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Menopause

Description

An in-depth report on the treatment of menopause-related symptoms.

Alternative Names

Estrogen; Hormone replacement therapy

Complications

After a woman reaches menopause, her average life expectancy is 30 to 40 years. During those years, however, she faces certain health risks due to lower levels of estrogen that cause accelerated bone loss and an increase in LDL cholesterol (the so-called bad cholesterol). Her risks for serious disorders are estimated at 46% for heart disease, 20% for stroke, and 15% for hip fracture. In addition, about 8% of people over 75 have dementia, with postmenopausal women having 1.4 to three times the risk for Alzheimer's disease compared to men.

Menopause and Heart Health

Heart disease is the number one killer of women. In 2003, more than 480,000 women died from diseases of the heart and circulation (cardiovascular diseases). Although young women have a much lower risk for cardiovascular disease than young men, after menopause women catch up. After age 51, 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.

Some studies indicate that women who reach menopause at an early age are at increased risk of heart disease. However, recent research suggests that the reverse may also be true. A 2006 study suggested that women who have heart disease risk factors (smoking, high total cholesterol levels, high blood pressure) during premenopause may enter menopause earlier than women with healthier heart profiles.

Estrogen has the following effects:

• Positive Effects on Cholesterol and Other Lipids (Fats in the Blood). About 2 years before menopause, as estrogen levels begin to decline, the levels of the harmful low-density lipoprotein (LDL) cholesterol begin to rise and the advantageous high-density lipoprotein (HDL) levels decrease.
• Positive Effect on Blood Flow. Estrogen has significant effects on smoothing, relaxing, and opening blood vessels, thereby increasing blood flow and reducing pressure.
• Antioxidant Actions . Estrogen is also an antioxidant. That is, it helps clean up particles called oxygen-free radicals that are released by natural chemical processes in the body, which can cause significant damage, including harm to the arteries.
• Mixed Effects on Blood Pressure. The effects of estrogen on blood pressure are not clear. Oral contraceptives, for instance, which contain estrogen, appear to increase pressure slightly.

• Mixed Effects on Blood Clotting. Estrogen affects many blood-clotting factors in the liver: It reduces blood viscosity (stickiness) and may enhance fibrinolysis , the natural process for breaking down blood clots. Unfortunately, estrogen also has other actions that increase the risk for blood clots. Women who take hormone replacement therapy are at risk for thromboembolism -- blood clots that block a vessel.

• This action may explain the higher rates of adverse heart events now observed in women with heart disease who take HRT.

Menopause and Bone Density

Osteoporosis is a disease of the skeleton in which bones become brittle and prone to fracture. In other words, the bone loses 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 lifetime risk of spinal fracture in women is about 1 in 3 and that for hip fracture is 1 in 6. Furthermore, between 10 - 20% of women who experience a hip fracture die within a year and about 25% require nursing home treatment.

Experts are still puzzled by the extreme speed-up of bone breakdown (resorption) after menopause. Estrogen may have an impact on bone density in various ways:

• Estrogen's most important effect on osteoporosis appears to be prevention of bone break down (resorption) . Some research suggests that estrogen may control the life span of osteoclasts, the cells responsible for bone breakdown.
• Part of estrogen's beneficial actions may involve maintaining normal levels of vitamin D, an important nutrient in bone protection.

Risk factors for osteoporosis include:

• Being tall and thin
• Being Caucasian
• Smoking
• Taking thyroid hormone
• Being sedentary
• Early menopause or surgical menopause (removal of ovaries)

Women at risk for osteoporosis should have a bone density test to measure their bone mass and then make a decision about treatment after consulting their doctor.

Menopause and Depression

Depression may occur as a woman transitions into menopause (perimenopause), even among women with no history of clinical depression. Hormonal changes and declines in estrogen levels are probably involved in this process. Research suggests that a depressive disorder is 2.5 times more likely to develop during perimenopause than premenopause. Women who transition to menopause at a younger age are at increased risk of a first episode of depression.

Symptoms of clinical depression include:

• Loss of interest or pleasure in activities once enjoyed
• Persistent (longer than 2 weeks) sad mood
• Decreased energy
• Sleep problems (insomnia or oversleeping)
• Feelings of guilt, worthlessness, and hopelessness
• Difficulty concentrating

Some of these symptoms may overlap with other symptoms that typically accompany perimenopause. Women who experience these symptoms should talk to their doctor. Depression is treatable. [For more information, see In-Depth Report #8: Depression.] For many women, depression eases once they reach menopause.

Estrogen Loss and Mental Decline

Estrogen, the primary female hormone, appears to have properties that protect against the memory loss and lower mental functioning associated with normal aging. Estrogen's effects on the brain include:

• Laboratory studies suggested that estrogen may help block production of beta-amyloid, the source of the sticky plaques found in Alzheimer's brains.
• Estrogen may trigger the temporary growth of nerve pathways in the memory portion of the brain.
• Estrogen may stimulate production of the neurotransmitters acetylcholine and serotonin, which are depleted in Alzheimer's patients.
• Estrogen also appears to smooth, relax, and open blood vessels, which may help blood flow in the brain.
• Estrogen is an antioxidant. That is, it helps clean up free-oxygen radicals, the unstable particles thought to play a role in Alzheimer's.
• Studies have been mixed on the association between natural estrogen levels and mental functioning in older women.

Gum Disorders and Tooth Loss

Estrogen therapy has been associated with reduced gum bleeding and with decreased bone loss around the teeth, and women who take estrogen are less likely to lose their teeth. Thus, the same principle that helps prevent bone loss in osteoporosis is also at work in preventing bone loss in the mouth.

Eye Disorders

Estrogen, progesterone, or both appear to protect against cataracts.

Studies are also indicating that estrogen helps prevent glaucoma and macular degeneration.

Urinary Incontinence

The drop in body estrogen levels brought on by menopause may contribute to both urinary stress and urge incontinence.

Urinary Tract Infections

Women are at increased risk for recurrent urinary tract infections after menopause. Research suggests that estrogen may prevent infection by increasing the number of lactobacilli, a microorganism that fights infection by preventing bacteria from adhering to vaginal cells.

Wrinkles

Some evidence suggests that estrogen may help prevent slackness and dryness in the skin and reduce wrinkles.

Sleep Disorders

Menopause is associated with more sleeping problems, including inability to fall asleep and nighttime wakefulness.

• Review Date: 6/11/2006
• Reviewed By: Harvey Simon, M.D., Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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