397 lines
16 KiB
Plaintext
397 lines
16 KiB
Plaintext
|
|
|
|
|
|
|
|
(word processor parameters LM=1, RM=70, TM=2, BM=2)
|
|
|
|
Taken from KeelyNet BBS (214) 324-3501
|
|
Sponsored by Vangard Sciences
|
|
PO BOX 1031
|
|
Mesquite, TX 75150
|
|
|
|
|
|
=================================================================
|
|
|
|
The following was prepared in response to questions on this
|
|
subject posted in the Medicine Conference of Friends!Z BBS. Feel
|
|
free to share this file. I ask only that it be uploaded "as is"
|
|
including this header.
|
|
|
|
I accept no responsibility for the purposes to which you put
|
|
this information.
|
|
|
|
Comments, questions, and feedback are welcome. Messages
|
|
regarding medical issues should be left in the Medicine
|
|
Conference which is Conference #1. I hope this information is of
|
|
service to you. .....alex...
|
|
|
|
Alex DeLuca, M.D.
|
|
Sysop: Friends!Z BBS
|
|
(212) 828-3989
|
|
|
|
=================================================================
|
|
|
|
A Family Practioner's View of the Menopause
|
|
|
|
Menopause, because of the emphasis on youth in our society,
|
|
is a difficult stage of life for women. Many of the emotional
|
|
and physical changes attributed to menopause are, rather, general
|
|
manifestations of aging and are not the result of decreased
|
|
estrogen levels. The hope that taking estrogen-containing
|
|
medications would protect women from normal aging, heart disease
|
|
and other conditions is ill-founded. This essay will attempt to
|
|
clear up some common misconceptions. It will briefly cover the
|
|
physiology, symptoms and treatment of menopause and related
|
|
conditions, and issues regarding the usefulness and risks of
|
|
estrogen replacement therapy.
|
|
|
|
PHYSIOLOGY, CAUSE, and SYMPTOMS
|
|
|
|
The generally accepted definition of menopause is one full
|
|
year without menstrual flow in a previously menstruation woman.
|
|
The incidence of menopause by this definition is about 10% by age
|
|
38, 20% by age 43, 50% by 48, and 100% by age 58.
|
|
|
|
The essential cause of menopause is less production of the
|
|
female hormone, estrogen, by aging ovaries. This results in
|
|
cessation of menses (periods). Some estrogen production
|
|
continues, mostly as a result of non-ovarian conversion of other
|
|
steroids. This non-ovarian estrogen production may be the reason
|
|
why 25% of women experience no menopausal symptoms.
|
|
|
|
|
|
|
|
Page 1
|
|
|
|
|
|
|
|
|
|
Hot Flashes
|
|
|
|
This term describes an uncomfortably warm sensation that
|
|
radiates up from the chest to neck and face and lasts seconds to
|
|
a few minutes before subsiding. Eating, exertion, emotional
|
|
stress and alcohol are know to precipitate hot flashes. It is
|
|
believed that hot flashes are related to the rate of estrogen
|
|
withdrawal. Menopausal women can experience up to 20 episodes
|
|
per day. In most people, this symptom subsides after 2-3 years,
|
|
but it may continue for 6 years or more. About 10-35% of
|
|
menopausal women suffer from severe, disabling hot flashes.
|
|
While no link between emotional makeup and symptoms has been
|
|
demonstrated, clearly hot flashes can be a source of significant
|
|
misery and annoyance.
|
|
|
|
Atrophy of the Vagina
|
|
|
|
As estrogen levels decline, the vagina becomes smaller and
|
|
less compliant and lubrication decreases. This makes vaginal and
|
|
urinary tract infection more likely. It can lead to symptoms of
|
|
itching, painful intercourse, discharge, and bleeding. It is
|
|
interesting that sexually active women show less vaginal atrophy.
|
|
|
|
Cardiovascular Disease
|
|
|
|
There is no evidence that estrogen decline is responsible for
|
|
the increased incidence of cardiovascular disease that parallels
|
|
the menopause. Data regarding the effects of taking estrogens on
|
|
cardiovascular morbidity and mortality are conflicting. The two
|
|
major prospective studies have produced opposite results, with
|
|
one showing an increase in the risk of heart disease, the other a
|
|
decrease. This is a vitally important issue...further research
|
|
is desperately needed to resolve it.
|
|
|
|
There does not appear to be an increased risk of
|
|
thromboembolism (the formation of blood clots) among menopausal
|
|
women taking estrogens, but those with a history of same who are
|
|
taking estrogen preparations should be closely monitored.
|
|
|
|
Osteoporosis
|
|
|
|
Osteoporosis refers to a generalized weakening of bone that
|
|
leads to an increased risk of fractures of various types. It is
|
|
an important consequence of estrogen decline. Decreased
|
|
activity, poor nutrition, and the general aging process also
|
|
contribute to the development of osteoporosis. Although the
|
|
process is irreversible once established, it can be prevented by
|
|
the prophylactic administration of estrogen.
