Menopause and Hormone Replacement Therapy
From the mid-twenties a woman's fertility starts to decline ever so slowly. By the time a woman reaches her early 40s her chances of becoming pregnant have dropped quite significantly and by the time she gets to her late 40s her chance of having a baby is almost zero! This is because the eggs stored within her ovaries since before she was herself born have slowly degenerated and lost their ability to respond to hormonal signals from the brain. This degeneration or aging is caused partly by many years of bombardment by the radiation we are constantly exposed to without knowing it and partly by the effects of toxic chemicals either in our food or produced by normal chemical reactions. When the eggs are too old they cannot ripen and be released to be fertilised.
The other tissues within the ovaries which produce the important ovarian hormones, œstrogen and progesterone, also decline and gradually less and less of these hormones are produced. When these hormones are not present in sufficient quantities to do their important "jobs" within the body gradually the body starts to suffer for want of these vital hormones.
Menopause is the name for this stage in a woman's life when egg and hormone production by the ovaries fail. There are many effects of the failure of the ovaries to respond to the brain's hormone messages some of which are often considered beneficial by women while others can make life a misery and some are nothing short of disastrous!
- Women lose the ability to have babies due to failure of the ovaries to "ripen" and release eggs for fertilisation. Many women welcome this loss of fertility while others who have postponed babymaking to further their careers or pay off the mortgage suddenly find that they've "missed the boat"!
- Menstrual bleeding becomes unpredictable and may become totally irregular, heavier with flooding and cramping pelvic pains, or lighter, or just stop all of a sudden; no woman likes to have embarrassing accidents or suffer horribly severe cramping pains and most women find it a blessed relief not to have periods!
- Hot flushes may occur due to the opening effects of increasing quantities of the brain's hormonal signals on the skin's blood vessels as the brain struggles in vain to get the ovaries to respond by making the ovarian hormones! Many women find their lives become miserable for many months or several years until the hot flushes gradually subside. Some lucky women don't have any hot flushes at all!
- Body tissues which are involved in reproduction and which require high levels of ovarian hormones (œstrogens and progesterone) in the blood start to deteriorate as the hormone levels fall. These tissues include the pelvic floor muscles which support the bladder, the uterus and the lowest part of the bowel (the rectum), the skin of the genitalia (vulva and vagina) and the glands in the genital skin which produce lubrication during sexual arousal.
- The pelvic floor muscles become weaker and no longer support the bladder, the uterus or the rectum as well. As a consequence these organs sag lower and can actually drop so low as to bulge into the vagina causing a "prolapse". And when the bladder sags down into the vagina the valve which controls the release of urine from the bladder starts to become harder to control which causes women to lose control of their urine with incontinence developing.
- The lubricating glands don't make as much lubricating fluid with sexual arousal so intercourse becomes uncomfortable and even painful for women and even for their partners! When this happens it's understandable that a woman's desire to have sex (libido) will decline and this can dramatically affect a relationship!
- The skin of the vagina and vulva becomes thinner and more easily traumatised which also can make sexual intercourse painful and unwanted! Infections become more common as the skin becomes atrophic.
- Women's bones start to lose calcium and gradually become weaker and more brittle with the result that after one or two decades fractures of hips, ribs, wrists and the spine become very common. This progressive loss of mineral loss from bones causes osteoporosis (which is discussed in greater detail in another article on this website) and can be prevented as can all of the above problems resulting from the menopause.
- Women are increasingly at risk of having heart attacks and strokes because of declining levels of œstrogen and progesterone.
- Women are increasingly at risk of developing Alzheimer's dementia after the menopause has started.
- Emotional and psychiatric problems such as depression are more common in women who have entered the menopause.
What Can Be Done About The Problems Of Menopause?
Without a doubt the most obvious and effective form of treatment is to take hormones to restore the body's hormone levels to normal and this understandably is called hormone replacement therapy. Hormones can be taken by mouth using daily pills or tablets or absorbed through the skin from patches which are changed once or twice a week. Both forms of therapy have advantages and disadvantages and there is no way anyone can predict with accuracy which treatment is best for an individual - one just has to try one treatment and see if it works and is easily tolerated. If not then there are alternatives and just because one form of therapy isn't successful one shouldn't become disheartened or put off!
