The Centre For Women s Reproductive Care. Menopause - Some Questions Answered

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1 The Centre For Women s Reproductive Care Baringa Private Hospital, 31 Mackays Rd Coffs Harbour NSW 2450 Harvey Ward MB ChB, BSc(Med), FCOG (SA), MMed (O&G), FRANZCOG Obstetrician & Gynaecologist Phone: Fax: What is Menopause? Menopause - Some Questions Answered Menopause is that time of change in a woman's life when, generally between the ages of 45 and 55, the ovaries gradually stop producing eggs and hormones. This results in menstrual periods that become irregular and finally stop. The levels of the female sex hormones (mainly oestrogen and progesterone) in the body are significantly lower than during the previous decades of reproductive life. The characteristic symptoms of menopause are hot flushes a sensation of heat that spread through the body for several minutes. They may be accompanied by visually obvious flushing or sweating and can occur several times a day. They are typically worse at night. This can result in loss of quality sleep, tiredness and irritability. It is also a medical fact that the fall in oestrogen levels leads to an acceleration of bone loss that many decades later (or earlier in predisposed individuals) may be manifest as osteoporosis i.e. brittle bones that fracture or crush easily. Does Every Woman Experience Symptoms? A few women will have no symptoms at all associated with menopause i.e. apart from the cessation of menstrual periods. However, for 60% of women the problems are mild and can often be managed without medical intervention. Only one woman in 5 (or 20%) has such disabling problems with hot flushes, insomnia and mood swings that something has to be done. Unfortunately we cannot predict who will require medical help or indeed for how long the symptoms will continue. Whilst for most women hot flushes will decrease in frequency and severity over a period of 3 5 years, a small number of women experience disabling symptoms into their 60 s and 70 s. What is HRT? HRT is short for Hormone Replacement Therapy. It refers to the use of the prescribed drugs oestrogen (for women without a uterus) or oestrogen and progesterone (for women whose uterus is still present) to replace those hormones that are lower after the ovaries cease to cycle. What are the Benefits of HRT? HRT effectively relieves the menopausal symptoms of hot flushes and night sweats. For a woman who has disabling symptoms it is quite appropriate to use HRT for periods of months to years in order to cope with the enormous disruption that can arise from hot flushes and their accompaniments. HRT used for longer periods of time also provides protection against osteoporosis and urinary problems. For some time it was thought that other benefits such as a reduced risk of heart disease, mental function and skin ageing would make it desirable for most if not all women to take HRT throughout their menopausal years. However, it is now apparent that for most women it is not appropriate to have hormones for ever. To put it simply the overall risks of long term HRT use outweigh the benefits For a summary of the risks and benefits of HRT consult the table on Page 4 of this information sheet. What are the Risks of HRT? By the 1990 s it was becoming obvious that the longterm use of HRT is associated with a small but significantly increased risk of breast cancer. In 2002 an increased risk of venous thromboembolism (blood clots in veins with risk of travel to the lungs), heart attacks and strokes were also recognised as risks of HRT. There is also a slight but not significant increased risk of ovarian cancer. Whereas earlier studies had suggested that HRT protects women from the risk of Alzheimers and related mental

