Menopause
Highlights
Menopause
Menopause is a natural process that occurs as a woman’s ovaries stop producing eggs, and production of the hormones estrogen and progesterone declines. (Menopause can also occur if a woman’s ovaries are surgically removed.) Menopause usually happens gradually between the ages of 45 - 55. During this transition time, called “perimenopause,” menstrual periods become more irregular and begin to taper off. When menstrual periods have completely stopped for 12 months, a woman is considered to have reached menopause. On average, women reach menopause around the age of 51, but menopause can occur at younger or older ages.
Perimenopausal Symptoms
During perimenopause, women may have various symptoms. Symptoms vary among women, and may range from mild to severe. Some women have no symptoms.
Hot flashes, an intense sudden build-up of body heat, are the most common symptom. Other symptoms can include heart pounding, mood changes, vaginal dryness, sleep disturbances, and thinning hair. These symptoms are caused by changes in estrogen and progesterone levels. After most women pass through menopause, many symptoms eventually subside and disappear.
Treatment
Menopause is a natural condition. It is not a disease that needs medical treatment. However, some women seek treatment for the relief of perimenopausal symptoms -- especially hot flashes. Hormone replacement therapy (HRT) is the most effective drug treatment for hot flashes, but long-term use (more than 5 - 7 years) can increase the risks of heart disease, stroke, blood clots in the lungs, breast cancer, ovarian cancer, and endometrial cancer. Therefore, doctors recommend that women who use HRT should take the lowest possible dose for the shortest possible time.
Other prescription drugs, such as antidepressants, are also sometimes used to manage hot flashes and mood changes. Although some women try herbal remedies for symptom management, little scientific evidence supports their effectiveness.
Menopause and Heart Health
When a woman reaches menopause, her risk for heart disease increases. It is important for postmenopausal women to follow preventive lifestyle modifications (healthy diet, exercise, not smoking) to ensure heart health.
Introduction
The ovaries have 200,000 - 400,000 follicles, tiny sacks that contain the materials needed to produce mature eggs, or ova. The ovaries produce two major female hormones: estrogen and progesterone.
Estrogen. Estrogens have an effect on about 300 different tissues throughout a woman's body:
- They are essential for the reproductive process and the development of the female organs.
- Estrogens determine the characteristic female distribution of body fat on the hips and thighs, which develops during adolescence.
- They also are involved in tissues in the central nervous system (including the brain), the bones, the liver, and the urinary tract.
Estrogen has different forms:
- The most potent form is estradiol.
- The other important, but less powerful, estrogens are estrone and estriol.
Most of the estrogens in the body are produced by the ovaries, but they can also be formed by other tissues, such as body fat, skin, and muscle.
Progesterone. Progesterone, the other major female hormone, is necessary for thickening and preparing the uterine lining for the fertilized egg.
As a woman ages, her supply of eggs declines. Menopause occurs naturally after a woman's ovaries fail to function and menstruation ends completely. (Menopause may also be induced if the ovaries are surgically removed.)
Perimenopause. Menopause does not occur suddenly. A period called perimenopause usually begins a few years before the last menstrual cycle. There are two stages in the transition:
- Early Stage. Perimenopause can begin in some women in their 30s, but most often it starts in women ages 40 - 44. It is marked by changes in menstrual flow and in the length of the cycle. There may be sudden surges in estrogen.
- Late Stage. The late stages of perimenopause usually occur when a woman is in her late 40s or early 50s. In the late stages of the menopausal transition, women begin missing the periods until they finally stop. About 6 months before menopause estrogen levels drop significantly. The fall in estrogen triggers the typical symptoms of vaginal dryness and hot flashes (which can last from half a year to more than 5 years after onset of menopause).
Menopause. Menopause is considered to have occurred when a woman has gone a full 12 months without a period. At the point at which menopause occurs, the following hormonal changes occur:
- Ovarian secretion of estrogen and progesterone ends.
- Once the ovaries have stopped producing estrogens, however, they still continue to produce small amounts of the male hormone testosterone, which can be converted to estrogen (estradiol) in body fat.