|
|
|
|
Emotional Disturbances
|
|
|
|
Symptoms such as headache, nervousness, and depression are
|
|
common during early menopause. These are felt to be more a
|
|
result of the emotional stress associated with this difficult
|
|
stage of life than of hormonal changes per se. Some women report
|
|
feeling better emotionally on estrogen therapy, but this may be a
|
|
placebo effect. No specific psychiatric problems have been found
|
|
to be linked specifically to the menopause.
|
|
|
|
|
|
Page 2
|
|
|
|
|
|
|
|
|
|
|
|
Cosmetic Changes
|
|
|
|
While breast atrophy, loss of skin tone, and redistribution
|
|
of body fat to the abdomen and thighs have been attributed by
|
|
some to the menopausal decrease in estrogen, clinical evidence
|
|
does not support this. These changes are most likely part of the
|
|
more general process of aging.
|
|
|
|
MEDICAL MANAGEMENT OF MENOPAUSE
|
|
|
|
The objective of medical practioners in treating the
|
|
menopausal women is to alleviate any disabling symptoms resulting
|
|
from estrogen deficiency and to provide support for the host of
|
|
emotional and functional problems that are often associated with
|
|
this phase of life.
|
|
|
|
Estrogen Replacement Therapy
|
|
|
|
Estrogen deficiency does cause serious medical problems, for
|
|
example osteoporosis, and estrogen replacement can be of great
|
|
value in avoiding these conditions. However, there are risks to
|
|
taking estrogens, and the decision to administer them is not a
|
|
simple one and requires a "cost-benefit" analysis. There is no
|
|
one right answer; each woman, in consultation with her physician,
|
|
must make the decision.
|
|
|
|
First we will consider the risks of estrogen replacement
|
|
therapy, then the benefits that can be expected from such
|
|
treatment.
|
|
|
|
Risks of Estrogen Replacement Therapy
|
|
|
|
-- Endometrial Cancer
|
|
|
|
The major risk associated with this treatment is cancer.
|
|
There is an increased incidence of endometrial carcinoma (cancer
|
|
of the lining of the uterus) in menopausal women taking estrogen
|
|
regularly.
|
|
|
|
This risk correlates with the dose and duration of treatment
|
|
and declines with cessation of treatment. The risk is apparently
|
|
not related to the type of estrogen administered. What is the
|
|
magnitude of the risk? Case-controlled studies reveal an
|
|
incidence of endometrial cancer of 4.5 to 13.9 times higher for
|
|
estrogen users compared to non-users. Other studies have shown
|
|
that at dosages of 0.625 to 1.25 mg of conjugated estrogens cause
|
|
a seven-fold rise in the incidence of endometrial cancer when
|
|
taken daily for 2 to 4 years.
|
|
|
|
The mechanism of the malignancies caused by estrogen
|
|
medication is related to the effect that estrogen has on the
|
|
lining of the uterus. Estrogen stimulates the growth and
|
|
differentiation of the uterine lining such that if pregnancy were
|
|
to occur it would be supported. Prolonged, continuous use makes
|
|
for excessive stimulation inducing a state called "cystic
|
|
hyperplasia of the endometrium" which is a pre-malignant
|
|
condition.
|
|
|
|
The addition of another hormone, progestegin, to the estrogen
|
|
program does help reduce the risk of endometrial cancer.
|
|
|
|
Page 3
|
|
|
|
|
|
|
|
|
|
However, it also causes the return of light to moderate menstrual
|
|
periods and causes an unfavorable change in serum lipoproteins
|
|
which might lead to an increased risk of cardiovascular disease.
|
|
Large, controlled, long term, prospective studies are not yet
|
|
available; such studies are needed to better determine safety and
|
|
effectiveness.
|
|
|
|
-- Breast Cancer
|
|
|
|
This remains an area of controversy. Some studies suggest an
|
|
increased risk of breast cancer with the use of long term
|
|
estrogen replacement therapy, other studies show no such effect.
|
|
What is know is that women with the type of breast cancer that
|
|
has "estrogen receptors" experience stimulated cancer growth with
|
|
estrogen exposure, while those with the type of breast cancer
|
|
without these receptors improve with estrogen administration.
|
|
|
|
-- Cardiovascular Morbidity and Mortality
|
|
|
|
We covered the high points of this risk earlier.
|
|
|
|
-- Other Adverse Effects
|
|
|
|
Administered estrogens can also cause fluid retention,
|
|
elevated blood pressure, gallstones, glucose intolerance, and
|
|
headaches. Recurrent uterine bleeding (which can make the
|
|
diagnosis of uterine cancer tricky) is also common.
|
|
|
|
Benefits of Estrogen Replacement Therapy
|
|
|
|
-- Disabling Hot Flashes
|
|
|
|
As mentioned above, usually this problem is self-limited.
