Hormone replacement therapy - Research findings
The Better Health Channel is currently developing an article on this topic. In the meantime, you may like to visit another site for more information by clicking on the Better Health Channel logo below.
Menopause
Menopause is the last menstrual (monthly) period in a woman's life. It is a natural occurrence, which marks the end of the reproductive years, just as the first menstrual period, during puberty, marked the start.
Most women reach menopause somewhere between the ages of 45 and 55, the average age being around 50. Menopause before the age of 40 is called 'premature menopause'.
Hormone levels fluctuate as menopause approaches
As we approach menopause, the production of hormones (for example oestrogen) by the ovaries starts to slow down. As this process accelerates, hormone levels fluctuate more and often a woman notices changes in her menstrual cycle.
Signs of change include:
· Cycles may become longer, shorter or totally irregular
· Bleeding may become lighter
· Bleeding may become unpredictable and heavy (seek advice from your doctor).
Eventually the hormone levels will fall to a level where menstruation (periods) will cease altogether and the menopause is reached.
Contraception is still needed, until you have had one year without a natural period.
Other signs and symptoms
The most common symptom is the hot flush. However, women sometimes experience several of these other symptoms:
· Aches and pains
· Crawling or itching sensations under the skin
· Forgetfulness.
· Headaches
· Irritability
· Lack of self-esteem
· Reduced sex drive (libido)
· Sleeping difficulty
· Tiredness
· Urinary frequency
· Vaginal dryness.
Risks
A decline of female hormones after menopause may lead to:
· Thinning of the bones (osteoporosis), leading to increased risk of fractures
· An increase in the risk of heart attack.
Manage the menopause with a healthy lifestyle
Often, if you improve your lifestyle habits as outlined below, unpleasant symptoms of the menopause will be greatly reduced, so try these first.
Healthy diet
· Choose a wide variety of foods, including plenty of fresh vegetables, fruits, cereals, whole grains and small portions of lean meat, fish or chicken several times per week. Increase fluids and eat low fat dairy foods with high calcium content.
· Decrease caffeine and limit alcohol (to one or two standard glasses or less, per day).
Regular exercise
At least 45 minutes of exercise three times per week will make a difference. Regular exercise will:
· Maintain your heart health as well as improve your general health
· Keep your bones healthy and prevent bone loss through osteoporosis
· Help maintain good balance and so reduce the risk of injury from falls
· Provide a feeling of relaxation and wellbeing.
Avoid smoking
It's important to avoid smoking because of the associated risk of osteoporosis, coronary heart disease and lung cancer (which may soon exceed breast cancer as the leading cause of death in women).
Think positive
Some women experience mood changes, such as mild depression and irritability. These symptoms are often secondary to physical changes such as hot flushes, night sweats and poor sleeping. It's important to keep a positive outlook.
Regular Pap smear and breast checks
You should have:
· Two-yearly Pap smears (see your doctor)
· A two-yearly mammogram (a free service if you are over 50).
Hormone replacement therapy
Hormone replacement may reduce many of the unpleasant effects of symptoms of the menopause. If you are in a category at risk of heart disease or osteoporosis, hormone replacement should by considered, as it can stop the progression of osteoporosis and may reduce the risk of heart disease. Discuss the advantages and disadvantages of hormone replacement with your own doctor or the Jean Hailes Foundation.
Natural therapies
These can be of benefit to some women. It is important to remember that 'natural' herb and plant medications can have unpleasant side effects in some women - as can prescribed western medications. For long term guidance and balance through the menopausal years, it is important to see a registered naturopath.
Natural therapies can often be taken in conjunction with hormone replacement. It is important to let both your doctor and naturopath know exactly what each has prescribed.
Where to get help
· The Jean Hailes Medical Centre for Women Tel. (03) 9562 6771
· Your doctor
· Your local Community Health Service
· Women's Health Victoria Tel. (03) 9662 3755
· Mammogram screening Tel. 132 050 (ring for an appointment at your nearest centre).
