Menopause and Estrogen Replacement Therapy 



by Alan Bonsteel, M.D.

Menopause seems to catch women unprepared no matter when it begins, but it can be especially jarring if it comes prematurely. Most women seem to think of menopause as being preordained to come around the age of fifty, but it’s not unusual for it to start in the mid-thirties, especially in a woman whose mother and grandmothers had an early menopause.

At whatever age it comes, it is a shock. It is an incontrovertible milestone telling women that things will never again be as they once were and that the years of childbearing are now gone. It also brings the mood swings and hot flashes that can make it doubly difficult to bear.

The hormonal treatment of menopause has gone through a revolution in just the last ten or fifteen years. It wasn’t that long ago that estrogen—most often sold under the trade name Premarin—was used almost exclusively in the first few years after menopause to quiet down the mood swings and hot flashes. However, while estrogen is unarguably helpful in achieving those goals, we now know that its far more important long-term effects are to decrease dramatically the risks of heart disease and osteoporosis while improving mood and decreasing depression. There is also strong new evidence that estrogen replacement decreases the incidence of Alzheimer’s disease. For almost all women, estrogen should be taken lifelong after the onset of menopause.

Before menopause, women have far fewer heart attacks than men, because their estrogen is protective and because, until recently, they smoked less than men. But after the menopause, and especially for women who smoke, the rate of heart attacks almost catches up with that of men. For women who take estrogen, however, the risk of a postmenopausal heart attack is cut almost in half. (In case you are wondering, when men are given estrogen, it is not protective against heart attacks, for reasons that remain largely a mystery.)

A recent study that received enormous publicity questioned the link between estrogen replacement and decreased heart attack rates in women. It is important to remember that this study is in conflict with numerous other excellent studies that came to the opposite conclusion. And the link between the onset of menopause—when estrogen levels plummet—and dramatically increased heart attack rates in women is established beyond question.

Osteoporosis is the loss of calcium from the bones; it strikes women past menopause far more seriously than men of the same age. It causes the “dowager’s hump” that gives many older women a stooped-over appearance, and it weakens all other bones, including the hips and wrists, which frequently fracture in older women. Estrogen dramatically decreases the loss of calcium from the bones of postmenopausal women, thereby reducing the risk of osteoporosis.

Estrogen also helps to keep the sexual organs firm and in good health, which, in turn, leads to a better-functioning urinary tract and fewer urinary tract infections. It also helps to keep the skin moist and youthful.

Finally, five studies indicate that estrogen decreases the risks of Type 2 diabetes and colorectal cancer, delays the worsening of symptoms of Parkinson’s disease, improves sleep in women who suffer from insomnia, and improves balance and decreases the risk of falls in older postmenopausal women.

Unfortunately, though, estrogen replacement does not come without a price, mainly an increased incidence of endometrial cancer, a cancer of the lining of the uterus. Since this cancer is usually detected early through vaginal bleeding, however, it is not one of the big killers. The risk of endometrial cancer can also be dramatically decreased by adding progesterone (most commonly marketed under the trade name Provera) to the estrogen regimen.

Estrogen may also slightly increase the risk of breast cancer; the results of various studies on this are contradictory. Some recent studies seem to show a slight causal effect, whereas other, less publicized studies have shown either no effect or even a slightly protective effect.

To further complicate the issue, a major study has been released indicating that adding progesterone (provera) to an estrogen replacement program may increase the risk of breast cancer. The jury is still out on whether the link between hormone replacement and breast cancer actually exists, but even if it does exist, it is a weak link. It is important to remember that, whereas the average woman has a lifetime risk of 1 in 9 for breast cancer, her lifetime risk of heart disease is almost 2 in 3. The almost 50 percent reduction in the incidence of heart disease with estrogen use thus far outbalances any small increase in the risk of breast cancer—a risk that may not even exist.

My own sense is that many of the risk/benefit analyses that have been made of estrogen have focused almost exclusively on mortality rates. While virtually all these studies have shown that using estrogen comes out far ahead of forgoing it, that’s really only one side of the story. The other side is the overall “youthening” effects of estrogen—the improvement in women’s sex lives, the decrease in urinary system atrophy and urinary tract infections, and the improvement in skin and muscle tone—not to mention the overall improvement in mood and sense of well-being that occurs with estrogen, long after the hot flashes and mood swings have ceased.

There are two basic philosophies about cycling estrogen and progesterone. The older practice was to replenish these hormones in as natural and physiologic a way as possible by giving estrogen on days 1 through 25 of the month and progesterone on days 15 through 25. This approach without question produces better bone health, as well as a more natural hormonal milieu, which provides numerous other benefits. Unfortunately, in most women, it also has the effect of restarting the menses at a time in their life when it no longer serves any purpose, but still produces the same discomfort and inconvenience as ever.

