Dr S.P. Moodley
DEFINITIONS:
The menopause is defined as the age at which menses stop permanently for one year. It is therefore a retrospective diagnosis. The climacteric refers to the period that encompasses the transition from the reproductive stage of life to the post menopausal years. The menopause transition refers to the period of time immediately before menopause when the endocrinological, biological and clinical features of approaching menopause commences. Thus some patients may have symptoms even prior to the cessation of menses.
TYPES OF MENOPAUSE:
Natural: Age of menopause is reached physiologically. Average age = 51 years.
Surgical: Occurs in patients in whom the ovaries have been removed surgically or destroyed by chemo or radiotherapy.
PREMATURE OVARIAN INSUFFICIENCY:
Menopause is reached at an age less than 40 years. The diagnosis is made by finding 2 elevated FSH levels at least 1 month apart. The most reliable indicator of ovarian reserve is anti mullerian hormone (AMH).
In this category of patients, there is no controversy as far as treatment is concerned. They must be treated with hormone therapy till the age of natural menopause (50 – 51 years). Whether one uses the oral contraceptive pill or conventional hormone therapy, depends on risk factors in each individual patient and her desires. Some patients prefer the oral contraceptive pill, as it is more appropriate in this age group.
Women will experience menopause differently and will need individual attention and consultation. Modern medicine has ensured longevity and a woman can expect to live a 1/3rd of her life in the climacteric. Hormone therapy should be prescribed only when there are definite indications. Like with any medical intervention, the benefits verses the risks must be assessed. This applies especially to hormone therapy, where it may be used in a preventative role.
The biochemical hallmark of menopause is decreased oestrogen. The effects of decreased oestrogen include: hot flushes, painful intercourse, disturbed digestion, bladder infection, breast tenderness, cold hands and feet, joint pains and mood swings.
BENEFITS OF HORMONE THERAPY:
1) It is the best treatment for hot flushes, night sweats and sleep disturbances due to hot flushes.
2) It reduces the risk of oesteoporotic fractures.
3) It reduces the incidence of colorectal cancer.
4) It reverses vaginal atrophy.
The three main indications for hormone therapy would be to treat the symptomatic patient, lesson the risk of osteopenia and osteoporosis, and to improve sexual function.
Female sexual dysfunction (FSD) is complex with anatomical, physiological and psychological components. Simplistically FSD can be clarified into diminished sexual desire, decreased sexual arousal, orgasmic dysfunction and difficult or painful intercourse. The physiological changes of menopause mitigates against sexual enjoyment. If this causes personal or couple distress, hormonal equilibrium is a prerequisite even if there are associated psychological problems. Hypoactive Sexual Desire Disorder (HSDD) is the commonest sexual dysfunction of patients in the climacteric. Testosterone levels decline as a function of aging rather than an abrupt decline because of menopause (as opposed to oestrogen). The only categories of patients in whom the testosterone levels fall abruptly are in surgical menopause. Women reported greater sexual satisfaction and performance when testosterone levels were normalised. One usually ensures that the patient is oestrogen replete prior to presenting testosterone therapy.
I will now discuss the effects of hormone therapy on different systems.
1.) Cardiovascular system:
The 2010 statistics update from the American Heart Association stated that one in three females have some form of cardiovascular disease (CVD). The mortality for CVD complications exceeds that of breast cancer 10 fold. The early observational studies showed a definite benefit of hormone therapy on CVD. The WHI (Women Health Initiative) study showed an increase in cardiac events, especially in the first years of life. However, the study population in the WHI had an average of 63 years. More than 70% had a BMI greater than 30, a significant number had hypertension, diabetes, previous coronary artery disease and some were smokers. The latter does not reflect the patients that we normally treat in the climacteric. Healthy endothelium is needed to respond to oestrogen. The optimal approach would be to start hormone therapy close to the onset of menopause, avoiding a significant period of exposure to low oestrogen. This window of opportunity for treatment allows oestrogen to prevent the development of atherosclerotic plaques. In older patients in whom atherosclerosis is already present, oestrogen therapy may precipitate their rupture and increase cardiovascular morbidity and mortality. Therefore it is inadvisable to administer hormone therapy to a patient with a recent cardiac event. The use of hormone therapy for approved indications should not be tempered by fear of increased coronary heart disease in younger, healthier recently menopausal women.
