Menopause: Change, Choice and HRT

A Rockpool book

PO Box 252

Summer Hill

NSW 2130

Australia

www.rockpoolpublishing.com.au

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First published in 2013

Copyright © Dr Barry G Wren and Margaret Stephenson Meere

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the publisher.

National Library of Australia Cataloguing-in-Publication entry

Wren, Barry G. (Barry George)

     Menopause: change, choice and hrt

     Dr Barry Wren; Margaret Stephenson Meere.

     ISBN: 9781925017052 (ebook).

     Includes index.

     Menopause.

     Menopause–Treatment.

     Menopause–Alternative treatment.

     Menopause–Hormone therapy.

618.175

Cover design by Ingrid Kwong

Edited by Jody Lee

Illustrations by Swift Prosys

Typeset by Peter Guo, Letterspaced

Every effort has been made to identify copyright holders of extracts in this book. The publishers would be pleased to hear from any copyright holders who have not been acknowledged. The information provided in this book is intended for general information and guidance only, and should not be used as a substitute for consulting a qualified health practitioner. Neither the author nor the publisher can accept responsibility for any adverse events arising out of the contents of this book.

As this book lists many commercially available products, both the authors and the publisher emphasise that this does not in any way convey their endorsement of these products and they are therefore not responsible for any adverse events arising as a result of their use.

This book is dedicated to girls and women everywhere.

A woman in the autumn of her life deserves an Indian summer rather than a winter of discontent.

— Robert Greenblatt, 1907–1987, First President,

International Menopause Society

To everything there is a season, and a time to every purpose under the heaven:

a time to be born and a time to die;

a time to plant, and a time to pluck up that which is planted;

a time to kill, and a time to heal;

a time to break down, and a time to build up;

a time to weep, and a time to laugh;

a time to mourn and a time to dance;

a time to cast away stones, and a time to gather stones together;

a time to embrace, and a time to refrain from embracing;

a time to get, and a time to lose;

a time to keep, and a time to cast away;

a time to rend, and a time to sew;

a time to keep silence, and a time to speak;

a time to love, and a time to hate;

a time of war, and a time of peace.

— Ecclesiastes 3:1-8, The Book of Wisdom

How to use this book

This book has been written for women, to explain the menopause and the influence of the ovary and its hormones on a woman’s body and health. It is a guide to help them make choices for their future health and life potential. This is not a book that needs to be read from beginning to end, nor is it a book of hard science. It is a book written to explain the history, biology, scientific studies and treatments for the menopause, a time in a woman’s life that has until now, been a mystery and often a misery for many.

While this book has been created primarily for women, it has been structured in a way that makes it accessible for all readers. Consequently it has been divided into five sections for quick access to the essence of its content. The first four sections cover the history and definition of menopause and Hormone Replacement Therapy (HRT), menopause and health, the management of menopause, and finally the therapy choices or options that are available.

For the reader who scans the book there are the summaries that conclude each chapter in the first three sections. For the reader who wants to probe more widely, there is extensive detailed information in the body of each chapter. The fourth section of the book provides an overview of menopause today. Section five contains the appendices for the reader who wants to delve more deeply into the many different therapies of the menopause as well as providing more details of hormones and cancer.

Menopause is a time in every woman’s life that is a journey of personal change and new growth. This journey does not come with a road map. However, this book provides some direction and new understanding of the menopause. It is up to a woman herself to choose her own path, and to determine how she wants to achieve her intended purpose in life.