2 deterioration it has now emerged that there is no such benefit and HRT may even increase the risk of Alzheimer s. It needs to be emphasised that the risks of HRT seem to arise only after prolonged use i.e. for periods of greater than 5 years. Moreover, the risks appear to be small in terms of the number of women affected. For example, in the very large US study reported during 2002 that involved continuous combined oestrogen and progestin taken as tablets, for every 10,000 women using the HRT there were 7 more heart attacks, 8 more strokes, 8 more blood clots with lung effects, 8 more invasive breast cancers and 2 3 more ovarian cancers. The overall excess risk of the events specified was 19 per person-years. It is important to note that the overall risk death from cancer is not increased and a number of studies have confirmed that women using HRT have a lower risk of dying from breast, colon and uterine cancer. A possible explanation for this finding is that women using HRT see their doctor more regularly and have more screening that results in diagnosis at an earlier and more treatable stage. The evidence is further confused by the use of varying forms of HRT and by different routes of administration. The earliest studies involved the hormone oestrogen alone and showed positive benefits in terms of preventing osteoporosis and heart disease. However, for women who have not undergone hysterectomy the use of oestrogen alone carries a significant risk of uterine cancer as well as much more frequent bleeding problems. So, for women who still have a uterus, progesterone is required. What remains uncertain is whether all of these long-term risks apply also to the use of HRT administered by other means eg patches, and to newer forms of HRT that have been developed to avoid uterine and breast stimulation. eg Livial and Evista. A Word about Breast Cancer Less than 10% of all cases of breast cancer are in women with a strong family history of the disease. If your mother or sister developed breast cancer before the age of 45 years then are you at increased risk of developing this cancer but a family history of later cancers or in more distant relatives is of no relevance to your lifetime risk. All women over the age of 50 should participate in a breast-screening program and have a mammogram every two years. Women with a strong family history of breast cancer should undergo mammography every 12 months from the age of 40 years. It is also recommended that women of all ages examine their own breasts regularly Page 2 and also have an examination by a health professional (nurse or doctor) every 12 months. What about Side Effects of HRT? Initial side effects with HRT can include irregular vaginal bleeding, breast tenderness, headaches and irritability. It is very important that you discuss these in detail with your doctor so that therapy can be adjusted to meet your individual needs. Many of the troublesome side effects settle with time and persistence. It is preferable not to discontinue HRT suddenly or stop and start because this simply magnifies many of the side effects (especially bleeding) or causes rebound symptoms. See Is HRT addictive? below. Does HRT cause Weight Gain? Both women and men tend to experience an increase in abdominal girth and trunk fat as they enter middle age. This is often due to changes in physical activity and food intake, but changes in sex hormones and other hormonal factors are also responsible. From the early 40s most women become aware of a redistribution of fat from the buttocks and thighs to the stomach. Whether this change is caused by menopause alone, ageing alone or a combination of both is unclear. HRT does not cause weight gain. Many studies confirm that hormone treatment does not produce weight gain in menopausal women. When commencing HRT some women experience feelings of bloating, breast tenderness and fullness but these should not be mistaken for weight gain. These side effects tend to settle within the first few months of therapy. Avoiding Weight Gain To reduce the impact of age on weight and body shape, you should reduce your fat intake, increase your consumption of complex carbohydrates and fibre, and have at least three balanced meals a day. You should also exercise regularly such as brisk walking, dancing, bicycling and swimming. However endurance is the key because exercising for one hour three times a week at a moderate pace is better than 15 minutes flat out every day. Menopause & Sexuality Sexuality does not begin and end at any particular stage in life. Nor is it easy to define. For some couples caressing, physical closeness and companionship can be as integral a part of their sexual relationship as intercourse. With age there is a normal decline in both male and female sexual activity. Problems may occur when partners experience differences in libido.

