Menopause: Treatment

Menopause Know the signs of menopause, and how to alleviate its symptoms.

More about Menopause: Definition Causes and symptoms Diagnosis Treatment Alternative treatment Prognosis Prevention Resources

When a woman enters menopause, her levels of estrogen drop and symptoms (such as hot flashes and vaginal dryness) begin. Hormone replacement therapy can treat these symptoms by boosting the estrogen levels enough to suppress symptoms while also providing protection against heart disease and osteoporosis, which causes the bones to weaken. Experts disagree on whether HRT increases or decreases the risk of developing breast cancer. A Harvard study concluded that short-term use of hormones carries little risk, while HRT used for more than five years among women 55 and over seems to increase the risk of breast cancer.

There are two types of hormone treatments: hormone replacement therapy (HRT) and estrogen replacement therapy (ERT). HRT is the administration of estrogen and progesterone; ERT is the administration of estrogen alone. Only women who have had a hysterectomy (removal of the uterus) can take estrogen alone, since taking this "unopposed" estrogen can cause uterine cancer. The combination of progesterone and estrogen in HRT eliminates the risk of uterine cancer.

Most physicians do not recommend HRT until a woman's periods have stopped completely for one year. This is because women in early menopause who still have an occasional period are still producing estrogen; HRT would then provide far too much estrogen.

Most doctors believe that every woman (except those with certain cancers) should take hormones as they approach menopause because of the protection against heart disease, osteoporosis, and uterine cancer and the relatively low risk of breast cancer. Heart disease and osteoporosis are two of the leading causes of disability and death among post-menopausal women.

Critics say the benefit of taking hormonal drugs to ease symptoms isn't worth the risk of breast cancer. Since menopause isn't a disease, many argue that women shouldn't take hormones to cure what is actually a natural process of aging. Advocates of HRT contend that the purpose of taking hormones is not to "treat" menopause but to prevent the development of other diseases.

There are risks with HRT and there are risks without it. In order to decide whether to take HRT, a woman should balance her risk of getting breast cancer against her risk of getting heart disease, and decide how bad her menopause symptoms are. Most doctors agree that short-term use of estrogen for those women with symptoms of hot flashes or night sweats is a sensible choice as long as they don't have a history of breast cancer.

For a woman who has no family history of cancer and a high risk of dying from heart disease, for example, the low risk of cancer might be worth the protective benefit of avoiding heart disease. Certainly, for Caucasian women aged 50 to 94, the risk of dying from heart disease is far greater than the risk of dying of breast cancer.

Women are poor candidates for hormone replacement therapy if they have:

• had breast or endometrial cancer
• a close relative (mother, sister, grandmother) who died of breast cancer or have two relatives who got breast cancer before age 40
• had endometrial cancer
• had gallbladder or liver disease
• blood clots or phlebitis

Some women with liver or gallbladder disease, or who have clotting problems, may be able to go on HRT if they use a patch to administer the hormones through the skin, bypassing the liver.

Women would make a good candidate for HRT if they:

• need to prevent osteoporosis
• have had their ovaries removed
• need to prevent heart disease
• have significant symptoms

Taking hormones can almost immediately eliminate hot flashes, vaginal dryness, urinary incontinence (depending on the cause), insomnia, moodiness, memory problems, heavy irregular periods, and concentration problems. Side effects of treatment include bloating, breakthrough bleeding, headaches, vaginal discharge, fluid retention, swollen breasts, or nausea. Up to 20% of women who try hormone replacement stop within nine months because of these side effects. However, some side effects can be lessened or prevented by changing the HRT regimen.

The decision should be made by a woman and her doctor after taking into consideration her medical history and situation. Women who choose to take hormones should have an annual mammogram, breast exam, and pelvic exam and should report any unusual vaginal bleeding or spotting (a sign of possible uterine cancer).

A new type of hormone therapy offers some of the same protection against heart disease and bone loss as estrogen, but without the increased risk of breast cancer. This new class of drugs are known as anti-estrogens. The best known of these anti-estrogens is raloxifene, which mimics the effects of estrogen in the bones and blood, but blocks some of its negative effects elsewhere. It's called an anti-estrogen because for a long time these drugs had been used to counter the harmful effects of estrogen that caused breast cancer. Oddly enough, in other parts of the body these drugs mimic estrogen, protecting against heart disease and osteoporosis without putting a woman at risk for breast cancer.

Like estrogen, raloxifene works by attaching to an estrogen "receptor," much like a key fits into a lock. When raloxifene clicks into the estrogen receptors in the breast and uterus, it blocks estrogen at these sites. This is the secret of its cancer-fighting property. Many tumors in the breast are fueled by estrogen; if the estrogen cannot get in the cell, then the cancer stops growing.

Women may prefer to take raloxifene instead of hormone replacement because the new drug doesn't boost the breast cancer risk and doesn't have side effects like uterine bleeding, bloating, or breast soreness. Unfortunately, the drug may worsen hot flashes. Raloxifene is basically a treatment to prevent osteoporosis. It doesn't help with common symptoms and it is unclear if it has the same protective effect against heart disease as estrogen does.

The ovaries also produce a small amount of male hormones, which decreases slightly as a woman enters menopause. The vast majority of women never need testosterone replacement, but it can be important if a woman has declining interest in sex. Testosterone can improve the libido, and decrease anxiety and depression; adding testosterone especially helps women who have had hysterectomies. Testosterone also eases breast tenderness and helps prevent bone loss. However, testosterone does have side effects. Some women experience mild acne and some facial hair growth, but because only small amounts of testosterone are prescribed, most women don't appear to have extreme masculine changes.

Women who are still having periods but who have annoying menopausal symptoms may take low-dose birth control pills to ease the problems; this treatment has been approved by the FDA for perimenopausal symptoms in women under age 55. HRT is the preferred treatment for menopause, however, because it uses lower doses of estrogen.

— Laith Farid Gulli, M.D.