Author’s note

In my practice as a gynaecologist, I ask a woman attending her first consultation to complete a short questionnaire. This provides me with her relevant essential personal details and helps me to ascertain what she perceives to be her concerns or problems. At the end of the questionnaire there are a few lines available for comments or questions that she may have. These comments and enquiries contain some of the most enlightening statements regarding the impact the menopause may have on a woman. Among the hundreds of written comments, the most frequent are those expressing confusion and bewilderment. The questions most often asked are ‘How long does the menopause last?’, ‘Why do I feel so flat?’, ‘I’ve lost interest in everything – is this due to the menopause?’, ‘Can I do something to prevent my body from deteriorating?’, ‘What can I do to prevent osteoporotic fractures?’, ‘Is it alright to have sex?’, ‘Will I be able to have a satisfactory relationship with a new sexual partner?’, ‘If I begin hormone therapy, can I fall pregnant?’, ‘Will I go mad/demented if I take HRT?’, ‘Will I be able to do the things I did before the change?’, ‘What will become of me?’, ‘What can I do?’

A woman today has a good general knowledge about sex and contraception, and she can readily obtain information on matters such as rearing children and coping with inter-personal family matters. However, the symptoms of her menopause can come as a surprise and the management of them is surrounded in confusion and controversy. The underlying physiology of the menopause is also a mystery for many women. They want to know what is happening to them, how the menopause will affect their future, and what options are available to treat their problems.

It became apparent that the majority of women attending my office had no clear idea of the physiology of ovarian hormone activity, the effect of hormone deficiency on cells and organs in the body, or the possible treatment options to reduce the effects of hormone deficiency. They complained that often their busy family doctor diagnosed them as suffering from ‘the menopause’ but cautioned that hormone treatment caused breast cancer or stroke which meant that hormone replacement therapy was contraindicated. Very few family doctors are able to give the time to discuss the role of hormones in maintaining health and quality of life, or in reducing disease, nor are they able to discuss recent research results related to breast cancer, heart attacks, hypertension, dementia or osteoporosis. Alternative therapies such as neurotransmitter inhibiters, plant extracts, herbal mixes and other treatments are offered as a means of reducing hot flushes, but there is very little or no advice regarding the reduction of other diseases associated with the post-menopause.

For more than 30 years, I have written a number of books for medical students and doctors to provide medical information on hormones and hormone replacement therapy. Some of the women attending my consulting rooms acquired copies of these or other medical books related to the menopause, in order to obtain the information for which they were searching. Most of those who had read my medical books were complimentary about the information and many suggested that I should write a book especially for them – one which would explain the physiology and the long-term effect of hormone deficiency so that all women could understand it and make their own decisions about their available options.

Even though the post-menopause will last for about half of their adult life, women have not been able to easily obtain accurate and unbiased information about the changes that will happen to them during a significant phase of their life.

Many women have criticised their family doctor for not explaining the impact of estradiol and testosterone deficiency as well as the importance and significance of progesterone. Some women have blamed the media for accentuating and exaggerating the adverse findings in the Women’s Health Initiative study report, and many have been angry with the media for not providing a balanced and objective coverage of research about the menopause. In presenting the information in this book, I have based all the evidence and information on the many research reports which have been published by scientists working in institutions that have an impeccable reputation. All significant papers from which I have drawn my information are listed in the reference section. In quoting important research and published results, I have attempted to make the details easily understood and, I hope, of value, for women who ask ‘why does this happen?’

For all of you who have requested it, here is your book.

BARRY G. WREN

CONTENTS

Cover

Title

Copyright

Dedication

How to use this book

Author’s Note

PROLOGUE

INTRODUCTION

SECTION ONE

History, Menopause, HRT and the Women’s Health Initiative Study

1.  A HISTORY OF THE MENOPAUSE AND HRT

A history of management of the menopause

Sex and its influence on the understanding of menopause

The development of effective hormone therapy

The development of oral contraception and HRT

The development of Hormone Replacement Therapy (HRT)

