Menopause occurs when the last period finishes and the ovaries no longer produce estrogen. Due to low estrogen the pituitary gland produces more FSH and LH, which is used to diagnose that the woman is in menopause. Most women enter into the age of menopause around 50 or 51 in the US.
At first, the follicular phase of the cycle is getting shorter meaning that there is less estrogen production in the ovary. This leads to shorter menstrual cycles. There are also more irregular menstrual cycles as well. Finally after a last menstrual period her periods stop altogether.
Hot flashes are the most pronounced symptoms that women complain about with menopause. The skin feels warm or hot, some women perspire, occasionally profusely. Head and neck region are most affected and the skin in that region might look reddish. What causes hot flashes? The lack of estrogen in the circulation opens up the skin vessels and the sweat glands are sweating easier.
Postmenopausal women are more sensitive to hot pepper, alcohol and large meals that will all make hot flashes worse. They last for a few seconds or a few minutes and lead to a sensation of heat from the chest upwards in the neck and head. Some women get reddish skin discoloration and the skin feels warmer than in the skin of the lower body. When the bedroom temperature is kept on the cool side women with hot flashes will have 50% less symptoms.
Without treatment the episodic hot flashes last for between 1 and 5 years. There are also psychological symptoms ranging from emotional lability, to irritability, trouble falling asleep to depression. Menopause can cause heart palpitations without ECG changes; nausea, joint aches and muscle pains are also part of the symptom complex. Because of the estrogen reduction there are marked changes in the lower genital tract with thinning of the vaginal wall and urethral mucosa, the labia and the clitoris. This leads to painful sexual intercourse, causes vaginal infections and frequent bladder infections.
Some women have no hot flashes. They seem to have enough androgen hormones from the remaining ovarian function as well as from the adrenal glands so that estrogen can be formed in fat cells and skin, which prevents hot flashes.
Osteoporosis and menopause are clearly linked. White women are at a higher risk than black women. Other risk factors are smoking, alcohol abuse, lack of exercise and certain drugs (like prednisone and levothyroxine). About 25% of women have severe osteoporosis and fractures of bones are found in about 50% of them , if they do not take estrogen replacement and calcium supplements and exercise. The typical osteoporosis fractures are compression fractures of the spine, fractures of the hip, wrist fractures and ankle fractures.
Finally, heart disease and stroke become more common as the cardiovascular protective effect of estrogen is no longer active as it was during the reproductive life cycle.
A menopause test is a simple blood test where the FSH level is measured. This is the most important single test, which when elevated, is sufficient proof that the woman is in menopause. If the LH level is included in the test, this usually is equally elevated. If there is suspicion for bone loss, a bone density test should be done by dosimetry (DEXA scan) or other tests that your family doctor can order. If the patient’s test result is 1 standard deviation below the norm, the risk of sustaining a fracture is 3-5 fold higher. If the bone density is 2 standard deviations below the expected value, the risk of a fracture is 6-10 fold! Blood tests such as total cholesterol, LDL and HDL cholesterol as well as triglycerides should also be done. Before hormone replacement treatment is started, it is important to get baseline hormone tests, best with saliva testing where a panel of 5 hormones are tested (estrogen. progesterone, testosterone, DHEAS, cortisol). If your own physician is uncomfortable with bio-identical hormone replacement, look for an A4M certified physician. The physician will likely order more blood tests such as thyroid tests, IGF-1, CRP and others. The reason is that many women in menopause can also be thyroid deficient, can be growth hormone deficient and may have underlying inflammatory diseases that have not yet been diagnosed.
As often in other areas of medicine, the value of a diet and exercise program should not be overlooked. Exercise like power walking (minimum 1/2 hour 5 times per week) will strengthen the bones due to small pulses of natural growth hormone that is released by the pituitary gland. Stopping smoking and quitting alcohol (large amounts) is definitely beneficial.
A zone diet program (Ref.1 and 12) or a similar balanced diet (= low glycemic diet) has also been shown to free suppressed cyclic AMP, which is beneficial in activating alternative estrogen pathways. As mentioned above androgens can be metabolized in the skin and fat cells and produce enough estrogen in some women to stop the hot flashes. Such balanced diets play a major role in making this happen.
If this is not enough and hot flashes are still a problem, then bio-identical estrogen therapyshould be considered using nature identical estrogen cream from a compounding pharmacy. Depending on what the hormone and blood tests showed, there are some complications that have occurred with the use of SYNTHETIC hormones and should be thought about. Synthetic hormones are molecules that resemble hormones, but that have had some modification of atoms done or a side chain added that makes them patentable (financially good for the company), but that disfigures their structure so that not all of the information regarding the hormone can be read by the hormone receptors of the tissues (bad for the postmenopausal women as this is the reason for the side effects of synthetic hormones like heart attacks, strokes and cancer).
