Focus On Health
The Change
Menopause in the 21st Century, Part 1

It was once believed that a woman’s uterus floated through her body, causing a variety of problems -- including psychological and emotional distress, often referred to as hysteria (from the Greek hyster -- womb).  Since that time, Western medicine has unlocked the key to many of the mysteries of women’s complex physiology.  Yet for women facing the significant transition of menopause, modern medicine has raised as many questions as it has answered.

What Is Menopause Anyway?
Menopause is the cessation of the menstrual cycle and therefore of the reproductive years.  To a considerable degree, it is culture that establishes the meaning, and therefore, at least to some extent, the experience of menopause.  Some cultures see it as the gateway to wisdom and power.  But our own culture often portrays menopause as a loss -- of youth, of beauty, and of vitality.

Recently, as we have refined hormone replacement therapy (HRT), we have seen what some call “the medicalization of menopause."   This has raised at least one debate concerning menopause, only one among many, but a significant one, nonetheless:  

• Is menopause a “hormone deficiency disease,” or a natural biological stage for which women are physiologically prepared?

The answer?

Conflicting medical studies and dogmatic attitudes, as well as political and economic agenda, all add to the confusion and can leave a woman with little more than unanswered questions, fears, and hot flashes.  The hope here is that we can clear up at least some of the confusion.

Understanding the Sequence
Just as owning a car doesn’t mean you know how your engine works, being a woman does not insure that you understand your delicate, complex balance of hormones and health.  So, a little background may be in order.

In her thirties, a woman’s ovaries (which produce eggs) begin to produce less hormones.  These include not only the famous estrogen, but progesterone and androgens (testosterone and DHEA), as well.  It is the relationship among these hormones that maintains the monthly cycle of ovulation and menstruation. 

In her forties, production of these hormones drops more sharply, causing some or all of the signs that signal the onset of menopause.  This period of time -- before the menstrual cycle halts completely -- is usually called perimenopause.

Generally, menopause itself is determined in retrospect.

One year without menstruation means that menses has stopped.  Although estrogen levels are low after menopause, they don’t drop to zero.  Other parts of the body, including the adrenal glands and fat cells, continue to produce estrogen, progesterone and androgens.  From menopause on, however, which means the rest of her life, a woman is considered post-menopausal.

"Is It Hot In Here?" -- Effects of the Menopause Transition
The physiological and psychological effects of these hormonal changes are different for each woman, just like pregnancy and puberty.

But many of the most uncomfortable effects of this shift come during perimenopause, when hormone production is fluctuating widely and before the body can adjust to new levels.  For instance, estrogen levels may rise higher than normal in some cycles, causing some of the perimenopausal symptoms like heavy menstrual bleeding.

Hot flashes:  Hot flashes are often one of the first signs, and affect about 85% of perimenopausal women.  Although most women do not find them disruptive, anxiety and stress can make hot flashes worse.  They can come once a week or once an hour.  Nighttime hot flashes and sweats can significantly disturb sleep for some women, causing fatigue and depression.

Menstrual changes:  Fewer and lighter periods, or very heavy and more frequent periods, result as the ratio of estrogen to progesterone changes.  Flow can become heavy enough to disrupt normal activities.  Heavy flow and more frequent periods can also cause fatigue and even low iron.  Premenstrual problems like tension, anxiety, depression, cravings, and bloating can worsen as can menstrual pain.  As one woman put it, “I feel like I’m back in adolescence."  Premenstrual migraines can also worsen during perimenopause.

Urogenital problems:   "It has been reported that as many as one third of women aged 50 years and older experience urogenital problems," according to Rogerio Lubo in his comprehensive article, “Menopause Management for the Millennium."  Often, such symptoms are the result of the thinning of vaginal tissue that can begin in perimenopause, causing dryness and irritation.  This can also result in urinary frequency, urgency, and, sometimes, even incontinence.

Skin changes:  Collagen is what gives skin its firmness and elasticity.  Without it, skin begins to sag or wrinkle.  Estrogen has a positive effect on collagen, which is important for bone and skin.  "The loss of collagen is more rapid in the first few years after menopause," notes Lubo.  "... 30% of skin collagen is lost within the first five years after menopause."

Weight and shape changes:  The average menopausal weight gain is only 2-5 pounds.  For many women, however, fat distribution shifts, moving toward the abdominal region.  But fat cells produce estrogen.  Thus, those with less body fat are more likely to have postmenopausal problems.