3 What causes Loss of Libido? Loss of libido, loss of interest in sex or reduced sex drive may occur at the time of the menopause for a variety of reasons including tiredness, stress and relationship problems. Menopausal changes such as vaginal dryness, skin crawling sensations, a change in skin sensitivity, tiredness due to hot flushes, and a sense of just not wanting to be touched are also a problem for some women. Sometimes a change in lifestyle and avoidance of stressors or even relationship counselling may be required. However, if the problem is due to oestrogen deficiency, then HRT will alleviate the vaginal dryness abolish hot flushes and most of the other skin symptoms. For a few women a small amount of testosterone or the HRT formulation called Livial may be beneficial. Skin & Other Changes Skin is an oestrogen dependent part of the body and is affected in a number of ways by the fall in oestrogen levels following menopause. Changes in hair, teeth and bladder control also occur. Skin thickness decreases with time after menopause and, as a result, cuts and abrasions often take longer to heal. A crawling skin sensation and dry, itchy eyes also responds well to oestrogen replacement. Wrinkles increase after menopause as a result of skin deterioration and are made worse by smoking and lifetime exposure to sun. Other than not smoking, sun protection is the best action Australian women can take sun shield to protect their skin against wrinkling and other sun damage. Will HRT help my Vaginal Symptoms? The vagina is highly oestrogen dependent. Prior to menopause the vaginal walls are ten cells thick and well lubricated. After menopause, in the absence of oestrogen, this lining shrinks to two cells in thickness. These changes can result in inflammations, vaginal dryness, painful intercourse, as well as bladder and vaginal infections. Some women also experience dry vulval skin. Vaginal Oestrogen Use One very effective and safe form of oestrogen use is by applications of low doses as a cream or pessary within the vagina. If used according to directions, then there is very little or no absorption of the hormone into the circulation and therefore no effect on breasts (no risk of cancer), uterus (no bleeding), and no effect on blood clotting, heart etc. This is not HRT as it is usually described and will not relieve hot flushes but it is putting oestrogen where it is needed most. It is suitable for long term use, improves vaginal health and helps to control bladder weakness. Can I Improve my Bladder Control? Problems with urinary control are extremely common in women over 50. There are several potential problems that require careful evaluation. There are also effective treatments available and, in general, all treatments are enhanced by the use of vaginal oestrogen. Are Changes in Hair Growth Normal? After menopause many women experience unwanted hair growth and this is one consequence of the hormone changes. It is best dealt with cosmetically. Thinning of pubic hair is a normal part of ageing and does not require treatment. Is HRT Addictive? Some women find it difficult to stop HRT because there is often a rebound with severe menopausal symptoms. Before cessation you should first discuss with your doctor your particular risk profile i.e. the pros and cons of continuing HRT as it applies to your medical needs or risks. If it is decided that cessation of HRT is the better option for you then it should be done very gradually indeed ideally over 4 6 weeks if possible. Your doctor can advise a suitable reduction regimen. It may be worthwhile keeping a diary of symptoms. If you carefully document what symptoms are and are not associated with HRT withdrawal or reuse then it may be useful in deciding whether you need to continue the use of HRT. Are there Alternatives to HRT? It is important to address matters of lifestyle. Smoking is associated with an earlier and more severe menopause as well as many serious diseases later in life. Excessive alcohol (more than 10 drinks. a week) should be avoided. Many women seek natural or dietary solutions to help them through menopause. Alternative therapies can take many forms including herbal or plant supplements, skin creams and foods. Little is known about the risks associated with alternative therapies sold in Australia, and you should not assume that supplements and extracts described as 'natural' are safe or effective. (See also page 4 of this information sheet). Page 3

4 Many factors need to be considered when thinking about the benefits and risks of alternative therapies. Validated information about the main alternative therapies can be summarised thus: Soy and Phytoestrogens : Soy food products are good for our health and are known to help reduce cholesterol. However, recent research has shown that it is not the phytoestrogen component of the soy protein that provides this benefit. Thus the widely promoted product called Promensil is no more effective than a placebo in reducing symptoms of menopause. Remifemin: This extract of Black Cohosh (Climicifugae racemosae rhizoma) has been shown in valid scientific studies to benefit a modest 30% of women suffering menopausal symptoms. Up to 4 tablets daily may be required and some women do not respond immediately. It s safety for long term use has not been established but most evidence suggests that it is NOT acting as an oestrogen. It is an option for women who have had breast cancer. Progesterone and Wild Yam Creams: There is no satisfactory