If there’s an Estrogen Deficit, why not just give some?

OK, that’s a very good question. But it comes with a very complicated answer – not impossible, just complicated. The use of estrogen or, more accurately, estrogen and progesterone (Hormone Therapy or HT) must be individualized according to the treatment goals of the individual woman. The prescription cannot be standard because people aren’t standard. The relationship between benefit of therapy and risk of therapy isn’t the same for everyone and even changes for each individual as she changes with time, her needs, and her risks.

Benefits relate to symptoms and these can be very different among individuals. But therapy has the potential to help vasomotor symptoms (“hot flashes”), vaginal atrophy, difficulty with sexual relations, osteoporosis, and other problems that influence quality of life.

None of the benefits come without some risk or potential risks. These are related to the baseline disease risks (those the woman already has when menopause occurs or those she is more likely than others to develop), her age, age at menopause, cause of menopause, time since menopause, prior hormonal use, and medical conditions that do occur during treatment.

The “media” and regular people are very aware of some benefits that can be gained from HT, although knowledge is often sketchy and centers around the elimination of hot flashes to the exclusion of many other good things. But it is the risk of HT that provokes the generation of miles of newspaper columns and hours of videotapes. Almost all the risk discussion centers around breast cancer. There has been an enormous amount of discussion and debate about this complex topic, reflecting the differences in research information and academic opinion.

More posts will follow to discuss not only this issue, but also:

• Vasomotor Symptoms
• Vaginal Symptoms
• Sexual Function
• Urinary Function
• Weight Osteoporosis
• Cardiovascular Effects
• Diabetes
• Endometrial Cancer
• Ovarian Cancer
• Lung Cancer
• Mood and Depression
• Premature Menopause
• Total Mortality
• Hormone Treatment

Menopause is no small topic. Many issues and many millions of women are involved.

So Along Comes Menopause

After about 5 years of perimenopause the last period occurs. One year later women are defined as being in Menopause, usually at the age of 51 or 52.

One hundred years ago that just happened to be the same as life expectancy so the time spent in menopause was brief NOT ANYMORE.  Life expectancy is now up to 80 years for women in the United States; a third of their lives, about 30 years in menopause.  In 2010 there were 80 million women who were in menopause.  There is an enormous need to optimize those 30 years of life that women did not have 100 years ago.

The simply unifying cause in menopause is a Decline in Estrogen, an ovarian hormone.  This decline manifests itself in many different was throughout the body, some obvious and serious, and some vague are poorly understood.  Receptors to estrogen rise in many parts of t the woman’s body including not only the breast and urogenital tract, but also in the skin, liver, bone, brain, heart and gastrointestinal tract.  Probably the most commonly recognized effect of estrogen loss is the “Hot Flash”, among the conditions attributable to menopause, it is not life threatening or the cause of serious illness.  But it has large consequences.  In women aged 40 to 64 years, 63% report symptoms that are very bothersome.  These symptoms last, on average, 10 years.  A large percentage reports a negative impact on their daily lives.

Other problems associated with menopause take their toll, as well.  Heart disease, bone disease and urogenital conditions are a big problem.  Those issues will be addressed, along with therapeutic approaches, in follow up posts in the discussing menopause.

Perimenopause II: Now What???

In the first segment on this subject the basics of this issue were reviewed. Perimenopause is not a disease and requires no management except as related to troublesome symptoms that occur in a minority of women. That symptom is usually abnormal uterine bleeding.

For many women episodes of problem bleeding are limited and take care of themselves. They often prompt a doctor visit, but not specific therapy. A conference with the gynecologist most often suffices. For others, bleeding episodes are frequent (more than monthly) long (more than seven days) or heavy. These problems are often accompanied by significant discomfort and worry. These require evaluation as previously outlined.

They also require therapy, done in a variety of ways. Hormones can be used, destruction of the uterine lining might be worthwhile, and in some cases hysterectomy is done (though much less so than in the past). Sometimes the diagnostic procedure of dilation and curettage (D&C) can actually be therapeutic as well.

When hormones are used they can be applied in a variety of ways, accomplished with different hormones. A single course of a form of progesterone over a period of days or weeks can produce loss of the uterine lining and cessation of the problem. Another alternative would be to “cycle” the progesterone over a period of months. As long as the patient does not smoke, standard oral contraceptive pills can regulate cycles in a way acceptable to the patient.

Intrauterine devices containing progesterone can be uses to either stop bleeding altogether or to significantly reduce it. This is an attractive, simple and well tolerated method, and carries little of the baggage associated with the IUD’s of the 1970’s and 1980’s.

Another means of bleeding control involves destruction (ablation) of the uterine lining. Following procedures of this nature, often performed in the office of the gynecologist, almost half of women have no further bleeding and the majority show at least an improvement. Ablation is reserved for women with no further interest in child bearing and those with relatively normal configuration of the cavity of the uterus.

In a minority of women, usually with complicating factors, hysterectomy is still done. Usually this means removal of the uterus (total hysterectomy) but also might involve removal of the tubes and ovaries (total hysterectomy with salpingoophorectomy).

Perimenopause... What is it?

“Perimenopause” is a commonly used word these days, and seems to carry a dreaded connotation, at least among many women. Most of the time it doesn’t mean anything much except that menopause itself can be anticipated in a few years.  “Menopause” means ceasing of menses but it is the decline and ceasing of ovarian function that is the prime mover of symptoms.

Ovarian function begins to decline before menopause itself comes at the average age of 51. This fact is of little significance for most women, but can cause conception to become difficult.  The decline comes to women in their 30’s, but, at least initially causes few symptoms.  By the time women are in their 40’s, symptoms of ovarian dysfunction become common and are usually in the form of abnormal bleeding.  This era from about age 45 until menopause is the time most appropriately referred to as “Perimenopause.”  Women in this age group are not ill and experience little or none of the problems that can arise during menopause itself.  They do however have problems with cycles that become abnormally frequent or too seldom or too heavy.  This can be a minor, self-limited problem or can make women clinically ill with pain or even anemia from blood loss.

When women have abnormal bleeding in the 40’s, it is most often from the phenomenon usually referred to by doctors as “Dysfunctional Uterine Bleeding”. Other possibilities exist however, because the problem could come from disease and not just “dysfunction”.  These include polyps inside the uterus, overgrowth in the uterine lining, or even cancer of the uterine lining. Because of these possibilities, the doctor needs to demonstrate that these problems are not present  before proceeding to treat the dysfunction, rather than assume that there is no disease present.  Ultrasound of the uterus and biopsy of the uterine lining are the procedures most commonly used for that purpose.  And these are most often done in the doctor’s office. More extensive evaluations such as dilation and curettage (D&C) are sometimes done in operating rooms because they might require anesthesia.