For those unlucky women who just cannot tolerate either of the above alternatives there is one other form of treatment which can be used but it can only deal with some of the problems of menopause! Creams or tiny tablets which contain small doses of hormones can be inserted high in the vagina once or twice a week and this local topical application of hormone can provide the benefits of hormone replacement therapy but just to the genitalia (vulva, vagina and pelvic floor muscles). These treatments aren't particularly messy or difficult to use but do require motivation and a little manual dexterity! They have few side-effects apart from possibly increasing a woman's tendency to suffer with Candida infections ("thrush" or monilia).
What Problems Can Hormone Replacement Therapy Cause?
This is a very contraversial topic and basically, for some of the more serious suspected risks, the "jury is still out"! The well understood problems are:
- there is always some cost to be borne when taking tablets or using medical patches.
- there is some inconvenience in having to take tablets or apply patches regularly.
- patches may not stick well to the skin and may come off well before they "run out" and are due to be replaced; they may not stay on in the shower as they should so replacing them too early costs more money!
- some women develop tender enlarged breasts when they first start treatment especially if they have been menopausal for some time. This tenderness nearly always settles down if patients can persevere and put up with the discomfort.
- some women develop periods again if they are on a cyclical type of hormone replacement therapy which includes a few days off all hormones or with reduced hormone levels specifically designed to cause periods; if they have enjoyed some time without periods women rarely enjoy going back to having periods. Mostly these periods become progressively lighter and eventually stop happening but this can take quite a few months to some years to stop.
- some women gain weight in the early days of hormone replacement therapy while others lose weight, especially if they had put on a lot of weight with the menopause. However the weight loss doesn't happen automatically and usually dietary measures and increased activity are needed to shed the unwanted weight ("no pain, no gain").
- a few women find that their blood pressure rises with some types of hormone replacement therapy and for this reason doctors usually watch the blood pressure closely, at least during the first 6 months of therapy.
- there is a small rise in the risk of having a deep vein thrombosis; this risk is higher in women who have already suffered from such a thrombosis or who have a close family member who has had this problem. Doctors may be reluctant to offer this treatment to women who have a known risk of this complication.
Some of the less understood problems are more serious and include the risks of cancer! Our knowledge on this issue increases day by day but there is still no consensus on what the risks actually are. Most probably there is a tiny increase in a woman's risk for developing breast cancer and cancer of the endometrium (the lining skin of the uterus). For this reason doctors encourage all women having hormone replacement therapy to have regular pap smears (see the other article in this website on this topic) and also regular mammograms. These are the best screening tests available at the moment for picking up breast cancer and cervical cancer at an early and potentially curable stage when cancers are too small to be felt by prodding or feeling for breast lumps or waiting for abnormal vaginal bleeding to occur!
The possible increased risk of breast cancer due to hormone replacment therapy is truly very small. If it was a large risk doctors would have discovered this many years ago and there just wouldn't be any controversy on this issue. Endometrial cancer is better understood and the added risk by taking hormone replacement therapy is very small indeed. Nevertheless this cancer is sometimes detected with pap smears and therefore it's logical to have this test on a regular basis (every 2 years).
Finally, how long should women continue taking hormone replacement therapy?
Most authorities recommend that hormone replacement therapy be taken for at least 10 years. Some people recommend 15 years, others say 5 years and others say indefinitely! Unfortunately it is very confusing for the average layperson to hear such conflicting opinions from so-called experts! The obvious fact is that no-one really knows. However if one is mainly interested in preventing osteoporosis and if women have their menopause at an average age of 45 and have a very high risk of fracturing their hips and possibly dying because of this when they are 75 or older, perhaps it's reasonable to take hormone replacement therapy for 10 years.
If women just want to put an end to messy heavy periods then perhaps 2-5 years may be long enough to wait until the ovaries have completely "given up the ghost"!
The bottom line is that hormone replacement is a fantastic treatment doctors can offer women to improve their quality of life and prevent nasty problems in later life. The risks are small and must be considered carefully before treatment is commenced and some regular screening tests are crucial to pickup dangerous problems at an early and treatable stage.