Beyond Menopause

You’ve heard all the news about hormone replacement therapy.  That’s what made you decide to quit taking it.  But what about all of those things that hormones were supposed to be good for, like preventing heart disease and osteoporosis?   What can you do to decrease the risks of those problems?

Just a few years ago, hormone replacement therapy (HRT) was routinely prescribed for the prevention of many problems - such as osteoporosis, heart disease and urinary incontinence – that can result from the rapid decline in estrogen that occurs with menopause.  That’s not the case today.  According to several recent studies, the increased health risks of taking HRT in many cases out weigh the benefits.  Whether you decide to take - or continue to take - HRT is something to discuss with your doctor.  There are still situations in which taking HRT may be recommended for a defined period of time.  Studies continue to shed light on when - and for how long – HRT use may be appropriate.

As you make decisions, remember that going without HRT doesn’t mean passively accepting all of the changes that come with age.  For many menopause-related problems that HRT can prevent or treat - there are a number of effective alternatives.

Life without the one-size fits – all HRT regimen may make your health choices seem confusing.  However, addressing your concerns topic by topic means a more individualized – and likely more effective – approach to your health care.

By understanding the alternatives to HRT, you and your doctor can work together to make decisions about managing your health beyond menopause.


Decline in estrogen

Estrogen and progesterone, the two major female hormones, are mostly produced by your ovaries and are involved in the process and  regulation of ovulation and menstruation.  Estrogen affects many other parts of your body, as well.  It helps maintain the health of your bones and the tissues of your skin, breasts, uterus, urinary tract and vagina.  It also plays a role in raising  levels of high density lipoprotein (HDL) cholesterol (the “good” kind,) and lowering levels of  low density lipoprotein (LDL) cholesterol (the “bad” kind.)

Estrogen and progesterone production often starts to gradually decline sometime in your 30s.  In the years leading up to menopause, these hormone levels may rise and fall unevenly.  Some women make it through these fluctuations with few problems.  Others may experience hot flashes, disturbed sleep or mood swings.                                                                                           

Menopause occurs when your menstrual period stops permanently.  For most women, this occurs somewhere between ages 45 and 55.  Some medical treatments – such as surgical removal of the ovaries or some types of chemotherapy,  which can result in  damage to ovaries – can induce menopause prematurely.  At or around the time of menopause, your body’s production of estrogen drops to about one-tenth of the pre-menopausal amount.  Progesterone production drops to just a trace.

Considering how beneficial estrogen is to many areas of your body, it’s understandable that a drastic decline in its production can affect your health.  The decline in estrogen production can lead to common  post-menopausal  changes in your health, such as hot flashes and mood swings.   However, you also may experience changes including:

  • A tendency for tissues throughout you r body – including your skin, urinary tract and vaginal tissues – to become thinner, weaker, less elastic and prone to dryness.
  • A decline in the density of your bones, which may lead to osteoporosis
  • An increase in your risk of fractures
  • Weight gain and loss of muscle mass

What gives?

If declining estrogen levels are to blame for so many problems, doesn’t it seem logical that restoring some of your lost estrogen would help treat or prevent these problems?

That’s what a lot of people- including many doctors and medical researchers – thought.  And for good reason. Early research seemed to indicate that, indeed, roughly doubling very low, postmenopausal estrogen levels with HRT could help treat or prevent many of the problems associated with menopause.  This could be done using either estrogen alone for women without a uterus, or estrogen plus a form of progesterone (progestin), for those with a uterus.

Still, the results of an ever-growing body of research on the topic were mixed.  On the one hand, HRT use provided a clear benefit for hot flashes, sleep disturbances and bone health.  On the other hand, although a good amount of evidence existed for estrogen’s suspected benefits in other areas – such as with heart attack or Alzheimer’s prevention – that evidence wasn’t conclusive.  And concerns emerged that HRT increased the risk of breast cancer or a stroke caused by a blood clot.

The mixed data was often the result of studies that involved monitoring the health of a group of women who decided for themselves to take HRT.  Their health was compared with the health of a group of women who chose not to take HRT.  One problem with these studies is that the women who chose to take HRT may have been healthier – or more health conscious – than were those who didn’t.  This could skew results. 

What was needed were long term, randomized, placebo-controlled studies in which large numbers of women with similar risks were randomly divided into two groups, one of which was given HRT, the other a placebo.  Several such studies were launched in the 1980s and 1990s. 

As results from these studies became known, it was clear that many of the benefits gained from HRT use were outweighed by the risks – primarily the increased risk of having a heart attack or stock or of developing breast cancer.  In fact, two large studies were terminated early – one in July 2002 and one in February 2004 – because continuing the HRT regimens of the women in the study would have put them at increased risk, while likely not changing the final outcome of the studies.