Menopause brain:  Cognitive changes are more commonly known as “menopause brain” by women who suddenly cannot remember where they parked their car, what their cat’s name is, or why the house keys are in the refrigerator.  Estrogen is important for some types of brain function.  In fact, some women with Alzheimer’s have responded to high doses of estrogen.  But there’s no evidence that low estrogen causes Alzheimer’s or other forms of dementia.  Like many of the conditions associated with menopause, dementia is associated with other factors linked to aging, including hardening of the arteries, inactivity, poor nutrition, smoking, and even lack of mental stimulation.

Mood?  There’s hot debate over whether loss of estrogen increases the likelihood of or causes depression and anxiety.  Premenstrual symptoms aside, studies consistently show that depression is not linked to the hormonal changes of menopause.  An Australian study, reported in Medscape, is a good example: 

“This study of middle-aged women found them to be remarkably positive in their appraisal of life as shown by their responses to the statements in the life satisfaction measures, indicating that middle age is not a time to be feared with regard to quality of life.  These findings are not what one would predict on the basis of common negative community-held stereotypes of the middle-aged woman." 

In another study, reported by Lubo, 

“More than half (51%) of 752 postmenopausal women participating in the North American Menopause Society (NAMS) 1998 menopause survey reported that they were happier and more fulfilled in their postmenopausal years than in their 20s (10%), 30s (17%), or 40s (16%).  ... They reported that many areas of their lives had improved since menopause, and almost 75% had made some health-related lifestyle change at midlife (e.g., smoking cessation).  More than half reported that their sexual relationship was unchanged at menopause, and women who had undergone hysterectomy expressed that they had improved sexual relationships and spouse/partner relationships, a sense of personal fulfillment, and improved physical health." 

Researchers suggest that the stresses of midlife: work, caring for elderly parents, shifting roles, and the idea of menopause itself are responsible for the depression, anxiety and irritability that so many blame on the menopause process.

But try telling that to the perimenopausal woman who, after a lifetime of relative emotional balance, finds herself weeping over … well … the misplaced car keys.  Perhaps the rocky hormonal road to menopause should be studied separately.

Long Term Risks?

Most of the discomforts of perimenopause stop or subside after menopause.  But it is the long-term effects of menopause that often frighten women and provide the basis for the decision to use hormone replacement therapy.  Thus, it can be very frustrating to find out that studies of estrogen’s role in these diseases are sometimes contradictory and often inconclusive.

Cardiovascular disease (CVD) is the number one killer of women in this country.  It’s been widely held that low estrogen dramatically increases the risks of CVD and that estrogen replacement protects against it.  In reality, however, this is a point of great debate, with several major studies failing to support these assumptions.

Nonetheless, the National Institutes of Health’s Menopause site states, "The majority of past clinical studies have shown that women who use estrogen substantially reduce their risk of developing and dying from heart disease.  One or two studies demonstrate conflicting evidence, but they are far outnumbered by the positive reports.  Results from a 1991 study showed that after 15 years of estrogen replacement, risk of death by CVD was reduced by almost 50 percent and overall deaths were reduced by 40 percent.”

On the other hand, Medscape’s Menopause site states, “The Heart and Estrogen/Progestin Replacement Study (HERS), published in 1998, was the first large, randomized, controlled trial to evaluate the efficacy of estrogen and progesterone replacement therapy in reducing CHD risk.  Overall, the study found that continuous hormone replacement therapy (HRT) in women with CHD did not reduce cardiovascular risk at an average of 4.1 years of follow-up.  In addition, there was an early increase in the risk of thromboembolic events.”

Osteoporosis, a debilitating and sometimes even fatal loss of bone mass, has also been linked with low estrogen.  But both of CVD and osteporosis are also linked to lifestyle factors, such as smoking, diet and exercise, as well as to heredity.  What is not known is the importance of the estrogen factor in the development of these diseases. 

Medscape’s Menopause site concludes, "… as women age and experience the menopausal transition, the risk of developing osteoporosis increases.  In addition, low body mass index, low calcium intake, low level of physical activity and smoking can affect BMD [bone mass density].  The relative importance of these factors on BMD in midlife women is not fully established.  The impact of gynecologic history (parity, lactation, oral contraceptive use, age of menarche) on BMD is uncertain.  Many factors have been implicated as influencing bone loss, but the evidence for some is unsubstantial.”

Is There Good News?
Most of the discomforts of the menopause transition end with menopause.  There are also many preventive and therapeutic steps women can take to reduce these discomforts, as well asthe risks associated with menopause.  And just as a woman’s body is designed to handle puberty, pregnancy, childbirth, menstruation ... it’s designed to deal with menopause, as well.

Next month, in part two of "The Change: Menopause in the 21st Century" we'll learn about some of the details of this good news.

Laura Wisniewski     

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Lou Colasanti, Editor & Laura Wisniewski, Associate Editor
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