Things to remember
· Menopause means the end of monthly periods
· You may experience a range of symptoms
· A healthy lifestyle will help to manage symptoms
· You should have regular breast checks and Pap smears
Mammogram screening is free if you are over 50.
Menopause and alternative therapies
Menopause occurs when a woman stops ovulating, the ovaries no longer produce oestrogen (the female sex hormone) and her monthly period (menstruation) ceases. It is a natural event that marks the end of the reproductive years, just as the first menstrual period during puberty marked the start. Many women are troubled by menopausal symptoms that occur with the loss of oestrogens. These include vaginal dryness, hot flushes and night sweats, and many psychological symptoms. The long term risk of disorders such as osteoporosis and cardiovascular disease is also increased after menopause. Some women use hormone replacement therapy (HRT) - a combination of hormones - to ease menopausal symptoms and reduce the risk of associated disorders. However, some women prefer to try alternative therapies to manage their menopause.
Alternative therapies are controversial The 1995 South Australian
Health Omnibus Survey found that menopausal women are high users
of alternative therapies.
Alternative therapies for the management of menopausal symptoms remain controversial. Many of these therapies have not been subjected to clinical trials, so their efficacy is unclear. Some make claims that have yet to be medically confirmed. To date, no alternative therapy has managed to reduce a menopausal woman's risk of osteoporosis. Another concern is that these products may not be prepared to the same strict manufacturing standards as pharmaceutical products.
Popular alternative therapies
Some of the more popular alternative therapies include:
· Phytoestrogens
· Progesterone creams
· Wild yam creams
· Herbal medicines.
Phytoestrogens
Phytoestrogens are plant compounds that are similar in chemical makeup to the female sex hormone oestrogen, but with much lower potency. They act at the oestrogen receptor sites in a woman's body. This can moderate menopausal symptoms. The three types of phytoestrogens and their dietary sources include:
· Isoflavones - good sources include soy products and beans (such as lima and lentil).
· Lignans - good sources include fruit, vegetables and grains, and oilseeds such as linseed.
· Coumestans - good sources include sprouting seeds such as alfalfa.
Progesterone creams
Progesterone is a female sex hormone that also declines after menopause. Medical science accepts that menopausal symptoms are due to falling oestrogen levels, but some people believe that an incorrect ratio of progesterone to oestrogen is the culprit. To date, there is no medical evidence to support the theory that supplementing the body's progesterone levels with progesterone creams, pessaries or suppositories can ease menopause symptoms or reduce the risk of osteoporosis. The main use of progesterone is to protect the lining of the uterus in women using oestrogen. Progesterone products are now available on prescription only.
Caution for women on HRT
Some women who use combined HRT (oestrogen + progesterone) substitute progesterone creams for the progestogen component of their HRT. This can increase the risk of cancer in the uterine lining (endometrium), because not enough progesterone is absorbed through the skin from these creams. A study published in The Lancet found that progesterone creams applied to the skin don't increase the amount of progesterone levels in the blood to any significant degree and do not protect the endometrium.
Wild yam creams
Any over-the-counter cream or preparation that claims to contain progesterone should be avoided as a waste of money, since all products containing progesterone are only available on prescription. The compound diosgenin (an oestrogen-like compound) is found in wild yams. The progesterone in creams, pessaries, suppositories and the contraceptive pill is synthesised from diosgenin. Oestrogens and testosterone can also be synthesised from diosgenin. However, this doesn't mean that wild yam creams have a progesterone-boosting effect, as diosgenin has to be chemically changed in the laboratory to produce progesterone, and the human body doesn't have the enzymes to do this. There is no medical evidence to support the claims that wild yam creams can ease menopausal symptoms.
Herbal medicines
Some herbs (such as ginseng and false unicorn) are said to ease menopause symptoms in the same way as phytoestrogens - by acting at oestrogen receptor sites. After menopause, the adrenal glands become the main manufacturers of oestrogen, so herbs such as liquorice and sarsaparilla are used to boost the adrenal glands. Research is needed on the efficacy of herbal preparations in the management of menopause. Studies undertaken so far on evening primrose oil have found that, contrary to popular belief, it has no effect on menopause symptoms. Herbs can act on the body as powerfully as pharmaceutical drugs and should be treated with respect and caution. Always inform your doctor of any herbs you are taking. A registered practitioner should prescribe herbal medicines - self-medicating is not advised. Traditionally, herbs are prescribed short term and not for continuous use.