- In addition, the adrenal gland continues to produce androstenedione (a male hormone), which is converted to estrone and estradiol in the body fat.
Click the icon to see an image of the adrenal glands.
- The total estrogen produced after menopause, however, is far less than that produced during a woman's reproductive years.
The average age that women reach menopause is 51 years although it can occur as early as age 40 to as late as the early 60s. Women now have a life expectancy of more than 80 years. Currently, women can expect to live some 30 or 40 years of their life in the postmenopausal state.
Menopause is not a disease. However, many conditions are associated with estrogen depletion, including heart disease, osteoporosis, and other complications. Fortunately, effective treatments are available for these conditions.
In a number of studies, most women have reported menopause as a positive experience and have welcomed it with relief and as a sign of a new stage in life.
Symptoms
The most prominent symptoms of the transition to menopause include:
- Hot flashes and night sweats. Women often feel hot flashes as an intense build-up in body heat, followed by sweating and chills. Some women report accompanying anxiety as the sensation builds. In most cases, hot flashes last for 3 - 5 years, although they may linger in some women for years after menopause. Women who have surgical removal of both ovaries, and who do not receive hormone replacement therapy, may have more severe hot flashes than women who enter menopause naturally.
- Heart pounding or racing can occur, with or without hot flashes.
- Difficulty sleeping. Insomnia is common during perimenopause. It may be caused by the hot flashes, or it may be an independent symptom of hormonal changes.
- Mood changes. Mood changes are most likely to be a combination of sleeplessness, hormonal swings, and psychological factors as a woman undergoes this intense passage in her life. Once a woman has reached a menopausal state, however, depression is no more common than before, and women with a history of premenstrual depression often have significant mood improvement.
- Sexuality. Sexual responsiveness tends to decline in most women after menopause, although other aspects of sexual function, including interest, frequency, and vaginal dryness vary. It is useful to remember that most symptoms of menopause eventually go away.
- Forgetfulness. This appears to be one of the few symptoms that are common across most cultural and ethnic groups.
- Urine leakage.
- Vaginal dryness.
- Joint stiffness.
Women from different ethnic and or cultural groups report different menopausal symptoms. For example, in one study hot flashes occurred in about 30% of Caucasians and 45% of African-Americans. Hispanic women tended to complain of urine leakage, vaginal dryness, and heart pounding. Japanese and Chinese women had far fewer menopausal symptoms, except for forgetfulness. All groups complained about this symptom.
Complications
The decline in estrogen after menopause can increase the risk for a number of health problems for women.
Heart disease is the number one killer of women. Although young women have a much lower risk for cardiovascular disease than young men, after menopause women catch up. After age 60, women’s risk of dying from heart disease is very close to that of men. Estrogen loss is believed to play a major role in this increased risk. Woman who reach menopause before the age of 35 have a significant increase in risk for heart disease as they age. This increase is primarily due to a rise in levels of LDL (“bad” cholesterol) and triglycerides, and a decrease in levels of HDL (“good”)cholesterol). [For more information, see In-Depth Report #3: Coronary artery disease.]
Click the icon to see an image of thromboembolism.
Osteoporosis is a disease of the skeleton in which bones become "thin" and prone to fracture. In other words, the bone loses calcium and density. At age 65, about 30% of women have osteoporosis, and nearly all of them are unaware of their condition. After age 80, up to 70% of women develop osteoporosis. Osteoporosis is a major risk factor for fracture in the spine and hip. The decrease in bone density can also lead to bone loss in the jaw and subsequent tooth decay. [For more information, see In-Depth Report #18: Osteoporosis.]
Click the icon to see an image of osteoporosis.
The hormonal changes associated with perimenopause may trigger depression, irritability, and anxiety in some women. Some of these mood changes may be related to sleep problems associated with the menopausal transition, such as inability to fall asleep and nighttime wakefulness. For many women, depression and other mood problems ease once they reach menopause. [For more information, see In-Depth Report #8: Depression.]
Estrogen, the primary female hormone, appears to have properties that protect against the memory loss associated with normal aging. Many women who are either perimenopausal or menopausal complain of mild forgetfulness, but estrogen replacement therapy does not preserve mental function.
