Menopause And Hormone Replacement Therapy
Menopause is the physiologic cessation of menses due to decreasing ovarian function. It presents as hot flushes, atrophic vaginitis which means dryness of the vagina including the surrounding area and osteoporosis. Diagnosis is made by absence of menses for 1 year. Symptoms can be treated with hormone replacement therapy or Selective Serotonin Reuptake Inhibitors (SSRI's) which are antidepressants used to treat anxiety and depression.
Physiologic menopause is established when menses have been absent for 1 year. The average age of menopause is 51. Perimenopause refers to the years before and 1 year after the last menses. Perimenopause is an increase in frequency of menses, followed by oligomenorrhea which means very light periods. Conception is possible during perimenopause.
Premature menopause is cessation of menses due to noniatrogenic ovarian failure before age 40. Premature menopause may be caused by smoking and undernutrition.
Symptoms and Signs
Perimenopausal changes in menstruation usually begin during a woman's 40s. Menstrual flow and cycle length can vary. Menses become irregular then are absent. Poor concentration, memory loss, depression, anxiety may occur but are not directly related to decreased oestrogen. This is where SSRI's can be of benefit.
Hot flushes and sweating affect 75 to 85% of women and usually begin before menses stop. Hot flushes continue for more than 1 year in most women and for more than 5 yr in 50%. Core temperature increases. The hot flush last from 30 seconds to 5 minutes and may be followed by chills. Flushes may occur during the night as night sweats.
Decreased oestrogen leads to vaginal and vulvar dryness and thinning, which may result in inflammation of the vaginal mucosa, this is called atrophic vaginitis. Atrophy may cause irritation, dyspareunia which means pain during intercourse and dysuria which is pain on passing water. The labia minora, clitoris, uterus, and ovaries decrease in size.
Risk of osteoporosis increases because oestrogen is decreased, increasing bone resorption by osteoclasts. The most rapid loss occurs during the first 2 years after oestrogen begins to decrease.
Diagnosis
Diagnosis is clinical where menses have gradually decreased in frequency and have been absent for 6 months. Women with amenorrhea are examined to exclude pregnancy if they are less than 50 and are always examined to exclude ovarian tumors.
Treatment
Soy protein may be of benefit but more studies are required. Regular exercise, stress avoidance, and relaxation techniques may improve sleep and reduce irritability. Relaxation techniques can also reduce vasomotor symptoms. Paced respiration, a type of slow, deep breathing, may help relieve hot flushes. Non hormonal drug treatments for hot flushes and lowmood include SSRIs. Over The Counter vaginal lubricants and moisturizers help relieve vaginal dryness.
For many women, risks of oral hormone therapy outweigh the benefits. Women who have a uterus who are given an oestrogen must be given a progesterone.
Hormone therapy relieves moderate to severe menopausal symptoms. For women who have had a hysterectomy, oestrogen should be used aloneott. Women who have a uterus, if given oestrogen in any form or type, are also given a progestin as combination therapy because unopposed oestrogen increases risk of endometrial cancer. Oral hormone therapy also has other risks. For most women, these risks outweigh benefits.
Benefits of oral combination therapy include reduction in yearly incidence of osteoporosis and colorectal cancer.
Risks of oral combination therapy are reflected in an increased yearly incidence of breast cancer, ischemic stroke, deep venous thromboembolism, pulmonary embolism, dementia, and coronary artery disease. Breast cancers that develop are larger and more likely to be metastatic, and false-positive mammograms are common. Urinary incontinence develops more often whilst existing incontinence tends to worsen.
Oral oestrogen-only therapy does not affect incidence of coronary artery disease but increases incidence of ischemic stroke and deep venous thromboembolism. Oestrogen-only therapy, like combination therapy, contributes to urinary incontinence. Dementia risk is probably increased with oestrogen only therapy.
When HRT is prescribed only for the prevention of postmenopausal osteoporosis it should be considered only for women at significant risk of osteoporosis and for whom non-oestrogen medications are not considered appropriate.