Summary

2.  THE ANATOMY AND PHYSIOLOGY OF THE MENOPAUSE

Menopause

Peri-menopause

Post-menopause

Premature menopause

The endocrine system

Ovarian hormones

Anatomy of the reproductive organs of the pelvis

Ovarian physiology and the sex hormones

The end of female production of estradiol and progesterone

Physiological changes during peri-menopause

Summary

3.  THE WOMEN’S HEALTH INITIATIVE STUDY

The Study

The suitability of women selected for HRT studies

Unfortunate consequences of the WHI Study

Medical research reports, studies and their interpretation

Summary

SECTION TWO

MENOPAUSE AND HEALTH

4.  HORMONES AND GENITAL CANCER

Endometrial (uterine) cancer

Ovarian cancer

Breast cancer

Genetic mutations in pre-menopausal women

Risk factors associated with development of breast cancer

Cluster cancers

Summary

5.  ESTROGEN AND THE CARDIOVASCULAR SYSTEM

The protective effect of estrogen

Thrombosis (clot)

Varicose veins

Summary

6.  OSTEOPAENIA AND OSTEOPOROSIS

Bone mineral density studies

The role of estrogen in prevention and treatment of osteoporosis

The increased risk of osteoporosis for a woman who stops HRT

Summary

7.  HORMONES, BRAIN FUNCTION, MEMORY AND DEMENTIA

Alzheimer’s dementia

Summary

8.  LOSS OF LIBIDO (HYPOACTIVE SEXUAL DESIRE DISORDER)

Estrogen, progesterone and testosterone

Summary

SECTION THREE

MANAGEMENT OF MENOPAUSE

9.  HORMONE REPLACEMENT THERAPY REGIMENS

The development of hormone therapy regimens

Progesterone and progestogens (progestins)

Testosterone

Prescribing advice and HRT

For how long should HRT be used?

Summary

10.  METHODS OF DELIVERING HRT REGIMENS

Oral hormone therapy regimens

Transdermal therapy regimens

Hormone implants

Troches

Vaginal therapy

Summary

11.  ADVERSE SIDE-EFFECTS OF HRT

Breakthrough bleeding

Mastalgia

Skin, hair growth and hair loss

Weight gain

Summary

12.  OTHER MEDICAL TREATMENTS FOR MENOPAUSE

(SERMs) Specific estrogen receptor modulators

Neurotransmitter modulators

Summary

13.  COMPLEMENTARY AND ALTERNATIVE THERAPIES FOR THE MENOPAUSE

Proof of efficacy

Vitamins

Soy products

Red clover extract (Promensil)

Black cohosh (Remifemin)

Evening primrose oil

Traditional Chinese herbal medicines—Ginseng and Dong Quai

Progesterone cream

Wild yam cream

DHEAS (Dehydroepiandrosterone sulphate)

Over-the-counter products

Summary

14.  HRT FOLLOWING BREAST CANCER, ENDOMETRIOSIS OR FIBROIDS

HRT after breast cancer

HRT and endometriosis

HRT and fibroids (fibromyoma)

Summary

SECTION FOUR

CHOICES

15.  THE BALANCE AND BEAUTY OF AGEING

16.  MENOPAUSE TODAY

EPILOGUE

SECTION FIVE

GLOSSARY

ACRONYMS

APPENDICES

Appendix 1: Therapeutic goods administration (TGA)

Appendix 2: Oral hormone preparations: estrogen/progesterone progestogens

Appendix 3: Progestogens for use with estrogens

Appendix 4: Transdermal therapy regimens – patches, creams, gels, sprays

Appendix 5: (SERMs)

Appendix 6: Neurotransmitter modulators used for menopause symptoms

Appendix 7: Treatments of osteopaenia and osteoporosis

Appendix 8: Hormones involved in homeostasis (balance) in humans

Appendix 9: Hormones and cancer

Appendix 10: Assessing research in medical studies

ENDNOTES

ACKNOWLEDGMENTS

INDEX

ABOUT THE AUTHORS

Prologue

In the last few decades, the demographic profile of a woman’s life has changed – a young woman is now delaying her entry into commitment with a partner and an opportunity of parenting in order to pursue a career, or to travel the world before what used to be euphemistically called ‘settling down’.

She feels she is invincible!