|
|
Symptoms severe enough to be disabling are an indication for
|
|
replacement therapy, and relief during the one or two year period
|
|
in which the symptoms are usually severe can be a blessing. A
|
|
program of estrogens in the dose range of 0.3-1.25 mg taken daily
|
|
for three weeks with one week off will prevent hot flashes. The
|
|
lower dose is usually adequate. Addition of a progestin is not
|
|
necessary if therapy is planned to be of one year or less
|
|
duration. Attempts to taper off the estrogens can be attempted
|
|
every 3-6 months.
|
|
|
|
-- Postmenopausal Osteoporosis
|
|
|
|
This condition can be prevented by long-term prophylactic
|
|
estrogen therapy. Controlled studies clearly demonstrate
|
|
decreased rates of vertebral, wrist, and hip fractures.
|
|
Exercise, and good nutrition including enough calcium and vitamin
|
|
D also slow the bone wasting, but are not as effective as
|
|
estrogen. Risk factors besides estrogen deficiency for
|
|
osteoporosis include: tobacco, heavy alcohol use, thin body
|
|
build, and prolonged bed rest.
|
|
|
|
The decision to use estrogens to prevent bone loss is a
|
|
difficult one. The condition is largely irreversible and resumes
|
|
once the therapy is discontinued; therefore treatment must be
|
|
begun when the menopause first manifests, and must be continued
|
|
indefinitely. Courses of treatment of 10-15 years are not
|
|
uncommon.
|
|
|
|
Page 5
|
|
|
|
|
|
|
|
|
|
If a woman is willing to accept the increased risk of
|
|
endometrial cancer, the uncertain cardiovascular risk, and the
|
|
regular gynecological follow needed to screen for endometrial
|
|
cancer in return for the best possible means of preventing
|
|
osteoporosis, then a program of estrogen, progestin, exercise,
|
|
and nutritional support is the best option. It should be
|
|
stressed that a program of exercise and nutritional therapy
|
|
without estrogen *will* retard the rate of bone loss and is an
|
|
option for those unwilling to take estrogens.
|
|
|
|
-- Atrophic Vaginitis
|
|
|
|
The dryness, discomfort, and difficulty of sexual relations
|
|
caused by diminishing estrogen levels in the menopause can be a
|
|
serious quality of life problem for many women. As stated above,
|
|
sexually active women seem to have less trouble with this than
|
|
celibate women. The atrophy of the vagina and vulva responds
|
|
well to estrogen-containing creams as well as to estrogen pills,
|
|
and though absorption into the blood stream does occur with
|
|
topical application, certainly the risks are much reduced
|
|
compared to long term oral replacement therapy. Use of the
|
|
estrogen creams, directly applied to the vaginal and vulvar
|
|
mucosa (lining), restores turgor and reverses the menopausal
|
|
changes outlined above.
|
|
|
|
However, because the risk of topical estrogens is not
|
|
completely known, prudence requires the use of estrogen creams
|
|
for short periods in response to severe symptoms. Milder
|
|
symptoms, such as mild dryness with intercourse, often respond
|
|
well to common water-soluble vaginal lubricants.
|
|
|
|
|
|
SO WHAT'S A WOMEN TO DO?
|
|
|
|
Given the list of potentially serious adverse effects of
|
|
estrogen replacement therapy, extreme care must be exercised in
|
|
deciding to embark on a course of long term treatment.
|
|
|
|
Certainly, disabling symptoms should be treated. Certainly
|
|
the dose should be as low as possible, and the duration of
|
|
treatment as brief as possible. For those who elect long term
|
|
treatment for prevention of osteoporosis, a progestin drug should
|
|
also be part of the regimen.
|
|
|
|
Patients must clearly understand the relative risks and
|
|
benefits and make their own decisions.
|
|
|
|
Patients who undergo estrogen therapy require careful
|
|
monitoring. Because endometrial cancer is usually asymptomatic
|
|
in the early stages, and because postmenopausal uterine bleeding
|
|
is both a clue that uterine cancer may be present, and because a
|
|
common side-effect of estrogen therapy is bleeding, for all these
|
|
reasons women who take estrogens postmenopausally often require
|
|
repeated uterine scrapings (D+C, Dilation and Curettage) both to
|
|
monitor for the development of endometrial cancer and to rule it
|
|
out when symptoms of bleeding occur. Indeed, a risk of estrogen
|
|
replacement therapy is the potential increase in frequency of
|
|
endometrial biopsy and D+C procedures. Women unwilling to follow
|
|
what is often a rigorous follow-up regimen are not good
|
|
candidates for chronic estrogen replacement therapy.
|
|
|
|
Page 6
|
|
|
|
|
|
|
|
|
|
-----------------------------------------------------------------
|
|
|
|
OK, that's it for now. I think we've covered the basics. Of
|
|
course I'd be more than happy to answer any further questions as
|
|
best I can. ...alex....
|
|
|
|
-----------------------------------------------------------------
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
FINIS
|
|
Page 7
|
|
|
|
|