How Does HRT help with menopause?

Women are living longer, so they are concerned about their long-term health.

Menopause can mean freedom from the problems of menstruation and contraception. It causes no problems to 20 percent of women, 50 percent have symptoms but don’t view menopause as presenting any difficulty, and 10 percent consider they are incapacitated.

What is the average age a woman stops menstruating?

Menopause happens about 50 and is heralded by declining, irregular menstruation over a few years.

A common indication is the onset of hot flushes for about 80 percent of women, for one to three years, but about 20 percent of women over 42 with regular menstrual cycles get them. Up to 20 percent of women have them for life.

What happens during menopause?

Hot flushes usually last for several minutes. They produce a sudden feeling of warmth in the chest which spreads up to the neck and face. The blood vessels in the skin dilate, sometimes producing a visible redness of the skin.

How often it happens can vary markedly, from less than once a week to many times a day. The severity can vary from one time to the next and may be accompanied by dizziness, nausea, headaches or palpitations. Flushes can be aggravated by stress, smoking, caffeine (in tea or coffee), alcohol or spicy foods.

The problem stems from a malfunction in the body’s temperature-control center located in the hypothalamus of the brain. A drop in estrogen causes a fault in the temperature control.

The body’s internal core temperature falls. The hot flush results when the body sheds heat to bring the skin temperature closer to the lower internal temperature. The blood vessels at the skin dilate, carrying heat to the surface to be radiated away. The heart rate increases up to 20 beats a minute producing more blood flow.

Night sweats, headaches, and dizziness seem to be linked with the control-center instability. Other problems surface at menopause such as a lowered desire and response in sex, with problems of vaginal lubrication and length of orgasm. Low estrogen can affect skin quality, producing dry, flaking skin and easy bruising.

A variety of other problems at menopause used to be attributed to hormonal changes but are possibly psychological — diminished energy and drive, difficulty concentrating, irritability, aggression, tension, depression, anxiety, and introversion. They are more common after recent changes in menstruation.

Hormone replacement therapy (HRT)

Hormone-replacement therapy is often used to relieve unwelcome problems of menopause.

Before menopause, the ovary produces three steroid hormones — estrogen, progestogen, and testosterone. Hormone-replacement therapy gives doses of one, two or all three of these. Estrogen (the most effective) or moderately high doses of progestogen will relieve hot flushes.

Estrogen affects the brain directly and may have a beneficial effect on mood as well as relieving other problems. If a woman feels that her libido has fallen even after taking estrogen, testosterone can be given. Testosterone takes some years after menopause to fall below normal levels.

Estrogen therapy aims to produce blood-serum estrogen levels equivalent to those of the early part of the menstrual cycle. Low doses of natural estrogen are used.

The contraceptive pill is a high dose of synthetic estrogen which is 1000 times more powerful, to suppress ovulation. The progestogen is also given for at least 12 days a month because experience since 1980 has indicated that estrogen alone promotes a marked increase in cancer of the uterus. The progestogen prevents this. Estrogen alone can be given to women who have had a hysterectomy.

What are the side effects of hormone therapy for menopause?

Many women have a withdrawal bleed within two or three days of finishing the progestogen for the month. The first few of these bleeds can be heavy but they usually lessen and they completely disappear in a third of women.

A continuous supply of progestogen may prevent withdrawal bleeding. As well as bleeding, there can be other unwelcome side-effects of hormone-replacement therapy. Some women get an increased appetite and so gain weight.

Estrogen slows muscle movements in the small intestine, sometimes producing constipation and excessive gas. Breast tenderness and nausea are common, as is an increased vaginal discharge.

How does hormone replacement therapy help osteoporosis and heart disease?

Hormone-replacement therapy is often recommended to protect against future bone problems and heart disease. Bone mass in women peaks at 20-35.

Once women reach 65, fractures due to osteoporosis are a major problem. Hip fractures can kill or may produce a loss of independence. Bone loss in women starts to accelerate after menopause for about 15 years and then levels off.

Taking an adequate dose of estrogen from menopause on largely prevents this bone loss. It is also possible that estrogen improves coordination and balance and so reduces falls.

With constant use, estrogen produces an average 5 percent increase in bone mass and a 50-70 percent reduction in the risk of fractures because of bone thinning. But the protection is lost when therapy stopped, so the therapy needs to be continued into old age.

For some women, the therapy does not prevent bone loss. It is sensible to measure bone density at the start of menopause since women with adequate bone mass do not develop osteoporosis.

After menopause, coronary heart disease in women increases dramatically but is always about a half that of men until about age 70. Estrogen alone reduces cardiovascular disease. It probably works by directly affecting the elasticity of the blood vessel walls.

The protection against heart disease may be overstated because women from higher socioeconomic groups are over-represented in those having the therapy. These women already have a lower-than-average risk of heart disease.

Is menopause a disease that needs treatment?

The biochemical approach of drug therapy assumes that it is.

For women who wish to be drug-free, a positive, natural approach to menopause is to develop a healthy lifestyle. Have a low-fat, high-fiber diet, plenty of calcium, good exercise, e.g. walking, and avoid substance abuse, particularly smoking and alcohol.

Is HRT good or bad?

There are risks and benefits in hormone-replacement therapy. Those who will benefit most are those who have significant unpleasant menopause problems, or poor bone density or osteoporosis, or coronary heart disease or a high risk of it.

Women having their menopause at less than 45 will also benefit. Women who have had breast or uterine cancer, fibroids, endometriosis, gallstones or liver disease should be very cautious about having the therapy.

What are the benefits for normal women?

A study in Western Australia indicated that a woman who started continuous estrogen therapy at 50 would have an increase in life expectancy of only 1.4 years, mainly because of a reduction in coronary heart disease. Since few heart attacks or hip fractures occur before 65, it would seem sensible to start therapy at 65.

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