scientific evidence that these products provide women with any therapeutic benefit. In Summary HRT is safe and effective short-term therapy for the relief of disabling or discomforting menopausal symptoms. Any decision about the long-term use of HRT requires a careful evaluation of your particular circumstances by your doctor and a clear understanding of the risks and benefits by the participating woman. Benefits Risks Immediate Long-term Immediate Long-term Reduces hot flushes Improves vaginal and bladder symptoms Keeps skin healthy Improves sleep Lessens problems with depression and mood swings Prevents osteoporosis. Reduces bone fractures by almost 50 percent Decreased risk of colon cancer Improved dental health Irregular bleeding Fluid retention Breast tenderness Headaches Dysphoria or Feeling Hormonal for some women sensitive to progestins Cancer of the lining of the uterus (if taken without progestin) Increased risk of breast cancer (but decreased deaths). Increased risk of heart attacks and strokes Gallbladder disease Improves mental functioning in some women Increased risk of blood clots with embolism Increased risk of Alzheimer s in older women in one study "Natural" Products for Menopause What are phytoestrogens and how do they relate to menopause? Phytoestrogens are naturally-occurring compounds in certain plants, herbs, and seeds that are similar in chemical structure to oestrogen and/or produce oestrogen-like effects. There is some suggestion that, in certain cultures where large amounts of phytoestrogencontaining foods are consumed, women may have fewer short-term menopause complaints and may derive other long-term health benefits as well (such as helping to prevent heart disease). Studies are currently underway to clarify their effectiveness and the amounts that would be necessary to achieve an effect. What specific foods contain phytoestrogens? Phytoestrogens consist of a number of types. For example, the lignan type is found in almost all cereals and vegetables, with the highest concentration in the oilseeds, especially linseed (sometimes called flax seed). The isoflavone type is most commonly found in legumes, with concentrations being particularly high in soybeans. Soy proteins generally contain high levels of two isoflavones: genistein and daidzein. Other soy products, such as miso (fermented soy product), may have little or no isoflavones. Several servings a day of tofu, tempeh or roasted soy nuts may be helpful. Page 4

5 How much dietary phytoestrogen is reasonable and likely to promote health? The average Asian diet provides about mg of isoflavones and the average Asian woman excretes in urine about 100 times as much isoflavone metabolites as an Australian woman. Experimental studies show that the equivalent of mg of isoflavones can improve menopausal symptoms and can reduce cholesterol levels. These levels of isoflavones provide very little or no bone benefit. What food soy sources provide the same amount of isoflavones that are in the usual Asian diet? Soybeans are composed of protein, carbohydrate, and fat. Most of the isoflavones are in the protein part; while the fat (oil) provides calories and the carbohydrate provides calories and may cause gaseousness. Therefore, protein-rich soy derivatives have been developed to maximize the isoflavone intake while minimizing calories. Soybeans are widely available dried or roasted. In some cities, fresh or frozen whole soybeans are available. Tofu is a solid form of soy that is precipitated from soymilk by addition of calcium (in a way similar to producing cheese from whole milk). There is considerable variability in isoflavone content of soybeans related to their growing conditions (the most harsh conditions produce the highest isoflavone content in the beans). There can be loss of isoflavone content if fat is extracted from soy products. For example, low-fat tofu is lower in isoflavone content and many of the "fastfood" soy products such as soy hot dogs, and hamburgers have no isoflavones. If grams of soy protein are eaten, calories will be added to the diet. Thus, some adjustment of other protein and caloric sources should be made. The following table outlines the soy products that can provide about 75 mg of isoflavones: Product Serve Protein(g) Calories Soybeans Dried 1/2 cup Fresh 1 cup Tofu 1 cup Soy milk 3 cups Isolated soy protein 1/3 cup Are "natural" products better or safer? Often certain foods and herbs (and sometimes the vitamins as well) are referred to as "natural" ways of dealing with menopause disturbances. Unfortunately, the term "natural" is misunderstood as meaning better or safer. While it is correct that these "natural" remedies are not prescription drugs, this does not mean that they are better or safer. In fact, until more studies are done to answer many outstanding questions, it is not known whether plants containing oestrogen-like compounds would be dangerous to some people. Decades of research have led to information about the potential of harmful side effects, as well as potential benefits, of prescription oestrogen drugs. These side effects are kept to a minimum by taking the lowest effective dose. It is reasonable to assume that studies now underway will discover similar side effects from intakes of phytoestrogens higher than the usual dietary intake in Asia. It is possible to take too much of many food supplements. Modified from the Internet Publication by the North American Menopause Society, 2000 Revised July 2010 Page 5