The drop in body estrogen levels brought on by menopause may contribute to both urinary stress and urge incontinence.
Women are at increased risk for recurrent urinary tract infections after menopause.
Estrogen loss can contribute to slackness and dryness in the skin and wrinkles.
Lifestyle Changes
Simple changes in lifestyle and diet can help control menopausal symptoms such as hot flashes. Avoid hot flash triggers like spicy foods, hot beverages, caffeine, and alcohol. Dress in layers so that clothes can be removed when a hot flash occurs. For vaginal dryness, moisturizers, and non-estrogen lubricants, such as KY Jelly, Replens, and Astroglide are available.
When women reach menopause, they are at increased risk for heart disease. A heart-healthy diet and other lifestyle changes are important ways to control cholesterol and blood pressure levels. [For more information, see In-Depth Reports #42: Heart-healthy diet and #03: Coronary artery disease.]
Heart-health recommendations include:
- Quit smoking. If a woman smokes, she should quit. Smoking is linked to a decline in estrogen levels. Women who smoke reach menopause about 2 years earlier than nonsmokers. Smoking doubles a woman's odds of developing heart disease and is a major risk factor for osteoporosis.
- Balance calorie intake and physical activity to achieve or maintain a healthy body weight. (Controlling weight, quitting smoking, and exercising regularly are essential companions of any diet program. Try to get at least 30 minutes, and preferably 60 - 90 minutes, of daily exercise.)
- Consume a diet rich in a variety of vegetables and fruits. Vegetables and fruits that are deeply colored (spinach, carrots, peaches, berries) are especially recommended as they have the highest micronutrient content.
- Choose whole-grain, high-fiber foods. These include fruits, vegetables, and legumes (beans). Good whole grain choices include whole wheat, oats/oatmeal, rye, barley, brown rice, buckwheat, bulgur, millet, and quinoa.
- Eat fish, especially oily fish, at least twice a week (about 8 ounces/week). Oily fish such as salmon, mackerel, and sardines are rich in the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Consumption of these fatty acids is linked to a reduced risk of sudden death and death from coronary artery disease. Women with heart disease may also consider taking a daily dietary supplement of 850 - 1,000 mg of EPA and DHA.
- Limit daily intake of saturated fat (found mostly in animal products) to less than 7% of total calories, trans fat (found in hydrogenated fats, commercially baked products, and many fast foods) to less than 1% of total calories, and cholesterol (found in eggs, dairy products, meat, poultry, fish, shellfish) to less than 300 mg per day. Choose lean meats and vegetable alternatives (such as soy). Select fat-free and low-fat dairy products. Grill, bake, or broil fish, meat, and skinless poultry.
- Use little or no salt in your foods. Reducing salt can lower blood pressure and decrease the risk of heart disease and heart failure.
- Cut down on beverages and foods that contain added sugars (corn syrups, sucrose, glucose, fructose, maltrose, dextrose, concentrated fruit juice, honey).
- If you consume alcohol, do so in moderation. The American Heart Association (AHA) recommends limiting alcohol to no more than 1 drink per day for women.
- The AHA does not recommend antioxidant supplements (such as vitamin E, C, or beta carotene) or folic acid supplements for prevention of heart disease.
- For women ages 55 to 79 years who have never had a heart attack or stroke, but are at risk of heart disease, a daily low dose (75 - 81 mg) of aspirin may be helpful for primary prevention.
A combination of calcium and vitamin D is important for helping to prevent the bone loss associated with menopause. [For more information, see In-Depth Report #18: Osteoporosis.]
Calcium. Women should consume low-fat dairy products or calcium-enriched orange juice to get enough calcium and vitamin D in their diet. Calcium supplements may be another option for some women. For calcium supplements, calcium citrate (Citracal) is better absorbed than calcium carbonate (Tums, Os-Cal) and other types of calcium compounds.
Click the icon to see an image of the benefits of calcium.
The standard recommended calcium dose for adults age 50 years and older is at least 1,200 mg per day, depending on risk factors. High doses (over 2,500 mg per day) of calcium supplements may increase the risk for kidney stones. (Because many commercial foods are now fortified with calcium, this upper limit may be easier to reach than people think.)
