasm of arteries that deliver blood and oxygen to the heart and lower the level of proteins that may cause harmful blood clots in those arteries. Studies showed that estrogen therapy may also help heal damaged blood vessels, prevent blood from coagulating (thickening), and may help to keep the walls of blood vessels pliable and open. In a 1997 study reported in the medical journal, Obstetrics and Gynecology, researchers found a lower incidence of coronary artery calcification in women who took HRT. Moreover, according to epidemiologist Deborah Grady, MD, for patients who have already had one heart attack, HRT may reduce the chance of a second heart attack by 84%.(3) Estrogen/progestin combinations may also help decrease heart disease by working to lower LDL ("bad") cholesterol levels and increasing HDL ("good") cholesterol levels.

However, recent studies have contradicted the beneficial effects of HRT on the heart. In fact, these newer studies suggest that HRT may actually increase the risk of heart disease in some women. In July 2002, the National Institutes of Health (NIH) stopped short a major study of HRT, called the Women's Health Initiative, because early findings showed that HRT was harmful to the heart. The NIH found that for every 10,000 women who take a combined estrogen/progestin version of HRT, 7 more will have a heart attack, 8 more will have a stroke, and 18 more will have blood clots, including 8 with blood clots in the lungs. The most recent analysis of the study's results (from 2003) showed that estrogen plus progestin use was associated with a 24% overall increase in the risk of heart disease, with an 81% increased risk in the first year of use The study did find benefits to HRT, including fewer hip fractures (often a sign of osteoporosis) and a decreased risk of colon cancer.

Osteoporosis is a degenerative bone disease that affects approximately one third of women over age 50. HRT is commonly prescribed to help prevent osteoporosis in post-menopausal women and appears to be particularly effective against osteoporosis if taken during the first five years after menopause begins. It is estimated that HRT can lead to a 50% to 80% decrease in vertebral fractures and a 25% decrease in non-vertebral fractures with five years of use. However, women may lose protection once they have stopped taking HRT. The Women's Health Initiative study results also showed HRT to be beneficial for bone health. On average, the researchers found that if a group of 10,000 women takes estrogen plus progestin for a year, 5 fewer cases of hip fractures will occur than in 10,000 nonusers.

HRT may also prevent osteoarthritis, a degenerative joint disease. Osteoarthritis is a major cause of hip and knee replacement surgeries among the elderly. As with osteoporosis, protection against osteoarthritis ends after HRT has been stopped.

Alzheimer's disease is a degenerative brain disease that leads to confusion and memory loss as well as restlessness, problems with perception, speech trouble, trouble moving, and paranoia. Currently, there is no cure for Alzheimer's disease. However, some small studies suggest that estrogen or various combinations of HRT may delay the development of Alzheimer's.

Past studies suggest that women who take HRT have a reduced risk for Alzheimer's disease. In one study, elderly women were followed for five years. Among the women who did not take estrogen, 16% developed Alzheimer's disease compared to only 1.7% who did take estrogen. In another study, women who suffered only moderate memory problems from Alzheimer's disease improved their memory while on HRT.(3)

However, in 2003, results from the Women's Health Initiative Memory Study showed that estrogen plus progestin doubled the risk for developing dementia in post-menopausal women age 65 and older. Dementia is defined as a decline in mental ability in which the patient can no longer function independently on a day-to-day basis. The risk increased for all types of dementia, including Alzheimer's disease.

Patients with Type II (adult onset) diabetes are resistant to the action of insulin (a hormone released by the pancreas in response to high levels of sugar in the body). Past studies suggest that HRT may improve the body's response to insulin. Rather than making the body's blood sugar level go up, HRT may improve blood sugar metabolism.

The link between HRT and breast cancer remains controversial. Some studies have shown the risk of breast cancer to be minimal among women who use HRT while other studies have shown a more significant risk. Although studies have been inconsistent, there appears to be an emerging consensus that HRT may increase the risk for breast cancer.

Recently, women have been overwhelmed with reports that HRT may increase the risk for breast cancer. One particular study of 46,355 women in the Breast Cancer Detection Demonstration Project, a national breast cancer screening program, found nearly a 9% increase in breast cancer risk among women who used combined HRT (estrogen and progestin) each year. However, Dr. Judith Reichman, a professor at the University of California, Los Angeles who spoke at the Congress on Women's Health and Gender-Based Medicine meeting in June 2000, said that the results of the Breast Cancer Detection Demonstration Project are often misinterpreted. Some women may incorrectly assume that a 9% increase in breast cancer risk each year would mean that in 10 years, a woman's risk of breast cancer would be 90%. In reality, the researchers noted a 9% per year incidence of breast cancer among women who took HRT for a long period (typically over five years).

Other studies have shown that HRT can also increase the risk of breast cancer. Most notably, the Women's Health Initiative recently found that postmenopausal women taking estrogen with progestin have an increased risk of breast cancer as well as heart attack, stroke, and blood clots.

Nevertheless, other studies present a different point of view. In a study published in a March 1999 issue of the medical journal Cancer, 9,494 women with benign (non-cancerous) breast diseases (such as fibroadenoma) who took HRT were found to be at the same risk of developing breast cancer as women with benign breast diseases who did not take HRT. Lead researcher David Page, MD of Vanderbilt University, said that women need to know that the risk of breast cancer for low-dose ERT (HRT with estrogen alone) is minimal, and that there are many benefits to HRT. Dr. Page emphasized that the decision to use HRT or not should be an informed one and not one made out of fear.

The type of estrogen prescribed may have some biologic significance. For instance, ethinyl estradiol is more potent than traditionally used conjugated estrogens and has been associated with a 20% greater breast cancer risk that increases with the length of exposure. In addition, estrogen that is injected into the body (through a vein) rather than taken orally in pill form has been shown to be four times as likely to increase breast cancer risk, according to recent studies.(3)

Some research suggests that long-term use of HRT (10 years or more) increases the risk of ovarian cancer. In a study of more than 200,000 women, researchers from the American Cancer Society found that using estrogen replacement therapy (estrogen without progestin) for 10 or more years increases the risk of death from ovarian cancer. While the chances of developing ovarian cancer doubles with prolonged estrogen use, the risk still appears to be small-approximately 2% over a lifetime. However, the study did not include data from women who used combination hormone replacement therapy (estrogen and progestin), which is the most common regimen prescribed today.

While researchers are not certain why estrogen therapy increases the risk of ovarian cancer, they do know that estrogen causes ovarian cells to produce at faster than normal rates. One theory is that the more times a cell divides, the higher the chances that it will result in an abnormal gene copy. If the abnormal copy controls cell growth, this could result in uncontrolled (cancerous) growth.