- Some women have precancerous conditions of the uterine lining or breast cancer and these women should stay away from synthetic estrogen therapy. Others develop blood clots (thrombophlebitis) easily and they too should stay away from synthetic hormone replacement.
- Liver disease, such as cholestatic hepatitis, is another reason not to take synthetic estrogens.
- There is a twofold risk to develop uterine cancer on synthetic estrogen therapy, but with regular Pap smears and yearly endometrial biopsies this can be followed closely. Even when uterine cancer occurs, there is enough time to do a hysterectomy in most cases before it spreads. With natural estrogen cream in combination with progesterone cream where the hormone ratio in the saliva test is 200 to 1 progesterone versus estrogen, NO cancer risk is observed (see Ref.16) due to the cancer prevention effect of progesterone.
- In order to mimic what nature does, a small amount of synthetic progesterone (Provera) was given cyclically in an attempt to create a hormone cycle similar to the one that happened during the reproductive cycles. It was thought that this would minimize or eliminate the uterine cancer risk. However, the risk of heart attacks and strokes in postmenopausal women was unacceptably high, so that this is now no longer the accepted treatment modality by most physicians (due to the results of Ref. 17). We now know that this was the effect of the misfit between the synthetic hormones (Provera and Premarin) and the woman’s hormone receptors. However, many studies in Europe have shown that if we simply stick to the concept of using only bio-identical hormones as replacement therapy there is no risk there.
- The risk of developing breast cancer is about 1.6 fold higher with synthetic estrogen replacement compared to when women do not use it. Yearly mammography is suggested as well as regular monthly breast self examination. This way, should there be a suspicious breast lump; this would be biopsied right away before it becomes an incurable problem. Again, do not use synthetic estrogens, but bio-identical estrogen cream that is balanced by also taking bio-identical progesterone cream to neutralize any cancer risk (the ratio of hormone levels of estrogen to progesterone should be 1:200 or more), which prevents breast cancer development.
- Having said all of this, hormone replacement with synthetic estrogens should be abandoned. Many women feel that it is unnatural to interfere with nature and they prefer to leave things alone. I sympathize with these women on the one hand; but I also understand the women who want to prevent heart attacks, strokes and fractures with bio-identical estrogen creams (balanced with other hormone creams to compensate for those hormones that are missing). Those women who do bio-identical hormone replacement will likely live 15 to 20 years more than those without any hormone replacement.
- There are benefits from the use of soy products. Isoflavones contain or stimulate production of natural estrogen and this may be more for women who want to keep it more natural.
To prevent osteoporosis, the postmenopausal woman should take elemental calcium mixed with equal amounts of magnesium, 4000 IU of Vit. D3 and vitamin K2 100 to 200 micrograms per day.
In the past doctors recommended the use of bisphosphonates (brand name: Didrocal, Fosamax etc. ). However, in the meantime further research showed that these chemicals may look good on tests, but do not on the long-term reduce the risk for osteoporosis. There are only a few hormones that stimulate bone cells to produce new bone and they are estrogen, progesterone, testosterone and calcitonin. Your doctor can advise you how to benefit from that. Read the details of osteoporosis treatment in the osteoporosis link.
1. B. Sears: “The age-free zone”. Regan Books, Harper Collins, 2000.
2. R.A. Vogel: Clin Cardiol 20(1997): 426-432.
3. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 8: Thyroid disorders.
4. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 7:Pituitary disorders.
5. J Levron et al.: Fertil Steril 2000 Nov;74(5):925-929.
6. AJ Patwardhan et. al.: Neurology 2000 Jun 27;54(12):2218-2223.
7. ME Flett et al.: Br J Surg 1999 Oct;86(10):1280-1283.
8. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 261: Congenital anomalies.
9. AC Hackney : Curr Pharm Des 2001 Mar;7(4):261-273.
10. JA Tash et al. : Urology 2000 Oct 1;56(4):669.
11. D Prandstraller et al.: Pediatr Cardiol 1999 Mar-Apr;20(2):108-112.
12. B. Sears: “Zone perfect meals in minutes”. Regan Books, Harper Collins, 1997.
13. J Bain: Can Fam Physician 2001 Jan;47:91-97.
14. Ferri: Ferri’s Clinical Advisor: Instant Diagnosis and Treatment, 2004 ed., Copyright © 2004 Mosby, Inc.
15. Rakel: Conn’s Current Therapy 2004, 56th ed., Copyright © 2004 Elsevier
16. Thierry Hertoghe, M.D.: “The Hormone Solution – Stay Younger Longer With Natural Hormone And Nutrition Therapies.” Three Rivers Press, New York ©2002 as well as several presentations by Dr. Herthoge at the 19th Annual World Congress Anti-Aging and Aesthetic Medicine in Las Vegas (December 8-10, 2011).
17. Writing Group for the Women’s Health Initiative Investigators: Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002;288:321-333.