Although these results have changed the landscape for women taking or considering taking HRT, it’s important to put the risk increase into perspective.  For example, one study showed that seven additional heart attacks would occur over one year among 10,000 women taking estrogen with progestin compared with an equal number of women who weren’t taking hormones.  For the individual, that’s a tiny increase in risk.  However, when this increased risk is applied to the roughly 6 million American women who were taking estrogen and progestin in 2002, the result would have been 4,200 additional heart attacks in one year. 

While the risk increase to the individual is small, it’s understandable why the results of studies HRT garnered so much attention.  It’s also understandable why many women, with the help of their doctors, have been re-evaluating the role of HRT in their lives, especially when effective – and safer – alternatives are usually available. 


Getting specific

Aside from a healthy lifestyle, treating or preventing menopause – related problems becomes specific to your individual circumstances.  Depending on your situation, you and your doctor may want to address. 

Hot flashes – These sensations of heat, which can be accompanied by a red face, perspiration, a rapid heartbeat and a feeling of light-headedness, are experienced by most women around the time of menopause.  The intensity, duration and frequency of hot flashes vary widely.  Most women, stop having hot flashes within one to five years, but some may have them for more than five years.  For a very small percentage of women, hot flashes may never go away.

Staying cool – Slight increases in your body’s core temperature can trigger hot flashes.  Keeping cool may involve sipping cold drinks, wearing clothing in layers that you can take off when you’re feeling too warm, opening windows or using fans or air conditioning.

Avoiding triggers – Spicy foods, hot beverages, caffeine and alcohol are among the more common hot flashes triggers.

Relaxing and reducing stress – Twice daily sessions of deep, rhythmic breathing to relax and to reduce stress have been shown to decrease hot flashes by up to 40 %.  These can be done for 15 minutes morning and night and whenever you feel a hot flash coming on. 

HRT remains the most the most effective treatment for hot flash relief.  If appropriate, your doctor may have you consider short-term HRT use at the lowest effective dose to help with your hot flashes.


Osteoporosis risk

Bone loss accelerates when estrogen levels decline – particularly within the five years or so after menopause.  Bone loss may also accelerate if you stop taking HRT.  This can lead to osteoporosis – a disease that causes bones to become brittle and prone to fracture.  A solid program for preventing bone loss includes:

Getting adequate calcium and Vitamin D – Aim for 1,500 mgs. of calcium and 400 to 800 units of vitamin D daily.

Weight-bearing exercise and strengthening – These include walking, jogging, stair climbing and strengthening using weights or resistance.


Vaginal dryness

Declining estrogen levels can cause thinning and shrinking of vaginal tissues.  This often causes burning, irritation and itching.  In addition, dryness can make sex uncomfortable or even painful.  You may be able to find relief from vaginal dryness using:

Lubricants – Nonprescription water based lubricants (Astroglide, K-Y Jelly, Liquid Silk), used during sexual intercourse, can help.

Moisturizers - These nonprescription products, including Replens and others, help moisturize vaginal tissues for a day or so with a single application.  They help Maintain the natural acidic environment in the vagina and may decrease the likelihood of infections.

Even if you ruled out oral HRT as a postmenopause option, you may want to consider using estrogen delivered vaginally using a tablet, ring or cream.  With these, the beneficial effects of estrogen on vaginal tissues are localized.  Tablets and rings deliver only a small, set amount of estrogen that can be absorbed into the bloodstream. 

However, if too much cream is used, the amount of estrogen absorbed can be higher.  Serious side effects from vaginal estrogen delivery are believed to be rare, although women with a history of breast cancer may be advised to avoid them to err on the side of caution.


Cardiovascular risk

Your risk of diseases that result from clogged arties – most notably heart disease and the most common type stroke – increases significantly as estrogen levels drop with menopause.  Before menopause, women have a lower risk of cardiovascular disease than do men.  After menopause, the risk evens out.  In fact, cardiovascular disease is by far the leading cause of death among women. 

There appear to be a number of factors that contribute to an increased cardiovascular risk after menopause.  The loss of estrogen’s beneficial effect on your cholesterol levels is one factor.  Other factors may include lifestyle changes, such as getting less exercise due to age-related factors, and metabolic changes that can lead to the development of diabetes and a common precursor to diabetes called impaired glucose tolerance.  One sign of these metabolic changes is the redistribution of fat from your hips to your abdomen, where it surrounds your organs.

To reduce your cardiovascular risk, maintain a healthy lifestyle and weight.  Monitor your blood pressure and cholesterol levels and, if you’re a healthy adult over 45, have a fasting blood glucose test every year.  Dr. Houston may recommend a low, daily dose of aspirin to reduce your risk of blood clots that could result in a heart attack or stroke.