Click the icon to see an image of calcium sources.
There are differing views on the use of calcium and vitamin D. Some doctors recommend that women over age 60 should take calcium and vitamin D for bone health. Other doctors feel that due to the risks of kidney stones, supplements are beneficial only for women (especially those over age 70) who do not get enough calcium in their diets. Ask your doctor whether you should take calcium supplements.
Vitamin D. Vitamin D is necessary for the absorption of calcium in the stomach and gastrointestinal tract and is the essential companion to calcium in maintaining strong bones.
Vitamin D is manufactured in the skin using energy from the ultraviolet rays in sunlight. It can also be obtained from dietary supplements. As a person ages, vitamin D levels decline. Levels also fall during winter months and when people have inadequate sunlight.
Click the icon to see an image of vitamin D sources.
The recommended daily intake of vitamin D is 600 IU a day after age 50. Drinking milk fortified with vitamin D and sunlight exposure supply most people's need for vitamin D. (One cup of whole milk provides about 100 IU of vitamin D.) Oily fish (sardines especially, as well as salmon, fresh tuna, and mackerel) are also important dietary sources of vitamin D. Wild salmon has a much higher vitamin D content than farmed salmon.
Effect on the Heart. One drink a day in women who are not at risk for alcohol abuse may be beneficial for the heart. Red wine in particular contains a substance called resveratrol, which is classified as a phytoestrogen and has estrogen-like effects.
Effect on Bones. Alcohol has different effects on bones, depending on how much is consumed. Three or more drinks per day are considered a risk factor for brittle bones and osteoporosis.
Effect on Breast Cancer. Women who drink have an increased risk for breast cancer, but the risk associated with mild-to-moderate drinking is small.
Many women need to increase physical activity and reduce caloric intake before and after menopause. Weight gain is common during these years, and it can be sudden and distressing, particularly when habitual exercise and eating patterns are no longer effective in controlling weight. Gaining weight around the abdomen (the so-called apple shape) is a specific risk factor for heart disease, diabetes, and many other health problems.
Click the icon to see an image of different types of weight gain.
For protection against all aging diseases, women should pursue a lifestyle that includes a balanced aerobic and weight resistance exercise program appropriate to their age and medical conditions. Brisk walking, stair climbing, hiking, dancing, and tai chi are all helpful. Several studies report that exercise can help control hot flashes. A healthy diet plus regular, consistent exercise can also help ward off the weight gain associated with menopause. Weight-bearing exercises are specifically helpful for protecting against bone loss.
Women should get at least 30 minutes of exercise each day (for weight loss, 60 - 90 minutes is preferred). While more exercise is better, any amount of exercise is helpful.
There are many unproven methods for relieving menopausal symptoms, some more effective than others. Acupuncture, meditation, and relaxation techniques are all harmless ways to reduce the stress of menopause. Some women report great benefit from these practices, but there is no scientific proof of effectiveness.
Women often try herbal or so-called natural remedies to treat menopausal symptoms. There have been numerous studies conducted on various herbal products and other complementary and alternative therapies. These studies have not found that these approaches have any benefit. Some herbs and supplements can have adverse side effects.
Phytoestrogens and Isoflavones. Many studies have researched plant estrogens (phytoestrogens), which are generally categorized as isoflavones (found in soy and red clover) and lignans (found in whole wheat and flaxseed). No evidence to date indicates that phytoestrogen foods or supplements provide any benefit for hot flashes, night sweats, or other menopausal symptoms. They also do not appear to help lower cholesterol or prevent heart disease.
Nevertheless, soy is a healthy food choice. Soy is rich in both soluble and insoluble fiber, omega-3 fatty acids, and provides essential protein. Soy proteins have more vitamins and minerals than meat or dairy proteins. They also contain polyunsaturated fats, which are healthier than the saturated fat found in meat. The best sources of soy protein are soy food products (tofu, soy milk, soybeans), not supplements.
