Menopause

With the onset of menopause, a woman's body stops making estrogen and progesterone. Estrogen and progesterone are the female hormones produced by the ovaries that prepare the uterus for possible pregnancy. During menopause, women stop menstruating.

Although the average age of menopause is between 50 and 51 years, some women experience unusually early menopause (before age 40) due to surgical removal of the uterus or both ovaries, chemotherapy or radiation therapy.

Hot flashes (or hot flushes), a result of a fall in estrogen levels, often begin several years before actual menopause and continue for several years after menopause. They are far more common at night and can disrupt sleep. Therefore, many women also experience symptoms related to sleep-deprivation, such as fatigue, irritability, difficulty concentrating and mood swings. Finally, many women begin to experience vaginal dryness or urinary symptoms, both of which are related to estrogen deficiency. Estrogen is the most effective treatment available for these symptoms.

 

Estrogen Replacement Therapy

Estrogen replacement therapy, or ERT, is a way for a postmenopausal woman to replace the estrogen her body is no longer making. While it does not make her fertile again, it does eliminate many of the symptoms of menopause. When women with a uterus take estrogen, they also need to take a progesterone-like hormone (called progestins) to eliminate the risk of uterine (endometrial) cancer. The term hormone replacement therapy (HRT) is used when estrogen and progestin are given together.

Estrogen or combined estrogen-progestin therapy remain the gold standard for relief of menopausal symptoms, and therefore is a reasonable option for most postmenopausal women, with the exception of those with a history of breast cancer, heart disease, a previous blood clot or stroke, or those at high risk for these complications. In otherwise healthy women, the risk of an adverse event is extremely low. Most experts agree that hormone therapy is safe and reasonable for healthy postmenopausal women who need to take it to relieve symptoms. When it is used, is should be taken for the shortest period of time possible.

Estrogen can be taken as a pill (orally), absorbed through the skin from a patch (transdermally) or inserted into the vagina. The most commonly prescribed progestin is medroxyprogesterone acetate, available in pill form under the brand names Provera, Cycrin or Amen. A natural progesterone, called Prometrium, is a good alternative for women who cannot tolerate medroxyprogesterone.

In women being treated for symptoms, the goal is to eventually taper and stop the estrogen (unless there is a compelling reason to continue it long term). After the planned treatment interval, the estrogen should be discontinued gradually, for example by omitting one pill per week, to minimize recurrence of the menopausal symptoms.


Benefits

Menopausal symptoms: Estrogen is the most effective treatment available for symptoms such as hot flashes, urinary symptoms and vaginal atrophy (atrophic vaginitis), a condition in which the vagina can become dry, resulting in pain with intercourse.

Quality of life: Women with severe menopausal symptoms often describe a dramatic improvement in their quality of life when they are treated with estrogen. This is due to relief of hot flushes and restoration of normal sleep.

Urinary tract infection: Estrogen has been found to decrease the frequency of urinary tract infections, possibly by normalizing the micro-organisms in the vagina. It does not help the symptoms of urinary incontinence.

Depression: Estrogen may improve mood and decrease depression in some menopausal women.

Studies show HRT also reduces risk of Type 2 diabetes, hip and spine fractures, and colorectal cancer.


Risks

Coronary heart disease: The rate of coronary events such as heart attacks is increased for women taking HRT, but still low.

Stroke: The rate of stroke is increased with combined estrogen-progestin. Most of the increase in risk is due to nonfatal strokes.

Blood clots: The rate of blood clots (in the leg and lung) increased with combined estrogen-progestin.

Breast cancer: The risk of breast cancer is increased, though still low, with combined estrogen-progestin.

Endometrial hyperplasia and cancer: Studies have found that postmenopausal women with a uterus who are treated with estrogen alone increase their risk of endometrial cancer and hyperplasia (a precursor to cancer).

Gallbladder disease: Estrogen therapy, especially in pill form, is associated with an increased risk of gallbladder disease. The risk of cholecystectomy, (removal of the gallbladder), increases the longer a woman uses hormone therapy and the higher the dose of estrogen used. The risk decreases substantially within one to three years after a woman discontinues hormone therapy.

 

Alternatives to ERT/HRT

Not all women are able or willing to take estrogen replacement, and alternative therapies are available.

 

Learn More

Your doctor is the best resource for important information related to your particular case. Not all patients are alike, and it is important that your situation is evaluated by someone who knows you as a whole person.

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