Today, a new mother is often well into her middle to late thirties, or even in her forties when not only is she experiencing the rigours of pregnancy, her birthing process and the raising of very young children, it is also the time when she may be entering her years of peri-menopause. It can be a very challenging time for her and her partner. This sociological change is not generally appreciated because a woman of today is remaining physically and mentally younger in her years with a belief that, as she will live a longer life than her parents with an average life span now of about 84 years, she has plenty of time left for family responsibilities.

However, her ovaries have not yet caught up with this social and scientific evolution (this will take a lot more than just a few thousand years), so even though a woman’s physical and mental maturity is developing over a longer span of time, her ovaries and their hormones and eggs begin to decline when she is in her mid to late thirties.

This is a book about hormones, particularly estrogen – what it is, what it does for a woman, and what happens to her when her body stops producing it. Estrogen is what makes a girl into a woman. It is involved in initiating menstruation, having a pregnancy, maintaining her feminine beauty and her vigour and when her ovaries no longer produce it, to mark the completion of her childbearing years. The changes resulting from loss of estrogen are often found to coincide with her years of maturity and freedom and although the symptoms of estrogen deficiency can be distressing, scientific research is revealing that estrogen can alleviate her problems and protect her in her future years.

In her maturity, a woman can determine who she is, and how she wants to live her life. She is responsible for her own health and the choices that she makes for it. The choices she makes in her menopausal years are particularly important.

This book has the strength of two voices – one has the knowledge and experience of a gynaecologist who, for over three decades, has researched the menopause and facilitated many grateful women through it. The other is the voice of a woman who has traversed the years of her menopause, made her choices, and emerged stronger in her new life and career.

There is some technical language in the book, but the science of the human body can’t avoid this. It is important for us to know our own self, not only our physical body but also the mental and emotional aspects as well, but this knowledge and the gaining of it requires endeavour and exploration in order to understand who we really are. Knowledge empowers and allows individuals to understand their life, to make decisions for themselves and to manage their own destiny.

Over the last 100 years women, with courage, have emancipated themselves and they continue to do so. However, there is still a way to travel because strangely, even though we are better educated, we are often ignorant of the function of our own body and quite at sea when it comes to how a woman functions physiologically in her middle and older age.

A girl now has a good basic knowledge of her first rite of passage – her menarche – and is better prepared for it through her schooling and a more open home environment. Her next rite of passage is more one of choice – the choosing to have a child – and this journey is well catered for through information in the media and also in pregnancy, childbirth and parenting education programs.

A woman’s third rite of passage is not of her choosing. It is the inevitability of her menopause, which still remains a mystery – a silent passage with no celebration, very little understanding and no education. This must change if a woman wants to continue to move forward with the respect and support and growth that is her right.

Up until now, some women have endured a miserable and often confusing period of personal turmoil in their menopause transition that may have lasted for years, as any possibility of dialogue about their menopause has been stifled by their own lack of knowledge of it and a sense of shame and grief for her loss of youth and reproductive capacity. Self-knowledge can help a woman to deal with the grief as well as grant her the courage to gather together with other women to talk about her fears, to learn from others, and to develop an understanding and compassion for other women in their transition.

For too long and, in more ways than one, the menopause has been a silent time in a woman’s life. It has been silent because there has existed a belief that it is a ‘natural event in a woman’s life’; that there was nothing that could or should be done about it; and it has also been silent because it hasn’t been privately talked about or publicly debated.

Introduction

When a woman has passed the age of procreation and she is no longer committed to active motherhood, she begins her age of creative energy, independent thought, and freedom of action. She, as a woman of our modern era, now rejects the old notion that she is expected to accept the passive, dutiful or obedient role associated with older age. In spite of her concerns and doubts about her future, she is now able to welcome her post-menopausal years. It is a time that can become a springboard for a new, different and exciting phase in her life. The important issue is – how can a woman cope with ‘the change’.

In the year 1900, women in Australia had an average life span of 59 years. While those living beyond 60 years were treated with veneration and respect, most were not expected to remain in, or to maintain a dominant role in society or to be actively involved in community affairs. Now, only 100 years later, their average life expectancy has increased to 84 years and women in the 21st century can expect to live over 40 per cent (35–40 years) of their lives after they have passed the menopause.