Menopause and hormone replacement therapy (HRT)
Menopause occurs when a woman stops ovulating, the ovaries no longer produce oestrogens (the female sex hormone) and her monthly period (menstruation) ceases. It is a natural event that marks the end of the reproductive years, just as the first menstrual period during puberty marked the start. Many women, although not all, experience uncomfortable symptoms during and after menopause, including hot flushes, night sweats and vaginal dryness. These symptoms, and associated physical changes, can be managed in various ways, including education, lifestyle changes with diet and exercise, and hormone replacement therapy (HRT) if required. See your doctor for further information.
Menopause symptoms can be reduced by HRT
The following symptoms are usually alleviated by HRT:
· Hot flushes
· Night sweats
· Vaginal dryness
· Thinning of vaginal walls
· Vaginal and bladder infections
· Mild urinary incontinence Insomnia
· Cognitive changes, such as memory loss
· Reduced sex drive
· Mood disturbance
· Abnormal sensations, such as 'prickling' or 'crawling' under the skin
· Palpitations
· Hair loss or abnormal growth
· Dry and itching eyes
· Tooth loss
· Gingivitis (gum problems).
Side effects of HRT
HRT needs to be individually tailored. Some women experience side effects during the early stages of treatment, which may include:
· Breakthrough bleeding
· Breast tenderness
· Bloating
· Blood clots (around 1 in 5,000 otherwise low-risk women per year will develop blood clots in the legs due to HRT).
· HRT does not cause weight gain
An increase in body fat, especially around the abdomen, can occur during menopause because of hormonal changes, although exactly why this happens is not clear. The age-related decrease in muscle tissue and the slowing down of the metabolism can also contribute to weight gain. Contrary to anecdotal evidence, various studies prove that weight gain is not linked to HRT. If a woman is prone to weight gain during her middle years, she will do so regardless of whether or not she uses HRT. Some women may experience symptoms at the start of treatment, including bloating and breast fullness, which may be misinterpreted as weight gain. These symptoms usually disappear once the therapy doses are modified to suit the individual.
Contraception is still needed
HRT is not a form of contraception. The treatment does not contain sufficient hormones to suppress ovulation, so pregnancy is still possible in women who are ovulating occasionally in the perimenopause. It is generally advised that menopausal women should continue to use contraception until their natural periods have ceased for at least one year.
Long term use of HRT to prevent disease in older postmenopausal women
HRT reduces the risk of various chronic conditions that can affect postmenopausal woman, including: Bowel cancer - the risk of colorectal cancers is reduced with HRT.
· Potentially, Alzheimer's disease - preliminary research indicates that the risk of Alzheimer's disease might be reduced by HRT. More research is needed in this area.
HRT-related health risks
While HRT reduces the risk of some debilitating diseases, it also increases the risk of others. These small risks must be balanced against the benefits for the individual. Three areas of concern are:
· Cardiovascular disease - current research suggests that women over 50 have a small increased risk of developing both heart disease and strokes on combined oral HRT. Although this risk is small (7 heart attacks and 8 strokes per 10,000 treatment years - ie 1,000 women treated for 10 years), it needs to be considered when starting HRT, as the risk occurs early in treatment and persists with time. It is unknown if oestrogen alone, or other forms of oestrogen (including patches), also cause this increased risk. The results of ongoing research are awaited with interest.
· Thrombosis - or blood clots that form inside veins. Some women on HRT are more likely to get thrombosis than women who are not on HRT. This risk seems to be highest in the first 1-2 years of therapy and in women who have a high risk of blood clots anyway. This especially applies to women who have a genetic predisposition to developing thrombosis. More research is needed to clarify if oestrogen applied through the skin as patches, or as implants or gels, has the same effect. Limited research to date would suggest the increased risk of clots is mainly related to oestrogen in tablet form.