Soy isoflavones contain genistein and daidzein, which are estrogen-like compounds. Some studies have suggested that high intakes of soy may increase the risk of estrogen-responsive cancers such as breast cancer. The American Cancer Society recommends that women with breast cancer eat only moderate amounts of soy food and avoid taking dietary supplements that contain high amounts of isoflavones.
Other Herbs and Supplements. The following herbs and dietary supplements are sometimes used for menopausal symptoms and have certain risks:
- Black cohosh (Cimicifuga racemosa), also known as squaw root, is the herbal remedy most studied for menopausal symptoms. Although it contains a plant estrogen, this substance does not act like an estrogen in the human body. Studies have shown mixed results in preventing hot flashes. High-quality studies have found that black cohosh works no better than placebo for treating hot flashes and night sweats. Headaches and gastrointestinal problems are common side effects. This herb has been associated with liver toxicity.
- Dong quai (Angelica sinensis) does not appear helpful for hot flashes or other menopausal symptoms. Do not use dong quai with blood-thinning drugs, such as warfarin, because it may cause bleeding complications.
- Ginseng (Panax ginseng) may help menopausal symptoms of depression and sleep problems, but it has no effect on hot flashes.
- Kava (Piper methysticum) may relieve anxiety but it does not help hot flashes. This herb is considered unsafe, due to several reports of liver failure and death, especially in people with liver disease.
- Wild yam (Dioscorea villosa) is an herb sometimes used for menstrual problems as well as menopausal symptoms. It contains a plant progesterone. However, like black cohosh, there is no evidence that the human body can convert this substance into a hormone. Patients should be aware that some commercial herbal wild yam products contain prescription progesterones. (For more information on progesterones, see Hormone Replacement Therapy in Medications section.)
- Evening primrose oil has not been shown to be superior to placebo. It may increase the risk for seizures when taken with certain types of drugs associated with seizures.
- Dehydroepiandrosterone (DHEA) is a weak male hormone secreted by the adrenal gland. It is available as a dietary supplement. DHEA has no benefit for hot flashes and may increase the risk of breast cancer.
Generally, manufacturers of herbal remedies and dietary supplements do not need approval from the Food and Drug Administration to sell their products. Just like with drugs, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Patients should check with their doctors before using any herbal remedies or dietary supplements.
Medications
Doctors used to believe that HRT could help reduce the risk of heart disease and other health risks in addition to treating menopausal symptoms. The results of an important study, called the Women's Health Initiative (WHI), led doctors to revise their recommendations regarding HRT.
The WHI, started in 1991, enrolled 161,809 women ages 50 - 79 in 40 different medical centers. Part of the study was intended to examine the health benefits and risks of hormone replacement therapy, including the risks of breast cancer, heart attacks, strokes, and blood clots. Analysis of the data from this ongoing study and other studies have raised concerns about an increased risk of developing breast cancer, heart attacks, strokes, and blood clots.
As a result, there have been a number of changes in the way hormone therapy is prescribed. Current guidelines support the use of HRT for the treatment of hot flashes. Specific recommendations:
- HRT may be started in women who have recently entered menopause.
- HRT should not be used in women who have started menopause many years ago.
- HRT should not be used for longer than 5 to 7 years.
- Women who take HRT should have a low risk for stroke, heart disease, blood clots, or breast cancer.
To reduce the risks of estrogen replacement therapy and still gain the benefits of the treatment, your doctor may recommend:
- Using a lower dose of estrogen or a different estrogen preparation (for instance, a vaginal cream rather than a pill)
- Frequent and regular pelvic exams and Pap smears to detect problems as early as possible
- Frequent and regular physical exams, including breast exams and mammograms
Beginning estrogen replacement therapy years after menopause has occurred is generally not recommended.
In general, doctors recommend that patients who choose HRT take the lowest possible dose for relief of symptoms for the shortest amount of time.
When a woman stops taking HRT, perimenopausal symptoms may recur. There is some debate about whether it is better to abruptly stop the medication or to taper it off gradually. Gradual discontinuation of HRT may delay -- but not prevent -- the reappearance of symptoms. However, when a woman reaches full menopause, symptoms will eventually go away.
