|hormone replacement therapy|
At about the age of 50 a woman undergoes menopause. The menstrual periods stop, and as a consequence fertility ceases. Lack of fertility is however the least of a woman's problems: few women would want children at that age, and the absence of bleeding is in many ways a boon. However menopause is associated with several hormonal changes in the body, most of which are not desirable. It is now possible to delay menopause by the administration of certain drugs, and it appears that most rather than some women are candidates for this treatment.
the menopause and the menopausal syndrome
"Menopause" means cessation of menstruation. Menopause occurs between the ages of 40 and 55, with most women reaching menopause at about the age of about 48 years. Menopause occurring before the age of 40 is called premature menopause.
Cause of menopause. The menopause is triggered by a fall in the estrogen production by the ovaries. ("Estrogen" is a term that refers to a group of female sex hormones. The most important estrogen is a compound called estradiol.)This ovarian failure, a normal phenomenon, is called the climacteric, and culminates in the menopause. The levels of estradiol, one of the important estrogens, fall to about a tenth of their normal levels in the blood. Menopause may be iatrogenic (caused by a doctor or medical treatment), such as surgical resection of the ovaries, or destruction of ovaries by radiation treatment for various diseases. Heavy smoking may advance the onset of menopause.
Menopausal syndrome. While menopause is occurring, the woman often experiences an acute menopausal syndrome. This is characterized by hot flushes, or episodes of sensation of warmth all over the body. In addition there may be anxiety, irritability, depression, and sleep disturbances. The symptoms can sometimes be quite debilitating.
Changes in the reproductive organs. The uterus and the breasts, which are maintained by the estrogens, begin to shrink. Menstrual periods stop. There is a slight but definite loss of libido. The vagina becomes dry and susceptible to infection, and sexual intercourse can become painful, leading to further decrease in libido. While the estrogen levels are falling, the menstrual pattern changes. In most patients, bleeding becomes scanty and infrequent. Some patients may even have an increased flow for a short time. Bleeding in between periods needs investigation. In a few patients periods stop suddenly.
Effects of menopause on other organs.After menopause, reproductive organs are not the only ones affected. Other body systems face deleterious effects as well. The two important effects of the menopause are on the bones and on the heart.
The bones begin to thin out, with the onset of osteoporosis. Osteoporosis usually manifests as bone pains particularly in the knees. The calcium loss in postmenopausal women can be twice as much as in men.
The heart, before the menopause, is protected from heart attacks. Men in the forties are 5 times as likely to have heart disease as women of the same age. In contrast, men in the sixties have the same chances of heart disease as postmenopausal women in the same age.
There may be thinning of the urethra, the tube that leads out from the urinary bladder, with resultant disturbances in urination.
With HRT, the loss of the naturally occurring estrogens is compensated by orally administered estrogens. A woman's periods return, and the risks of heart attacks and osteoporosis diminish. Women who have the menopausal syndrome improve dramatically. The improvements are so marked that estrogens are sometimes believed to reverse aging. Recently it has been found that HRT delays the onset of Alzheimer's disease.
HRT is given using estrogens and progestogens in a manner that menstrual cycles are maintained. In patients who have had a hysterectomy (removal of the uterus) HRT is given with estrogens alone. HRT may be given in an estrogen-containing patch that is applied on the skin. The patch needs to be changed after 3-4 days. HRT can also be given by implanting estrogen-containing tablets under the skin. The effect lasts for 6 months. This method is only suitable for patients who have had hysterectomy. Preparations of estrogens are also available for use by inhalation.
Several regimes and drugs are available, that allow for maximum long-term safety with minimal side effects. HRT is usually given for about 10 years after menopause.
There are however some side effects of estrogens. Estrogens increase the coagulation of blood, which can lead to certain diseases such as clots in the legs (deep venous thrombosis), clots in the lung arteries (pulmonary embolism), cerebral stroke and others. Breast cancer is a hormone related disease, and some (but not all) studies have shown that its incidence may rise very slightly with HRT. The chances of developing gallstones also increase slightly. Some patients have breast tenderness on HRT, and a few have heavy bleeding during the drug induced periods. The last group can receive "bleeding-free" regimes. Patients on HRT may sometimes be fertile, and should probably use some form of contraceptive upto the age of 50. Some patients have nausea from HRT.
HRT should be considered for women at the time of menopause, with a few exceptions. It should be avoided in cases of existing cancer of the breast or the uterus, or suspicion of cancer (such as undiagnosed breast lump or undiagnosed vaginal bleeding). HRT is also not given during heart attacks and disorders of blood clotting. HRT is best avoided in liver disease, and diabetes if present should be treated before HRT is started.
In all other women HRT is advisable. It is permissible even in patients with cancer of the cervix, benign diseases of the breast and patients with gallstones.
before starting treatment
Before starting HRT the gynecologist will evaluate the patient in detail, including a search for conditions in which HRT is inadvisable. A mammogram (X-ray of the breast) should be taken to rule out occult breast cancer, and to serve as a baseline with which to compare later mammograms.
Drugs used for HRT include estradiol, estrone, diethylstilbestrol, norethisterone, medroxyprogesterone and tibolone.
Nearly all women near menopause are candidates for HRT, and should consult a doctor for replacement therapy. Post-menopausal women with bone disease may wish to start HRT if they have not already done so.
Sood, MBBS (AIIMS), MD (AIIMS), is a
senior Obstetrician and Gynecologist. After graduation
from the All India Institute of Medical Sciences, she
joined the Faculty of the University College of Medical
Sciences and Guru Teg Bahadur Hospital in 1988, where she
still works as Reader in its Department of Obstetrics and
Gynecology. Her chief interests are obstetric
ultrasonography and fetal medicine. In 1995 she was
invited expert at the World Congress of Adolescent
Gynecology at Singapore. From 1997 to 1999 she held the
chair of Professor and Head of Obstetrics and Gynecology
at the Himalayan Institute of Medical Sciences, Dehradun.
Her chief interests are obstetric ultrasonography and
fetal medicine. She has written several papers, and her
chapters have appeared in books published from India and
Dr Suneet Sood,MS, MAMS,
Editor in chief
Last revised: May 12, 2000