On Menopause: Part 2

Boris JIVKOV, Obstetrician and Gynecologist

Mostly, decision making in medicine is simple. When you wake up with an urgency to urinate – yet very little urine passes – with pain that feels like passing razorblades, you have a urinary tract infection.  If drinking a liter and a half of water and eating handfuls of dried cranberries doesn’t help, your doctor will give you a course of antibiotics and the problem is invariably solved. Menopause, however, is not a disease to treat. It’s an inherent part of the cycle of life that affects all three aspects of our quality of life: health, comfort and happiness.

Estrogen replacement alleviates both the symptoms of menopause and its physical effects on health.  Estrogen is the most effective treatment for hot flashes, and consequently improves sleep, mood, and the sense of wellbeing. It preserves pelvic floor strength, improves vaginal dryness and has positive effects on sex drive. Unfortunately, it also flies in the face of the ancient law of medicine: first, do no harm. Estrogen affects the inner layer of the uterus, the endometrium: this overstimulation may cause endometrial cancer. Women who’ve had a hysterectomy – removal of the uterus – for other reasons, don’t need to worry. But for the rest, they must counter these effects by taking another hormone: progesterone. Landmark trials conducted in the early 2000s in the USA, implicate both estrogen and progesterone in stimulating breast changes, and as consequence leading to an increased risk of breast cancer. The research showed that estrogen replacement also increased the risk of stroke and heart disease.

Nothing is simple. In 2007 a well-conducted trial in Denmark showed that for healthy, physically active women, estrogen replacement has no negative effect on the heart or breasts. Furthermore, overall health was actually improved. The difference was in lower body weight, better fitness and absence of preexisting conditions, like heart disease and adult-onset diabetes. If a modern synthetic estrogen/progesterone formulation is chosen (into the mid 2000s, the drug of choice was synthetized  from the urine of pregnant mares), with an alternative way to get it into the bloodstream – patches or gels, applied to the skin rather than oral tablets – negative outcomes are not observed. And, as illogical as it seems, the earlier one starts, the more protective hormone replacement is.

You may find this perplexing. The scary part is, doctors themselves are confused and often insecure how to transfer this knowledge into evidence-based practice. At present, your gynecologist should be guided by the following principles:

  • Treatment should be based on the individual needs of a woman, taking into account her familial, behavioral and personal medical history;
  • Treatment needs to start early. One must use the safest formula and delivery system and it should be continued for 5 years;
  • Before initiation, and once a year a thorough, clinical gynecological examination should include mammography and blood work, examining cholesterol levels and liver function.

In the next chapter of On Menopause we’ll venture into the complex, and often controversial, world of alternative therapies.