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Menopause - hormone replacement therapy

Manywomen,althoughnotall,experienceuncomfortablesymptomsduringandaftermenopause,
includinghotflushes,nightsweatsandvaginaldryness.Thesesymptoms,andtheassociated
physicalchanges,canbemanagedinvariouswaysincludingeducationandlifestylechangeslike
dietandexercise.
Hormonetherapy(HT)isalsoavailableifrequired.WhileHTreducestheriskofsomedebilitating
diseases,italsoincreasestheriskofothers.
Menopauseoccurswhenawomanstopsovulating,theovariesnolongerproduceoestrogen(oneof
thefemalesexhormones)andhermonthlyperiod(menstruation)ceases.Itisanaturaleventthat
markstheendofthereproductiveyears,justasthefirstmenstrualperiodduringpubertymarked
thestart.
Menopause symptoms can be reduced by HT
Thefollowingmenopause-relatedsymptomsmaybereducedbyHT:
Hotflushes
Nightsweats
Vaginaldryness
Thinningofvaginalwalls
Vaginalandbladderinfections
Mildurinaryincontinence
Insomnia
Cognitivechanges,suchasmemoryloss
Reducedsexdrive
Mooddisturbance
Abnormalsensations,suchaspricklingorcrawlingundertheskin
Palpitations
Hairlossorabnormalgrowth
Dryanditchingeyes
Toothloss
Gingivitis(gumproblems).
Side effects of HT
HTneedstobeindividuallytailored.Somewomenexperiencesideeffectsduringtheearlystages
oftreatment,whichmayinclude:
Breakthroughbleeding
Breasttenderness
Bloatingaroundonein10,000womenaged50experiencebloatingandthisincreases
withage
Bloodclotstheriskincreaseswithage.YoungerwomenonoralHTfaceaonein5,000to
onein10,000riskofbloodclots.Olderwomen,aged50to60years,faceaonein500to
onein1,000riskofbloodclotswhenonoralHT.
HT does not cause weight gain
Anincreaseinbodyfat,especiallyaroundtheabdomen,canoccurduringmenopausebecauseof
ourownhormonalchanges,althoughexactlywhythishappensisnotclear.Theage-related
decreaseinmuscletissueandtheslowingdownofthemetabolismcanalsocontributetoweight
gain.
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VariousstudiesprovethatweightgainisnotlinkedtoHT.Ifawomanispronetoweightgain
duringhermiddleyears,shewilldosoregardlessofwhetherornotsheusesHT.Somewomen
mayexperiencesymptomsatthestartoftreatment,includingbloatingandbreastfullness,which
maybemisinterpretedasweightgain.Thesesymptomsusuallydisappearoncethetherapydoses
aremodifiedtosuittheindividual.
Contraception is still needed
HTisnotaformofcontraception.Thetreatmentdoesnotcontainsufficienthormonestosuppress
ovulation,sopregnancyisstillpossibleinwomenwhoareovulatingoccasionallyinthe
perimenopause.Itisgenerallyadvisedthatmenopausalwomenshouldcontinuetouse
contraceptionuntiltheirnaturalperiodshaveceasedforatleastoneyear.
Long-term use of HT to prevent disease
HTreducestheriskofvariouschronicconditionsthatcanaffectpostmenopausalwoman,including:
Osteoporosisthinningofthebonestothepointwheretheybreakeasily.HTprevents
furtherboneloss,whichpreservesboneintegrityandreducestheriskoffractures,butis
notrecommendedasafirst-linetreatment.
Bowel cancertheriskofcolorectalcancersisslightlyreducedwithHT.
HT- related health risks
WhileHTreducestheriskofsomedebilitatingdiseases,italsoincreasestheriskofothers.These
smallrisksmustbebalancedagainstthebenefitsfortheindividual.Threeareasofconcernare:
Breast cancercurrentresearchsuggeststhatwomenover50yearsofage,whouse
oestrogenandprogestogenreplacementforlessthanfiveyears,havelittleornoincreased
riskofbreastcancer.WomenwhouseHTwithprogestogenformorethanfiveyears
appeartohaveaslightlyincreasedrisk.Womenonoestrogenaloneappeartohaveno
increasedriskupto15yearsofusage.Thereisnoevidencetosuggestthatawomanwith
afamilyhistoryofbreastcancerwillhaveanaddedincreasedriskofdevelopingthe
diseaseifsheusesHT.Theriskwithcombinedoestrogenandprogestogenisgreaterthan
withoestrogenaloneorwithnewerHTagents,includingTibolone,butresearchinthisarea
isongoing.
Cardiovascular diseasecurrentresearchsuggeststhatwomenover60haveasmall
increasedriskofdevelopingbothheartdiseaseandstrokesoncombinedoralHT.Although
thisriskissmall(7heartattacksand8strokesper10,000treatmentyearsthatis,1,000
womentreatedfor10years),itneedstobeconsideredwhenstartingHT,astherisk
occursearlyintreatmentandpersistswithtime.Oestrogenusedonitsownincreasesthe
riskofstroke(12per1,000womenperyear).WomenwhocommenceHTaroundthetime
ofmenopausemaynothavethesameincreasedriskaswomenaged60ormore.Therisk
withotherformsofhormonetherapysuchasTiboloneisunknown.Theresultsofongoing
researchareawaitedwithinterest.
Thrombosisthesearebloodclotsthatforminsideveins.SomewomenonHTaremore
likelytogetthrombosisthanwomenwhoarenotonHT.Thisriskseemstobehighestin
thefirstonetotwoyearsoftherapyandinwomenwhohaveahighriskofbloodclots
anyway.Thisespeciallyappliestowomenwhohaveageneticpredispositiontodeveloping
thrombosis.Moreresearchisneededtoclarifyifoestrogenappliedthroughtheskinas
patches,implantsorgelshasthesameeffect.Limitedresearchtodatewouldsuggestthe
increasedriskofclotsismainlyrelatedtooestrogenandprogestogenintabletform.
Endometrial cancerthisiscanceroftheliningoftheuterus.Long-termuse(for10
yearsormore)ofoestrogenaloneincreasestheriskofthiscancer,butthisriskis
neutralisedwiththeadditionofprogestogentothetreatment.
Long-term use is not recommended
Itiscurrentlybelievedthat,overall,therisksoflong-termHTuseoutweighthebenefits.HTshould
notberecommendedfordiseaseprevention.However,thejuryisstilloutontheuseofoestrogen
alone,otherHTpreparations(includingTibolone)andotherformsofHT(includingpatches).We
awaittheresultsoffurthertrialsbeforerecommendationsintheseareascanbemade.
However,inwomenwithlong-termseveresymptoms,HTmaybetheonlyeffectivetherapy.Seek
specialistadvicefromamenopauseclinicorspecialistphysician.Regularcheck-upsare
recommended.
HT and prior history of breast cancer

