Menopausal women can add whiplash to the laundry list of medical issues they face at midlife. The medical profession has done an about-face in their recommendations for hormone replacement therapy (HRT).
For women œof a certain age, doctors have rapidly gone from insisting on hormone replacement as prevention from life threatening consequences, to dire warnings that if they don't get off HRT they are doomed. This reversal leaves patients understandably reeling and is at least a symbolic œpain-in-the neck. But is the evidence so straightforward? Is it true that most women should be off their hormone replacement or never start it? It certainly looks that way. In contrast to years of conflicting data, the definitive answer is largely in" hormone replacement causes more problems than it fixes. While some may continue to ˜nit-pick at the evidence, the Womens Health Initiative (WHI) 1 results of July 2002 essentially changed the way physicians practiced"or, at least, it should have. That it may not is a tribute to the power of the message of the pharmaceutical companys physician education department and the reality that physicians, caught off guard, simply do not have options to offer.
The ˜WHI results continue to be analyzed, but what we know now, and only previously suspected, is that breast cancer, cardiac events, strokes, venous thromboembolism, dementia and mild cognitive impairment increase with HRT, while on the positive side, there is some reduction in hip/vertebral fractures and colon cancer. The question must be asked: Is there ever justification for treating a natural passage of a womans life, one that is not a disease, with interventions that cause disease? These findings have motivated a few in the medical community to at least peek through that here-to-fore locked door behind which lies alternative medicine. Enthusiasm for interventions with a sideeffect profile that may include headache, rash, and gastro-intestinal upset instead of cancer and heart disease still rates a caveat for each recommendation.
Typically it goes something like, œWhile this works in Japan...is the leading intervention in Germany¦has been used by women for 2,000 years¦we dont have double-blind-placebo controlled studies published in American Medical Journals"so take at your own risk. Additionally, there has been some acknowledgment of the power of lifestyle (including food and exercise) to impact the menopausal womans life. How certain foods influence production of estrogen metabolites and re-absorption is the subject of the newest research. 2Most efforts, however, continue to focus on tinkering with new combinations of pharmaceuticals and narrowing the list of who can safely take them. So what should you recommend to your peri/post menopausal clients? Here are five that represent the best integration of the research with clinical practice:
Bottom line, hormone replacement therapy should be reserved for younger women who have been unable to control hot flashes any other way and who do not have family or personal histories of breast cancer or heart disease.
It should be taken, according to the American Association of Obstetricians and Gynecologists (ACOG), for the shortest amount of time and in the lowest dose that is effective.
A trial of weaning off hormones is suggested every six months.
The regimen includes an annual visit to a physician and mammograms every one-two years before 40 and annually after that. (A caution is noted for women with dense breasts who thus have a slightly higher risk of breast cancer. HRT increases breast density and makes diagnosis even more difficult.)
There may also be a few osteoporotic women who for some reason cannot take the newer osteoporotic specific medications and will stay on traditional HRT. B IRONICALLY, THE WOMENS Health Initiative did not test for efficacy of hormone treatment for hot flashes, although there are many studies that show its effectiveness. Research tells us that anywhere from 60-80 percent of women suffer hot flashes from several months to two-three years (some +/- 10). Flashes affect quality of life because they disrupt sleep and can be distracting and uncomfortable.
They are a major reason women seek treatment. In January, 2004, the North American Menopause Society (NAMS) noted in an evidenced based position paper published in their journal, Menopause, that lifestyle and nonprescription drugs should be the first choice for relief of hot flashes before prescriptions. That includes wearing layered clothing, keeping cool, regular exercise, avoiding spicy food and alcohol, maintaining proper weight, not smoking, and practicing relaxation techniques to reduce stress while incorporating deep abdominal breathing at the beginning of a flash. Beyond lifestyle, NAMS recommends (with the usual caveats as mentioned above) daily isoflavones in the 40-80 mg. range (soy, red clover and flaxseed). Eating foods containing isoflavones versus taking supplements is preferred and soy supplements are not recommended for those with breast cancer. The most frequent recommendation (by prescription) in Germany is black cohosh (Actaea racemosa"standardized to 1 mg 27- deoxyactein content per 20 mg. tablet at dose equivalents of 40 mg. per day); also on the list is Vitamin E (400-800 IU daily).
