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Today’s menopausal women are in the unenviable position of having to make decisions about hormone replacement therapy at a time when all the information isn’t yet in. While research suggests there are health benefits to taking estrogen, many women feel a bit like guinea pigs when it comes to hormone replacement therapy (HRT).

Percentage of Deaths from Specific Conditions Among U.S. Women Over 50 Years of Age.

graph depicting heart disease as highest cause of deaths in women

Source: T.L. Bush, "The Epidemiology of Cardiovascular Disease in Postmenopausal Women, "Annals of the New York Academy of Sciences, Vol. 592, Multidisciplinary Perspectives on Menopause, 1990

While estrogen can successfully lower a woman’s risk of osteoporosis, its role in prevention of heart disease remains unclear. Estrogen also has some undesirable side effects and raises concerns, particularly about the cause and spread of breast cancer. Women need to weigh all the factors before making their decision. (For an updated article on estrogen replacement therapy for secondary prevention, go to HRT article).

Menopause marks the end of a woman’s reproductive years. During her 40’s, a woman’s ovaries reduce production of the female hormones estrogen and progesterone. Her fertility decreases, her cycle length may vary, she may skip periods and she may experience hot flashes. This peri-menopausal time can last from two to seven years. When a woman has gone a full year without a period, she is considered menopausal. The average age of menopause is 51, but there is wide variation.

How a woman experiences menopause varies since estrogen and progesterone levels will lower at different rates in each woman. Some women experience vaginal dryness, hot flashes, urinary tract infections, tearing of the skin of the vagina, inability to hold urine, shrinkage of the breasts or sleeplessness and irritability. Estrogen replacement can successfully relieve these symptoms, but there are other strategies as well. Vitamin E and B6 supplements, ginseng or dong quai can help with hot flashes, and there are various over-the-counter vaginal lubricants e.g. water-based gels, yam creams - that can effectively relieve vaginal dryness.

But what of osteoporosis and heart disease, the silent health consequences of menopause? Osteoporosis is the thinning of the bones of the skeleton. The process begins at age 35, but accelerates at menopause when estrogen levels decline. Thin bones in the spine can collapse, causing a loss of height and eventually a dowager’s hump. Thinned hip bones can easily break from even a minor fall. Up to one fifth of women with hip fractures die of complications, while up to one fifth will be in a nursing home one year after the fracture. Along with disability, osteoporosis can cause debilitating pain.

In addition to menopause, there are other risk factors for osteoporosis: old age, white race, smoking, poor nutrition, little or no weight bearing exercise and having a small, thin body frame. Estrogen replacement reduces osteoporosis risk by about 25 percent, but there are other strategies as well. Weight-bearing exercises like walking and weight-lifting, - are ways to slow the process of thinning bones along with a good diet and taking an extra 1,000 milligrams of calcium per day (check with your practitioner before starting a calcium supplements). Accident-proofing your home against falls will reduce risk of fractures.

Heart disease is the most serious consequence of the low estrogen state (refer to graph "Percentage of Deaths from Specific Conditions..." above). Estrogen in the pre-menopausal woman keeps the harmful cholesterol (LDL) levels lower and the good cholesterol (HDL) levels higher. It also helps keep the blood vessels dilated. This protective effect is reduced after menopause, so ten years later a woman has the same risk of heart attack as a man. The risk factors for heart disease include smoking, high blood pressure, diabetes, high cholesterol, if a close relative (parent or sibling) had a heart attack under 60, obesity and a sedentary lifestyle.

Estrogen replacement at menopause may reduce a woman’s risk of heart disease by about 35-40 percent, but study results are inconsistent and taking estrogen is not without risk. Other methods to reduce incidence of heart attack include smoking cessation, a diet low in saturated and hydrogenated fats, antioxidant vitamins, aerobic exercise and taking an aspirin a day.(Check with your healthcare practitioner before starting aspirin therapy).

If estrogen is so effective in reducing risk for osteoporosis and heart disease, why isn’t everyone taking it? Twenty years ago, researchers found that taking estrogen after menopause causes the lining of the uterus to grow as it did before menopause. Without progesterone, the hormone that women produce to shed the uterine lining and have a period, the uterine lining can become thickened and crowded and the cells can become cancerous. Any peri-menopausal woman taking estrogen who has not had a hysterectomy should be taking progesterone to prevent uterine cancer.

Taking estrogen-progesterone means the return of periods. For some women this combination may cause bloating, breast tenderness, weight gain and depression. Progesterone may reduce some of the beneficial effects of estrogen on heart disease.

A controversy surrounds estrogen’s relationship with the cause and spread of breast cancer. Researchers believe that there is no increased risk of breast cancer in women who take estrogen for less than five years, but they also think there may be as much as a 30% increase in the risk of breast cancer in women who have taken estrogen for 15 years. Researchers believe the beneficial effects of estrogen for heart disease outweigh the risk. The effects of progesterone on breast cancer are unknown.

If you’re interested in estrogen replacement therapy, then you need to understand the reason you are taking it. Are you one of the ten percent of women with severe menopausal symptoms like hot flashes and vaginal dryness? Are you a woman who is at high risk for osteoporosis or heart disease? Your reasons for taking estrogen will determine the method – patch, pill or cream – the length of time you need to be on it, the frequency and dosage. Women with risk factors for breast cancer will have to be more careful about taking estrogen until there are better ways to determine risks for it.

Before starting hormone therapy you should have a history and physical including a Pap, pelvic and breast exam, blood tests, mammography, bone scan, EKG and possibly an endometrial biopsy or pelvic ultrasound. Additionally, you willhave to have regular follow-up care and be examined for any unexpected vaginal bleeding. There are many types, schedules and dosages of estrogen and progesterone and it is usually possible to find the right combination for you.

While we need to advocate for research, menopause is not a disease. We should all adopt healthier lifestyles and find a primary care practitioner who will work in partnership with us to help us remain healthy and independent.

This page was contributed by Kate Thomsen, M.D., Woman’s Health Specialist at Planned Parenthood in New York.

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