Hormones Used in HRT. Hormone replacement therapy uses either estrogen alone (known as ET or unopposed estrogen) or in combination with forms of progesterone (known as combined hormone therapy or EPT). Women who have a uterus (have not had a hysterectomy) receive estrogen plus progesterone or a progestin. Women who do not have a uterus (have had a hysterectomy) receive estrogen alone.
For women who have a uterus, progesterone or a progestin is added to estrogen to protect the uterine lining (endometrium) and reduce the risk of endometrial cancer. (Progesterone is the name for the natural hormone that the body produces. Progestin, also called progestogen, refers to a synthetic hormone that has progesterone effects.)
The primary reason for using HRT is the relief of hot flashes, night sweats, and vaginal dryness. HRT comes in several forms:
- Oral tablets or pills
- Skin patches
- Vaginal cream or tablet
- Vaginal ring
- Nasal spray
- Topical gel
When estrogen and progesterone are prescribed together, recommended schedules include:
- Cyclic hormone therapy is often recommended when a woman is starting menopause. With this therapy, estrogen is taken in pill or patch form for 25 days, with progestin added somewhere between days 10 - 14. The estrogen and progestin are used together for the remainder of the 25 days. Then, no hormones are taken for 3 - 5 days. There may be monthly bleeding with cyclic therapy.
- Continuous, combined therapy involves taking estrogen and progestin together every day. Irregular bleeding may occur when starting or switching to this therapy. Most women stop bleeding within 1 year.
Woman who should not take hormone replacement therapy include those with the following conditions:
- Current, past, or suspected breast cancer
- Vaginal bleeding of unknown cause
- Current or past history of blood clots
- High blood pressure that is untreated or poorly managed
- Angina that is currently symptomatic or heart attack that occurred recently
- Active liver problems
"Biodentical" Hormones. Bioidentical” hormone replacement therapy is promoted as a supposedly natural and safer alternative to commercial prescription hormones. Bioidentical hormones are typically compounded in a pharmacy. Some compounding pharmacies claim that they can customize these formulations based on saliva tests that show a woman’s individual hormone levels.
The FDA, and many professional medical associations, warn patients that “bioidentical” is a marketing term that has no scientific validity. Formulations sold in these pharmacies have not undergone FDA regulatory scrutiny. Some of these compounds contain estriol, a weak form of estrogen, which has not been approved by the FDA for use in any drug. In addition, saliva tests do not give accurate or realistic results, as a woman’s hormone levels fluctuate throughout the day.
FDA-approved hormones available by prescription come from different synthetic and natural sources, including plant-based. (For example, Prometrium is a progesterone derived from yam plants.)
Periomenopausal and Menopausal Symptoms. HRT is mainly recommended for relieving menopausal symptoms, including hot flashes, night sweats, vaginal dryness, sleep problems, and mild depression. HRT does not prevent certain other problems associated with menopausal changes, such as thinning hair.
Osteoporosis. Estrogen increases and helps maintain bone density. HRT may be useful for some women at high risk for osteoporosis, but for most women the risks do not outweigh the benefits. Other drugs, such as bisphosphonates, should be considered first-line treatment for osteoporosis. HRT increases and helps maintain bone density.. Estrogen must be taken for life for maximum protection against osteoporosis, therefore increasing the risk of side effects. [For more information, see In-Depth Report #18: Osteoporosis.]
Colorectal Cancer. Estrogen plus progestin HRT may reduce the risk of colorectal cancer. Again, for most women the risks of longterm HRT do not outweigh the benefits.
Heart Disease. Younger women with a natural or surgically induced menopause are at increased risk for heart disease and may benefit from estrogen replacement therapy. This recommendation does not apply to older women.
Heart Disease. HRT does not prevent heart disease except in women with premature menopause and may increase the risk for heart disease and heart attack, especially in older women. Results from the Women’s Health Initiative study found that women who began HRT within 10 years of menopause had less risk of heart disease than women who begin HRT later on. This suggests that HRT may be safest for women younger than age 60, and should be avoided by women older than age 60. Any woman who is considering HRT should be sure to have her blood pressure and cholesterol levels evaluated. Estrogen can increase the risk for heart attack in women who have advanced heart disease.