Topical progesterone cream, which anecdotally and in a few studies helps some women, is rightfully difficult for NAMS to recommend wholeheartedly because many women purchase over-thecounter versions that vary greatly in content and are not potent enough to make much difference. Such creams can be made by compounding pharmacists in strengths that have been shown to contain a clinically effective dose. The intervention most likely to be recommended by physicians, however, is non-hormonal prescription drugs. They include antidepressants such as Effexor (venlafaxine), Paxil (paroxetine), Prozac (fluoxetine) and the anticonvulsant Neurontin (gabapentin). The NAMS recommendation is for very low doses that are slowly increased as necessary. While these drugs can be effective, they come with the usual plethora of side effects, including sexual dysfunction. Hormonally, new oral and intramuscular progestogen formulations are being researched along with SERMS, a class of drugs that does the work of estrogen while eliminating specific negative side effects.
Peri-menopausal women, who have been on low-dose birth control pills to calm down the erratic hormone levels of an approaching menopause, are encouraged to consult their doctors as to the time to transition off such medications, which contain higher doses of estrogen and/or progesterone than traditional HRT. The memory arm of the ˜WHI, known as œWHIM, put an end to the hope that estrogen given to older women would protect against memory loss. 3 The opposite was disclosed. It did find that there was reduced risk for women who took Vitamin C supplements and participated in moderate to strenuous physical activity four or more times per week. As definitive as this well-designed and large National Institute of Health Study was, there are legitimate questions and unanalyzed results. One glaring matter is whether the results were true only for the products used (Prempro and Premarin) or for other hormonal formulations as well.
Subsequent studies published throughout the world have found similar trends, despite brands or methods of delivery. There are still conflicting results as to exactly what increases the various risks. In December of 2002, The National Institute of Environmental Health Sciences listed estrogen as a carcinogen. Is the problem with estrogen alone or combinations of estrogen and progesterone? Do progestogens have their own risks and does it matter whether synthetic or natural versions are used? While it is clear that older woman are at greater risk than younger ones, are younger women being predisposed to damage as they age if they have taken HRT? The answer is illusive, only one in six subjects were within five years of menopause; this is essentially a late, rather than early, menopause study. In a therapeutic role, clients should be encouraged to consider making the menopausal passage as natural as possible.
Reassurance can be given that the majority of midlife women go through this journey without major physical problems. For those whose health, stress-level, and genetics make it a rough voyage, they need to be made aware of choices that ease symptoms, but do not cause disease, exist. No one has ever died from menopause. Discomfort can be an inducement to change. Midlife is a natural time of reevaluation of both emotional/physical health and lifestyle habits. It is a time when many women are highly motivated to reevaluate their lives and make changes that ensure that the final third will be lived well. Of course, the hormonal changes at midlife are not the only time in a womans life when hormones can be disruptive. For many women, feelings of irritation, anxiety, depression, and bloating occur a week to 10 days before the onset of menses and are relieved with the beginning of the menstrual flow.
This cyclic nature is diagnostic. Known as Premenstrual Syndrome (PMS), it can be occasional, mild, or debilitating. Largely dismissed in the past, it has been given more serious attention of late, particularly since the diagnosis of the most severe and distressing version, Premenstrual Dysphoric DisorderW three springs (PMDD). While its cyclic nature is the same as PMS, the severity of PMDD is such that it impacts a womans life by debilitating her to the point where she is unable to carry on her usual routine. For mild cases of Premenstrual Syndrome (PMS) lifestyle, including diet (reduction of sugar and other carbohydrates), exercise, supplements (calcium, magnesium, and the B-vitamin complex) and reduction of stress can be effective interventions.
For some, relief is provided by low-dose birth control pills, particularly if PMS is worsened by irregular periods. The exact mechanism of how estrogen and progesterone apparently affect the Central Nervous System, and in turn the neurotransmitters (particularly, Serotonin), is unclear. With PMDD, interventions that are directed at the hypothalamic-pituitaryadrenal (HPA) axis provide little relief. Instead, serotonergic agents (Paxil, Prozac, Zoloft, etc.) are the treatment of choice. Serotonin reuptake inhibitors (SSRIs) help attenuate mood. They can be given a few days before the cycle or continuously. The good news is that both PMS and PMDD are currently seen as more than trivial concerns, and although sometimes requiring trial and error, are addressed rather than dismissed. Online counseling is always available to help you out.
Mary Ann Mayo, M.A., M.F.T., is a licensed marriage and family Therapist, and a prolific author and speaker. She has authored 12 books that address the mental and physical health of women"her most recent being, Twilight Travels With Mother and Good For You. She is a widely sought-after speaker for the national media on womens health issues. Joseph L. Mayo, M.D., F.A.C.O.G., an obstetrician and gynecologist, has been a practitioner of womens health for more than 28 years. In 1992, Dr. Mayo co-founded with his wife, A Womans Place Medical Center, a clinic specializing in the health of mid-life women and issues of menopause. As an expert on women\'s health, Dr. Mayo has been quoted or written for such periodicals as Shape, More, Natural Health, Energy Times, and The International Journal of Integrative Medicine.