· Endometrial cancer - cancer of the lining of the uterus. Long term use (for 10 years or more) of oestrogen alone increases the risk of this cancer, but this risk is neutralised with the addition of progesterogen to the treatment.
Long term use is not recommended
It is currently believed that, overall, the risks of long term HRT outweigh the benefits. HRT should not be recommended for disease prevention. However, the jury is still out on the use of oestrogen alone, other HRT preparations (including tibolone), and other forms of HRT (including patches). We await the results of further trials before recommendations in these areas can be made.
Prior history of breast cancer and HRT
To date, there is no specific evidence that HRT will increase the risk of recurrence in a woman with a prior history of breast cancer. However, given that oestrogen does stimulate some types of cells in the breast and does increase the risk of breast cancer in women without a history of breast cancer, it is advisable that HRT be avoided by woman with a prior history of breast cancer. Similarly, there is no evidence that phytoestrogens increase the risk of recurrence but, under certain circumstances, breast cells may be stimulated. Other forms of management for menopausal symptoms may be advised, such as oestrogen vaginal creams or low doses of antidepressants for hot flushes. There are new forms of HRT - such as tibolone, which appears to have less effect on the breast - which may also be considered. Be advised by your doctor.
Alternative therapies
Alternative therapies for the management of menopausal symptoms remain controversial. Many of these therapies have not been subjected to clinical trials, so their efficacy remains anecdotal. To date, no alternative therapy has been clinically proven to reduce a menopausal woman's risk of osteoporosis, and preliminary studies would suggest there is no benefit for the bones. Some of the more popular alternative therapies include:
· Soy products
· Phytoestrogens
· Herbal medicines.
Where to get help
· Your doctor
· The Jean Hailes Foundation Tel. (03) 9562 6771
· Australian Menopause Society Tel. (07) 5456 2660
· Women's Health Victoria Tel. (03) 9662 3755
Things to remember
· Many women experience uncomfortable symptoms during menopause, including vaginal dryness, hot flushes and night sweats.
· Menopausal symptoms can be managed with support, education, lifestyle interventions and hormone replacement therapy (HRT).
· In the early postmenopausal years, HRT is an effective therapy for menopausal symptoms and, in most women with moderate to severe symptoms, the benefits outweigh the small increases in risk.
· The long term use of HRT does have other benefits including reduced risk of osteoporosis, fracture and colon cancer. However, it also has small risks including heart disease and blood clots in the veins. The role of long term HRT for the prevention of disease still needs to be clarified from ongoing research.
· The decision to use HRT, and for how long it should be used, must be based on individual assessment and needs.
· The HRT regimen used must be monitored and tailored to the individual and reviewed regularly with your doctor.
Menopause and osteoporosis
Postmenopausal women are prone to developing osteoporosis, a condition characterised by weakened bones that fracture easily. The female sex hormone oestrogen plays an important role in maintaining bone strength. The drop in oestrogen levels that occurs at menopause results in accelerated bone loss. It is estimated that the average woman loses up to 10 per cent of her bone mass in the first five years of menopause. If the peak bone mass achieved prior to menopause is less than ideal, the bone loss during menopause may result in osteoporosis. About half of all women over the age of 60 years can be expected to experience at least one osteoporosis-related fracture.
Clinical definition of osteoporosis
Osteoporosis is best diagnosed using x-ray technology (DEXA). Bone density is measured by the T Score, which means comparing the bone density under investigation to that of the average young adult (peak bone mass). A clinical diagnosis of osteoporosis is a T Score of 2.5 standard deviations below the young adult mean.
Lifestyle changes
A menopausal woman can reduce her risk of developing osteoporosis by making a few lifestyle changes, including:
· About 1,000mg of calcium every day, which equals about three serves of dairy food.
· At least half an hour of weight bearing exercise every day, such as walking.
· Half an hour of sunlight exposure daily to boost production of vitamin D.