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Todate,thereisconflictingspecificevidencethatHTwillincreasetheriskofbreastcancer
recurringinawomanwithapriorhistoryofthedisease.However,oestrogenandprogestinsmay
stimulatesometypesofcellsinthebreastandincreasetheriskofbreastcancerinwomenwithout
ahistoryofbreastcancer.Itisadvisableforwomanwithapriorhistoryofbreastcancertoavoid
HT.
Phytoestrogens and prior history of breast cancer
Thereisnoevidencethatphytoestrogensincreasetheriskofbreastcancerrecurringbut,under
certaincircumstances,somebreastcellsmaybestimulated.Otherformsofmanagementfor
menopausalsymptomsmaybeadvised,suchasoestrogenvaginalcreamsorlowdosesof
antidepressants,whichmayreducehotflushes.TherearenewformsofHTsuchasTibolone,
whichappearstohavelesseffectonthebreastthatmayalsobeconsidered.Beadvisedbyyour
doctor.
Alternative therapies
Alternativetherapiesforthemanagementofmenopausalsymptomsremaincontroversial.Manyof
thesetherapieshavenotbeensubjectedtoclinicaltrials,sotheireffectivenessisbasedonthe
experiencesreportedbysomewomen.Todate,noalternativetherapyhasbeenclinicallyprovento
reduceamenopausalwomansriskofosteoporosis,andpreliminarystudieswouldsuggestthereis
nobenefitforthebones.Someofthemorepopularalternativetherapiesinclude:
Soyproducts
Phytoestrogens
Herbalmedicines.
Where to get help
Yourdoctor
TheJeanHailesFoundationTel.1800151441
AustralianMenopauseSocietyTel.(07)54562660
WomensHealthVictoriaTel.(03)96623755
Things to remember
Menopausalsymptomscanbemanagedwithsupport,education,lifestylechangesand
hormonetherapy(HT).
Intheearlypostmenopausalyears,HTisaneffectivetherapyformenopausalsymptoms.
Inmostwomenwithmoderatetoseveresymptoms,thebenefitsoutweighthesmall
increasesinrisk.
Thelong-termuseofHThassomebenefitsbutitalsohassomerisks.
ThedecisiontouseHT,andforhowlongitshouldbeused,mustbebasedonindividual
assessmentandneeds.

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