Stroke. HRT may increase the risk of stroke, regardless of years since menopause. It is certainly no longer recommended as a strategy to prevent stroke. In addition, HRT appears to worsen the outlook for women who are at increased risk for stroke and women who have had a stroke.
Mental Decline. Reviews of the Women’s Health Initiative Memory Study, as well as other more recent studies, have found that combined HRT does not reduce the risk of cognitive impairment, and may actually increase the risk of cognitive decline.
Thromboembolism. HRT is associated with a higher risk for thromboembolism, in which blood clots form in deep veins. This places women at risk for pulmonary embolism, in which the blood clot travels to the lungs.
Click the icon to see an image of a pulmonary embolism.
Breast Cancer. Many studies have reported a higher risk for breast cancer in postmenopausal women who take combination estrogen-progesterone hormone replacement therapy. According to the most recent studies, long-term use (5 years or more) of combination HRT increases the risk of developing and dying from breast cancer. This risk decreases within 5 years of stopping combination HRT.
Estrogen-only HRT does not significantly increase the risk of developing breast cancer if it is used for less than 10 years. If used for more than 10 years, it may increase the risk of breast (and ovarian) cancers, especially for women already at higher risk for breast cancer.
HRT increases breast cancer density, making mammograms more difficult to read. This can cause cancer to be diagnosed at a later stage. Women who take HRT should be aware of the need for regular mammogram screenings.
The North American Menopause Society recommends that women who are at risk for breast cancer avoid hormone therapy and try other options to manage menopausal symptoms. Recent studies have noted that breast cancer rates have fallen as HRT use has declined.
Endometrial (Uterine) Cancers. Estrogen overstimulates the tissue lining the uterus (the endometrium) and causes uncontrolled cell growth, a condition known as hyperplasia, which is a strong risk factor for cancer. Taking estrogen-only replacement therapy (ERT) increases the risk of endometrial cancer at least five-fold. Adding progesterone or a progestin to estrogen helps to reduce this risk. Women who take ERT should anticipate uterine bleeding, especially if they are obese, and may need endometrial biopsies and other gynecologic tests.
Ovarian Cancer. Long-term use (more than 5 - 10 years) of HRT may increase the risk of developing and dying from ovarian cancer. The risk appears to be particularly significant for women who take estrogen-only HRT . The risk is less clear for combination HRT.
Despite its risks, hormone replacement therapy appears to be the best treatment for hot flashes. There are many nonhormonal treatments for hot flashes and other menopausal symptoms.
Antidepressants. The antidepressants known as selective serotonin-reuptake inhibitors (SSRIs) are sometimes used for managing mood changes and hot flashes. They include fluoxetine (Prozac), sertraline (Zoloft), venlafaxine (Effexor), desvenlafaxine (Pristiq), and paroxetine (Paxil,). However, these drugs can cause side effects, such as sexual problems.
Gabapentin. Several small studies suggest that gabapentin (Neurontin), a drug used for seizures and nerve pain, may relieve hot flashes. Gabapentin may cause drowsiness, dizziness, fatigue, and swelling of the hands and feet.
Clonidine. Clonidine (Catapres) is a drug used to treat high blood pressure. Studies show it may help manage hot flashes. Side effects include dizziness, drowsiness, dry mouth, and constipation
Testosterone. Some doctors prescribe combinations of estrogen and small amounts of the male hormone testosterone to improve sexual function and increase bone density. Side effects of testosterone include increased body hair, acne, fluid retention, anxiety, and depression. Testosterone also adversely affects cholesterol and lipid levels, and combined estrogen and testosterone may increase the risk of breast cancer. It is unclear whether testosterone is safe or effective for treatment of menopausal symptoms.
Resources
- www.menopause.org -- North American Menopause Society
- www.acog.org -- American College of Obstetricians and Gynecologists
- www.nia.nih.gov -- National Institute on Aging
- www.nih.gov/PHTindex.htm -- National Institutes of Health -- Menopausal Hormone Therapy Information
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Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