The more common practice now is to give both estrogen and progesterone every day, which usually does not have the effect of producing menses. There are still many holdouts for the older method, however, including many of the top researchers in the field, and the debate is not over. Although most women today who take estrogen supplements are on the more common regimen of taking estrogen and progesterone every day, exceptional patients who are willing to make the extra effort will want to discuss with their physician the more physiologic approach of cycling the hormones.

Women who have had a hysterectomy are often advised that they do not need to take progesterone, and while estrogen alone is the most common drug regimen for such women, it does not produce the optimal bone health and overall hormonal milieu that estrogen and progesterone together do. Ideally, even women who have had a hysterectomy should be taking cycled, rather than daily, estrogen and progesterone to most closely mimic the body’s natural hormone production. Because of the complexity of this approach, however, it is the rare physician who is now prescribing progesterone for women who have had a hysterectomy, and it is even rarer to see cycled hormone replacement in a woman posthysterectomy. Nevertheless, there is strong evidence for cycling both hormones in women who have and who have not had hysterectomies. As more than one researcher in this field has commented, “It’s hard to improve upon nature.”

For women who experience side effects with the usual combination of Premarin and Provera, the most frequent of which seems to be breast tenderness, several studies have shown fewer side effects and more ability to remain on hormonal therapy with the more natural and physiological hormones, micronized estradiol and micronized progesterone. The first is sold under the trade name Estrace by Mead Johnson, and the second under the trade name Prometrium by Solvay Laboratories and by several other pharmaceutical companies in powder form.

Whichever regimen is chosen, all postmenopausal women should be taking calcium supplements. I recommend 500 to 1,000 milligrams per day. Unfortunately, even here there is controversy in the medical profession. Osteoporosis is a disease of calcium loss, so it would seem intuitive that replenishing calcium would prevent it. It turns out, however, that, within limits, the amount of calcium in the diet has little connection to the rate of progression of osteoporosis. It is important to understand that the three main risk factors in osteoporosis are a sedentary lifestyle, smoking, and lack of estrogen replacement postmenopausally. Calcium does play a role, but it is far less important than the other risk factors.

I have talked with many women who believe that taking estrogen or, for that matter, many other drugs is not “natural.” Yet we’re in an era in which hardly anything is “natural,” simply because we’re living much longer now. More than 99 percent of human evolution took place under circumstances very different from today’s. Let’s not forget that, as recently as a century ago, even in the United States, the average life span was less than fifty years, so few women lived much beyond the menopause anyway. Now that the average woman reaching menopause can expect to live at least another thirty years, there are excellent reasons for taking hormones that are found naturally in the body, in order that women may stay youthful and avoid the curses of heart disease, osteoporosis, and Alzheimer’s.

There are a few “relative” contraindications to estrogen (reasons to consider forgoing the drug), according to the Physician’s Desk Reference. One is a history of blood clots, a problem greatly worsened in women who smoke. The others are a family history of breast cancer or a patient history of liver disease, breast cancer, or gallbladder disease.

The most potentially serious of these is a history of blood clots, which can be fatal. On the other hand, the decreased risks of heart disease, osteoporosis, and Alzheimer’s are so profound with estrogen replacement therapy that most experts feel the benefits far outweigh the risks, even in women who have had a blood clot—and the same could be said for a family history of breast cancer. The increased risks from liver or gallbladder disease with estrogen therapy are not great, and in my opinion should not be cause for much concern. Of course, you’ll want to talk over the risks versus the benefits with your physician, but I would strongly encourage almost all postmenopausal women at least to consider estrogen therapy.

The issue definitely has an emotional component as well as a rational one, and I have had many patients who had such strong feelings about estrogen replacement that they declined it even after an extensive discussion of the risks and benefits. Adults have an absolute right to make their own health care decisions, and, as any competent and caring physician would, I respect the right of patients to make those decisions free of any pressure or judgment from others.

Aside from the pharmacological aspects of estrogen, there are two crucial lifestyle choices that may well be more important than drugs. Regular exercise, or even yoga postures that put the bones under a slight stress, will dramatically reduce the loss of calcium that results in osteoporosis. But the most important risk factor for osteoporosis is smoking, which doubles the rate of calcium loss from the bones—yet another reason for making smoking cessation the top health priority for any smoker.

From Stay Young, Start Now, by Alan Bonsteel, M.D. Copyright © 2000 by Alan Bonsteel. Excerpted by arrangement with Celestial Arts. $15.95. Available in local bookstores or call 800-841-2665 or click here.