2.) Stroke:
There was no reported increase in stroke in younger post-menopausal women. The lower the dose of hormone used the less the risk. The presence of comorbid conditions like hypertension increases the risk. Hormone therapy appears to be associated with a small real increased risk of stroke. If a woman develops a stroke while taking hormone therapy, she should be advised to discontinue therapy. Women with a history of strokes or transient ischaemic attack should be discouraged from initiating therapy.
1.) Deep vein thrombosis:
The risk is increased and the effect is maximal in the first years of treatment. Risk factors include advancing age, obesity, history of previous thrombosis and underlying tendency to clot. The route of delivery also impacts on risk. The transdominal route has the least risk.
3.) Breast Cancer:
There is a modest increase after 5 years of use of combined oestrogen progesterone therapy. 2 extra cases per 100 after 5 years of hormone use and increasing to 6 extra cases after 10 years. The consensus is that hormone therapy increases the growth of an existing breast cancer thereby aiding better clinical detection. On stopping hormone therapy, the risk rapidly returns to that observed in never users of hormone therapy. The oestrogen only arm of the WHI trial demonstrated a decreased risk of breast cancer. Hormone users who develop breast cancer have a reduced mortality because their tumours are better differentiated more localised and smaller resulting in better survival rates.
The present information for breast cancer survivors is not that promising. Early information from RCT (Randomised Controlled Trials) demonstrates an increase in occurrences in users of hormone therapy. This is especially sad as many of these patients often have disabling symptoms which is compounded by the loss of body image as a result of the breast surgery. The use of vaginal preparations should not be forgotten in this group of patients.
HORMONE THERAPY AND BRAIN FUNCTION:
Hormone therapy is not indicated for the treatment of Alzheimer’s disease. Early commencement of hormone therapy will have no detrimental effect and may have some benefit on certain domains of cognitive performance.
LOW DOSE HORMONE THERAPY:
The move to use lower doses is motivated by the fact that there are fewer side effects and efficacy is maintained. Low dose hormone therapy is not advised in patients with premature ovarian insufficiency, established osteoporosis or where there is a prominence of psychological problems.
MANAGING VASOMOTOR SYMPTOMS IN THE PATIENT WHERE HORMONE THERAPY IS CONTRAINDICATED:
1) Lifestyle measures such as an exercise program or yoga is advised.
2) Gabapentin. The dosage advised is 900 mg daily (300 mg three times a day). I usually start with 300 at night for 4 days increasing to twice a day thereafter. This regime reduces the drowsiness that some patients experience.
3) Selective Serotonin Reuptake inhibitors. This is especially indicated in patients where mood disorders are the prominent symptoms.
ROLE OF PROGESTOGENS:
Progestogens are only needed in patients who still have an intact uterus. Progestogen component is largely if not exclusively responsible for increased incidence of breast cancer and cardiovascular diseases. The use of intrauterine delivery systems for progesterone is being increasingly used to decrease the unpleasant systemic side effects of progesterone ( breast tenderness, fluid retention, abdominal bloating and mood changes ). The spironolactone progestogen derivatives have an antimineralocorticoid effect. Thus choosing the right type of progestogens in certain classes of patients will reduce side effects.
CONCLUSION:
The climacteric is a life changing, not a life threatening phase of a woman’s life. As caregivers one should improve the quality of life in our patients and as my teacher and colleague Dr Mike Davey states: treat those individuals that need treatment, don’t treat those that don’t need medications and keep up to date with the expanding knowledge to benefit your patients.