Menopause
Menopause, or the cessation of menstrual bleeding, occurs on the average at age 51.4 years. However, one can go through menopause as early as age 35 or as late age 57. The perimenopause, however, can occur 8 to 15 years before the menopause. This life transition is characterized by an increase in body weight, mood fluctuations, insomnia, depression, dizziness, problems with balance, fatigue, memory problems, decreased libido, decrease in vaginal lubrication, and may or may not be accompanied by sweating or hot flushes. During this time, menstrual cycles become much more irregular, dysfunctional bleeding can occur which usually requires hormonal management.
Many of these symptoms resolve within 6-8 months after cessation of menstruation, however, 40% of women have symptoms over a lifetime. This condition occurs because of the depletion of the normal oocytes (egg supply in the ovary) as well as a deterioration in the genetic quality of the remaining oocytes. The end result of these changes is a decrease in production of the body’s primary estrogen, 17â-estradiol, often called a natural or bioequivalent hormone.
Concomitant with or sometime thereafter, testosterone production begins to decrease, this further aggravates problems with memory, sleep, strength, depression, general cognitive function, libido, muscle mass, and bone density. This is generally treated by the addition of molecular testosterone, also considered a natural or bioequivalent hormone.
The classic treatment of the menopause has been focused on the maintenance of bone stability and the prevention of osteoporosis. The secondary goal was the control of psychomotor symptoms, primarily hot flushes. There are many commercial preparations on the market including pill forms, topical gels, and patches. All of them prevent bone loss and may or may not control psychomotor symptoms. However, many women require customized hormonal therapy to treat the myriad of symptoms that accompany the perimenopause and menopause. A detailed assessment of the patient’s family history, general medical history, and physical condition can be carried out along with testing of serum estradiol, total testosterone, free testosterone, and sex hormone binding globulin. Ultrasound may be used to assess the uterine lining thickness which is also a marker of hormone production.
Therapy can then be customized based on whether or not a woman has a functional uterus, and therapeutic doses can be titrated based on the clinical response of the aforementioned biological markers which allows for the safe use of hormone replacement therapy.
It should be emphasized that this type of hormone replacement therapy is useful in the maintenance of general health and well-being if applied early in life. However, in all probability no type of hormonal therapy will prevent chronic diseases if applied to older patients with less than healthy lifestyles and large numbers of chronic disease processes.
Alternatives to hormone replacement therapy have been tried to treat menopausal symptoms. Psychoactive agents can at times block hot flushes and depression but have little effect on other symptoms. Most herbal preparations have been evaluated by placebo-controlled trials are not effective in the treatment of menopausal symptoms. Soy, while beneficial to general health, does not produce the same type of biological effect as hormone replacement therapy. Lifestyle modifications such as the maintenance of normal body weight, obtaining adequate sleep, avoiding smoking, alcohol intake, and excessive caffeine, seems to improve menopausal symptoms as does the participation in an adequate exercise program and the use of relaxation therapy such as medication or yoga.
Finally, it should be remembered that the menopause is a normal psychological life transition, not a disease process. In choosing to treat menopausal symptoms, one was simply using pharmacology to alter the aging process. These types of therapies not only improve our physical and mental well-being but enhance the quality of life.