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The half-century mark calls for a new look at a woman's health issues. The onset of menopause brings up the big question of hormone replacement therapy (HRT). Depression and mood changes increase during middle age and may require treatment. Women may also be concerned about the potential for other illnesses they are more prone to as they age, such as cancer and Alzheimer's disease.
Menopause begins when a woman has her last menstrual cycle and is considered complete when menstruation has stopped for one year, according to the National Institutes of Health. Menopause usually occurs naturally somewhere between the ages of 45 and 55, although it can be brought about surgically by removal of the ovaries. Estrogen levels after menopause are only about 10% of what they were before and progesterone levels are nearly zero.
Hot flashes; night sweats; insomnia; mood swings; and vaginal dryness, itching, and burning are the classic symptoms of menopause. During the years after menopause, heart disease and osteoporosis tend to increase. To treat both the short-term and long-term consequences of menopause, many women begin HRT. This therapy does not bring hormone levels to what they were before menopause, but it does help alleviate the symptoms.
The question of whether or not to start HRT is a weighty one for most women. The answer is not simple and it must be tailored to each individual's needs. There is a great deal of information circulating about HRT, and it can be confusing. "It's changing every day, it seems," said Jan Hastings, Pharm.D., FAPhA, associate professor of pharmacy practice at University of Arkansas for Medical Sciences College of Pharmacy, who specializes in women's health.
The constant change in information and guidelines is frustrating both for Hastings' patients and her friends, some of whom are now facing the HRT question. "Quality-of-life issues are so great for these women," she said of women facing menopause. The hot flashes and moodiness can be intolerable without HRT, she added.
The pros and cons of HRT
For a long time, there was little question about the value of HRT. "It used to be, we thought it was good for them," Hastings explained. HRT was thought to help prevent heart disease, osteoporosis, Alzheimer's disease, and certain cancers. This thinking was based on observational studies of mostly healthy women taking estrogen, according to NIH. Recent study results indicate some of these theories may have been faulty.
Cancer is probably the biggest concern associated with HRT. Estrogen can increase the risk of uterine and cervical cancer and may increase the risk for ovarian cancer as well. Some studies have indicated HRT can also increase the risk for breast cancer. In 2002, the Women's Health Initiative (WHI) trial of combined estrogen and progestin replacement therapy (CHT) was halted early when researchers noticed an increased incidence of health risks, including breast cancer, in this group of women.
The WHI trial made big news and sent a ripple of fear through HRT patients everywhere. A follow-up study analyzing the WHI data concluded that women taking CHT had both a higher incidence of breast cancer and more invasive breast cancer than patients on placebo. The result was similar whether the progestin component of CHT was given daily or only on certain days of the month.
Another key study, conducted at the Fred Hutchinson Cancer Research Center in Seattle, was published in 2003. The Hutchinson study looked at long-term HRT and compared estrogen-only therapy with CHT. Researchers found no correlation between estrogen-only therapy and cancer in women who had been taking the drug for 25 years or longer. It was a different story for women taking CHT. There was a significant increase in risk of cancer-from 1.5 to 2.7 times that of women not taking CHT, depending on the type of breast cancer involved. The risk increased the longer women were on CHT and regardless of how often they were taking the progestin component.
With all the evidence stacking up from WHI, Fred Hutchinson, and other studies, physicians and patients alike began to feel HRT was not worth the risk, particularly for women with a history of breast cancer or already at increased risk to develop it. However, additional studies have indicated women who have been diagnosed with breast cancer and who continue to take estrogen have no higher rate of recurrence or mortality than women not taking estrogen. Some studies even suggest women who have had HRT may actually have lower mortality rates after breast cancer diagnosis.
As for whether or not HRT could help prevent heart disease, the study results have not been promising. "They have not been able to prove there is a benefit," said Hastings. The estrogen-only arm of the WHI trial continued until March 1, 2004. The researchers found no evidence that estrogen therapy increased breast cancer risk. It also was not found to have any effect, either positive or negative, on heart disease. In fact, there has been evidence that estrogen alone increases incidence of stroke. The WHI study found that estrogen and progesterone together increased the risk for stroke, heart disease, and blood clots.
Despite the risks, there are certain benefits of HRT. Both estrogen-only therapy and CHT have alleviated the symptoms of menopause and decreased the risk for hip fracture in numerous studies. CHT also decreased the incidence of colon cancer in the WHI study. The news that there was no increased risk for breast cancer from estrogen alone was a great relief to both providers and patients.
"If the woman is having symptoms, she should be treated for those symptoms with HRT," said Hastings, summing it all up. Estrogen should be used alone in patients with no uterus, and progesterone should be added if the uterus remains, she said. Progesterone helps prevent the excessive endometrial growth that estrogen alone can cause, and the theory is that adding progesterone will help prevent endometrial cancer in women who have not had hysterectomies.
Hastings recommended using HRT for the shortest time possible and tapering off of it rather than stopping it suddenly. If symptoms return, she added, patients should go back on HRT and try to taper off again later.
HRT is available in numerous oral, transdermal, topical, vaginal, and injectable products. The estrogens and progesterones may be natural or synthetic and are available as single-agent and combination products. According to NIH, all of these products are equally effective in relieving the symptoms of menopause. The systemic levels of hormones from vaginal products are usually less than those from oral or transdermal products. Vaginal products do not appear to have any protective effect against osteoporosis. The transdermal products have proven to be equally effective to oral products in preventing osteoporosis during clinical trials. Any difference in effect these products might have on the heart and blood vessels is still unknown.
Many women are still leery of the risks of HRT and prefer to treat their symptoms with nonprescription remedies. The E and B vitamins, black cohosh, wild yams, valerian root, dong quai, and foods containing estrogen (soy, whole grains, seeds, etc.) have all been used to treat menopause symptoms. Research into whether or not these remedies actually work is ongoing.
Other health issues
Depression, mood swings, and moodiness may accompany menopause. HRT is sometimes effective, and sometimes antidepressants are needed. Several studies have evaluated antidepressants for hot flashes as well. Venlafaxine (Effexor, Wyeth), paroxetine, and fluoxetine have all proven to be somewhat effective in relieving hot flashes, at least in short-term trials. For women whose primary symptoms are mood issues and hot flashes, antidepressants may provide an alternative to HRT.
As women pass 50, they may also become concerned about memory loss and dementia, especially if they have a family member with Alzheimer's. Short-term memory problems already tend to be an issue with both middle-aged women and men. When the occasional memory lapse hits, "I think they start thinking about it," said Hastings.
Researchers are investigating the link between estrogen and dementia. Estrogen may be associated with a risk of dementia. The WHI study found that CHT doubled the risk of developing dementia over that of placebo. As women on HRT age, the diagnostic difficulty may distinguish true dementia from that brought on by HRT. There is no proven way to prevent Alzheimer's disease. Some experts recommend exercising the brain to keep it healthy, similar to exercising the heart. Continued learning, memory exercises, and so on may help ward off memory loss. Clinical trials are looking into whether certain supplements, such as vitamin E and selenium, may help prevent dementia.
The pharmacist's role
Women over 50 have some unique health and medication issues. Pharmacists can help women make sense of all the information they receive and provide much-needed counseling on HRT and other drug issues. Pharmacists can also provide many of the services these women might need, such as bone density scanning, immunizations, cholesterol screening, and drug therapy management.
How to age gracefully
Lifestyle choices can increase health and well-being as women age. Here are some recommendations from the National Institute on Aging:
Where to go for more information
Additional information about menopause and other issues for women over 50 is available at: