Menopause

Menopause is the permanent cessation of menstruation due to the ovaries’ “retirement” (primary ovarian failure) as a result of the depletion of eggs. It is defined as the time of the last period followed by 12 consecutive months of amenorrhea (no periods). Menopause transition or Perimenopause begins with the variability of menstrual cycle length and ends with the final menstrual period. Postmenopause is the period of life after the final menses.

The age of menopause has not significantly changed since Ancient Greece and occurs at a mean age of 51 years. This remains constant despite a great increase in life expectancy. We can now expect to grow old! In 1900, life expectancy in the United States reached only 49 years. In 2005, the average life expectancy for women was 80.7 years, and for men 75.4 years. Today, once women reach the age of 65, we can then expect to live to reach 85! This means that most women can expect to live 30 plus years in the postmenopausal state.

Attitude and expectations about menopause are very important. Menopause is a “normal” physiologic event, not a disease state. The symptoms that women report are related to many variables within their lives and are conditioned by sociocultural factors. Sometimes it is hard to determine biologic versus cultural variability. For instance, in Japanese, Chinese, and Mayan, there is no word to describe “hot flush”.

Medical intervention by a healthcare professional should be sought for at this point in life. It is an opportunity (and an obligation) of healthcare providers to address the principle health concerns of (post)menopausal women by providing and reinforcing a program of preventive health care. Maintaining health is much easier than regaining it! DNA and “epigenetics” analysis has revolutionized medicine, eliminating the practice of “one size fits all” and enabling a shift away from treatment by medication or surgery toward prevention (of illness) and slowing down the aging process of the “whole” unique individual.

The principle health concerns of postmenopausal women include:

• Vasomotor symptoms: Hot flashes, night sweats affect up to 75% of women and usually last for 1-2 years but may continue for 10 years or longer. Although there are many over-the-counter herbal supplements available for mild to moderate symptoms, systemic estrogen therapy is the most effective for severe, disruptive symptoms and the only therapy currently FDA approved for this indication.
• Cardiovascular disease: Diseases of the heart are the leading cause of death for women followed by cerebrovascular disease and malignancy. In 2005, 1 in 6 female deaths was from coronary heart disease compared to 1 in 30 for breast cancer; most cardiovascular disease results from atherosclerosis (hardening) of major blood vessels and the risk factors are the same for men and women. However, men prior to age 40 have 2x the risk of developing Coronary Heart Disease than women and this is due to the protective effects of Estrogen on our blood vessel walls (direct anti-atherosclerotic effects, coronary artery vasodilator, protects endothelial cells that line the blood vessels, an antioxidant that inhibits bad cholesterol [LDL] and increases good cholesterol [HDL] levels). The important role of estrogen in maintaining good cardiovascular health should not be ignored as primary prevention (in addition to smoking cessation, weight reduction if applicable).
• Osteoporosis: Bone is an active organ in a continuous process of “remodeling” involving resorption/breakdown (osteoclastic) and formation (osteoblastic) activity. Age-related changes in vitamin D and calcium metabolism and a loss of estrogen both lead to excessive resorption (osteoclastic activity). Osteoporosis is the most prevalent bone problem in the elderly and a major global public health problem. It is an epidemic in the U.S., affecting over 10 million Americans (four times more women than men). Hormone therapy at the time of menopause, especially for women at higher risk (because of medications, family history, body habitus) effectively prevents and treats osteoporosis and reduces the number of osteoporotic fractures.
• Urogenital atrophy:  Extremely low estrogen production in post-menopause causes atrophy (thinning) of the vaginal mucosal surfaces accompanied by vaginal dryness, pruritis (itching), dyspareunia (painful intercourse), stenosis (narrowing of entry), urgency incontinence, urinary frequency, urethritis (inflammation of the urethra), recurrent urinary tract infections. All of these symptoms can effectively be prevented by postmenopausal intravaginal estrogen treatment. In addition, a decline in skin collagen content, elasticity, and skin thickness that occurs with aging can be considerably avoided by postmenopausal estrogen therapy.
• Cancer: Lung cancer is the leading cause of cancer mortality in American men and women - 87%  of deaths occur in smokers; causes twice as many deaths in women than breast cancer); breast cancer is the most common cancer in women and 2^nd leading cause of cancer death; about 95% of all breast cancers occur after age 40 and is a prominent factor in clinical decision making regarding postmenopausal hormone therapy. The facts are that estrogen has not been found to initiate malignant growth and women who are on hormone therapy at the time of diagnosis of breast cancer do better and live longer than those who were not on hormone therapy at the time of diagnosis. Colon cancer ranks third in both incidence and mortality and is more prevalent than cancers of the uterus or ovary. Studies have shown a reduction (by 30% or more) of colorectal cancer incidence and mortality rates in current hormone therapy users with the increased effect the longer the duration of use. 

• Cognitive decline: Alzheimer’s is the most common form of dementia. Elevated Homocysteine levels with decreases in Folic Acid and Hormone levels may predict the risk for Alzheimer’s disease. The favorable effects of hormone therapy on cognition and the risk of Alzheimer’s disease are limited to women who initiate treatment close to their menopause and initiated at least 10 years before the symptoms of dementia appear. One trial conducted by the NIH (National Institute of Health) between 1965 and 1993 reported that higher midlife Tofu (soy) consumption is associated with poor cognitive test performance and other subsequent randomized trials have detected no effects (positive or negative) of soy protein, red clover, ginkgo biloba or black cohosh on memory, cognition, executive function or measures of quality of life.
• Sexual problems: The decline in sexual activity with aging is influenced more by culture and attitudes (influenced by stress, anxiety, depression, fatigue, and medications) than by nature and physiology (or hormones). However, a significant component of this decline can be attributed to menopausal symptoms associated with decreasing estrogen levels (vaginal dryness, atrophy, and elasticity) that can easily be ameliorated by local estrogen treatment. Prior levels of sexual activity and partner status and relationship are more important factors than hormone levels in determining sexual function during the perimenopausal and menopausal transition. 

• Hormones are the fountain of youth! Hormone balance is crucial to good health especially as we age. Menopause should not be a signal of impending decline but a physiologic event that should bring clinicians and patients together and provide an opportunity for education in health care and health maintenance. Medical intervention at this point in life offers women-years of benefit from primary preventive healthy lifestyle changes.