· Ideally, these lifestyle habits should be in place from childhood to maximise bone mass before menopause.
Exercise is crucial
Exercising regularly throughout life can reduce the risk of osteoporosis.
Recent research suggests that people with existing osteoporosis can also benefit from exercise. Weight bearing physical activity (such as walking) reduces the rate of bone loss and conserves remaining bone tissue. Currently, the required minimum of exercise for people with osteoporosis is unknown, but 15 to 60 minutes of aerobic activity two to three times per week, and two weekly sessions of strength training, are generally recommended. In addition to reducing bone loss, exercise will improve muscle strength, balance and fitness, thereby reducing the incidence of falls and fractures. Always consult with your doctor, physiotherapist or health care professional when you start an exercise program.
General recommendations for exercise
Be guided by your health care professional when deciding on your exercise program. General recommendations include:
· Avoid high impact activities or those that require sudden, forceful movements.
· Weight bearing exercise includes walking, Tai chi, dancing and weight training.
· Swimming isn't a weight bearing exercise because the buoyancy of the water counteracts the effects of gravity.
· Perform aerobic activity around two or three times weekly.
· Perform strength training once or twice weekly.
· Flexibility exercises or stretching should also be included.
Medical prevention and treatments
The range of medical treatments available includes:
Hormone replacement therapy (HRT)
· Bisphosphonates
· Selective oestrogen receptor modulators (SERMs)
· Vitamin D derivatives and calcium supplements
· Androgens
· Tibolone.
Vitamin D and calcium supplements
A menopausal woman may be prescribed a vitamin D derivative (as directed by a doctor) and calcium supplements. These may reduce the incidence of bone fractures by 30 per cent. Half an hour of sunlight exposure every day can also boost vitamin D production and contribute to bone health.
Hormone replacement therapy (HRT)
Hormone replacement therapy (HRT) relieves menopausal symptoms, such as vaginal dryness, hot flushes and night sweats. When taken at the beginning of menopause, HRT can also prevent bone loss and should be started soon after menopause for maximum benefit. A woman who has been postmenopausal for some time can still benefit from HRT. Some studies have shown that HRT can increase bone density by around five per cent in two years. On average, HRT reduces the risk of spinal fractures by 40 per cent. Long term HRT should be considered if there is a high risk of osteoporosis, because bone loss will resume as soon as HRT stops. Tibolone, a tissue specific therapy with similar actions to HRT, also maintains bone density. Androgens, such as testosterone, have also been shown to increase bone density.
Bisphosphonates
Bone cells are constantly being broken down and renewed. Bisphosphonates prevent bone loss by hampering the 'breaking down' process and preventing absorption of bone cells. Possible side effects of treatment include gastrointestinal upsets. Bisphosphonates may be taken daily or weekly, but are only available for use to treat established osteoporosis with fracture.
Selective oestrogen receptor modulators (SERMs)
The female body contains oestrogen receptors, which are special sites that respond to the hormone oestrogen. Selective oestrogen receptor modulators (SERMs) are medications that work by blocking the oestrogen effect at some receptor sites (antagonist), while prompting an oestrogen effect at others (agonist). However, SERMs can't relieve menopause symptoms. Possible side effects of treatment include leg cramps and deep vein thrombosis (DVT).
Tissue selective oestrogens, like tibolone, act on oestrogen receptors in bone to prevent bone loss as well as relieving menopausal symptoms.
Where to get help
· Your doctor
· The Jean Hailes Foundation Tel. (03) 9562 6771
· Australasian Menopause Society Tel. (03) 9543 9612
· Women's Health Victoria Tel. (03) 9662 3755
Things to remember
· Postmenopausal women are prone to developing osteoporosis, a condition characterised by weakened bones that fracture easily.
· It is estimated that the average woman loses up to 10 per cent of her bone mass in the first five years of menopause.
· Risk reduction strategies include eating a diet rich in calcium and exercising regularly, both before and after the menopause.
· Medical treatments may include hormone replacement therapy (HRT), bisphosphonates and selective oestrogen receptor modulators (SERMs).