Colorectal cancer risk

A reduction in your risk of developing cancer in your large intestine (colon) or rectum is one benefit of taking estrogen plus progestin.  However, given the balance of risk to benefit its unlikely that estrogen and progestin would be prescribed to reduce colorectal cancer risk – even if your risk is high.

Preventing colorectal cancer without the help of HRT involves having a healthy lifestyle, regular screening tests and possibly a daily aspirin.  A diet high in aft and calories and low in foods with fiber – such as whole grains, fruits and vegetables - increases your risk of colorectal cancer.  Smoking, regular alcohol consumption, a sedentary lifestyle and being overweight also are risk factors.

Screening for colorectal cancer often includes an examination of the inside of your colon (colonoscopy or sigmoidoscopy) using a scope inserted through the rectum.  These scopes are used to look for polyps growing from the inner wall of your colon.  If a polyp is found, it can be removed during a colonoscopy.  Ideally, the polyps can be detected and removed before cancerous.  Other screening tests may involve X-ray imaging or a test that looks for blood in your stool. 

The American Cancer Society recommends regular colorectal screening starting at 50.  Talk to your doctor about a screening schedule that’s right for you.  Long-term aspirin use may significantly reduce risk of colon cancer.  Talk to your doctor about whether taking a daily aspirin might be beneficial, since aspirin also helps prevent blood clots. 


Urinary problems

Reduced estrogen levels can contribute to the thinning, loss of tone and weakening of muscles that support the proper function of your bladder and urine tube (urethra).  This may cause problems with one or more parts of your urinary tract.  In some cases, women may have difficulty passing urine.  Women may also experience urinary incontinence.  Two common types of urinary incontinence are:

Stress incontinence – This leakage occurs in response to some kind of activity such as sneezing, coughing or exercising that jolts or abruptly increases pressure on your abdominal area.

Urge incontinence – This occurs when your bladder contracts on its own and overpowers sphincters in your urethra that normally hold back urine flow.  Women with urge incontinence often experience urine loss if they can’t get to a bathroom quickly when they feel an urge, or when they’re suddenly exposed to cold air or hear running water. 

These are very different problems with very different solutions, so it’s important that your doctor rule out certain conditions – such as infection or bladder cancer – and determine an exact cause.  Treatment for less serious urinary problems may include some combination of:

Inserts – If you know when you are likely to leak, such as during exercise, these small, balloon-tipped inserts can be placed into your urethra to block urine leakage. 

Behavior modification – You may be able to “train” your bladder by going to the bathroom at regular intervals, then gradually extending the interval between trips.  Adjusting your fluid intake and avoiding foods and beverages that can irritate the bladder such as alcohol, citrus juice and fruits, drinks with caffeine, chocolate and spicy foods, may help.  Behavior modification is generally more effective than drugs.

Strengthening the muscles of the pelvic floor - Your pelvic floor is like a multilayered hammock of muscle and other tissues that supports your uterus, small intestine, rectum and bladder.  You can strengthen pelvic floor muscles with Kegel exercises.  To do these, contract for up to 10 seconds the muscles that you’d use to stop urine flow, release for a few seconds then repeat.  Work up to 10 to20 contractions in a row at least three times a day.  Dr. Houston may refer you to a urologist for an additional strengthening option trying to hold a weighted cone inside your vagina using the pelvic floor muscles.

Medications – The drug oxybutynin, tolterodine and trospium may help keep the bladder from contracting when you don’t want it to.  Also available is an oxybutynin patch.  A drug related to the class of drugs called selective reuptake inhibitors – Cymbalta – shown to be effective for stress incontinence.  Results of studies of vaginal estrogen therapy for urinary incontinence are mixed.  However, many women do find it helpful.  Further study is needed to determine the precise role of vaginal estrogens in treating incontinence.


Alzheimer’s disease risk

Dementia, which is often caused by Alzheimer’s disease, occurs when brain tissue degenerates, causing a progressive decline in memory and mental abilities. Although the exact causes of Alzheimer’s are not well understood, its prevalence increases with age and its more common in women than in men.  It’s suspected that the decline in estrogen following menopause may be one of many factors that contribute to Alzheimer’s development.

HRT was once thought likely to reduce Alzheimer’s risk.  Now, even this suspected side benefit has been upended.  It has been shown that taking estrogen plus progestin and estrogen alone may slightly increase the risk of Alzheimer’s.  There are no proven ways to prevent or cure Alzheimer’s.  Prevention methods that have shown some promise include:

Staying mentally active and socially engaged – There appears to be an association between participating in mentally stimulating activities and a lower risk of Alzheimer’s.

Nonsteroidal anti-inflammatory drugs (NSAID) and statins – Preliminary studies have suggested that pain reducing NSAIDS and cholesterol-lowering statins may have a protective effect against Alzheimer’s.

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