The menopause has become a dramatic marker of a change in physiology and body function for all women. Some women may experience severe flushes, sweats, insomnia, mood swings, depression, loss of interest, loss of drive and loss of libido, while others may develop osteoporosis, heart attacks, dementia or cancer.

For hundreds of years, women have traditionally been categorised into three ages – the maiden, the mother and the wise old crone, or matriarch. But the 20th century ushered in the fourth age of a woman – the age of liberation and – an age for development – to be a mentor and adviser, passing on life experiences to younger women, supporting daughters and grandchildren and re-creating themselves with new vigour and determination. She now has the freedom and the years to embark on a new career, and to find new interests – the age to have fun and to enjoy life – the age of re-creation. This fourth age is the age when a woman who, having produced, nurtured and educated her children, and created a home for her family, gains the freedom in which to re-create herself as a significant individual, embarking on a new life, with new choices and the opportunity to develop a new vocation and the freedom to express her new sexuality. It is the age when a woman who, having ventured into one career path in her youth, should be able to receive the acclaim she deserves as she advances in her new chosen profession.

Women (and men) are taking much longer to become ‘old’.

However, many women do not enjoy the extra years they are now given – they are often adversely affected by the physical, psychological and sexual changes associated with loss of the hormones that, until the menopause, are produced by the ovary in order to maintain normal function of cells. For a large number of post-menopausal women, the use of sex hormone therapy to maintain activity of dependent cells, may allow them to continue their career, to embark on a new venture, to save their marriage or even begin a new life.

Mary, a woman in her late forties held a very senior position in a government department. She was lauded by her colleagues and political masters as being an exceptional public servant and, as a consequence, had been promoted to head a very important department. She was regarded as not only being an exceptionally intelligent woman but an outstanding administrator.

Then, without warning, she began to experience severe and distressing migraine headaches, episodes of memory disturbance, night sweats and embarrassing hot flushes. She felt her ‘brain was made of cotton wool’. These symptoms were so disturbing that she was unable to function adequately in meetings with government ministers and other senior bureaucrats. She often burst into tears for no apparent reason, and suffered extreme mood swings.

She saw her doctor who was concerned about her psychological state and the severity of her symptoms. He referred her to a psychiatrist who prescribed an anti-depressant and a sedative. When after three months there was no improvement, she felt convinced she had a brain tumour and this fear was accentuated by several episodes of panic attacks, insecurity and depression. She was even more devastated when her partner of many years decided he could not cope with her mood swings, outbursts of anger and her irrational behaviour and marked loss of libido. He decided to separate from her. After almost twelve months with no relief from various therapies (mostly psycho-trophic drugs such as anti-depressants, anxiolytic agents and sedatives) prescribed by her doctor, and distressed and embarrassed by her symptoms, she resigned from her position. Because of the marked effect on her general health and her wellbeing, she contemplated suicide.

Her sister, who was receiving hormone therapy, thought there may be a hormonal problem and persuaded her to attend the clinic at the Menopause Centre at the Royal Hospital for Women in Sydney. Her medical history revealed that she had suffered from severe and painful periods and for that reason a hysterectomy had been performed when she was 32. Physical examination and investigations confirmed that she was markedly deficient in ovarian hormones, so she was advised to begin hormone therapy.

Within a week of having estradiol and testosterone implants inserted in the fat in her lower abdomen she began to feel ‘normal’ again and her symptoms disappeared. Unfortunately she was unable to resume her previous position with the government. Her expectations of a successful career as the head of her department had been shattered by the onset of her ‘menopause’.

Mary’s story is not unique. Many women have told of their distress as they have attempted to cope with overwhelming change in their ability to function during and following the time of gradual loss of their ovarian hormones.

The classic image of the menopause is of a woman fanning herself vigorously as she experiences a flush associated with uncontrolled sweating, or it is of an older lady who has a dowager’s hump following osteoporotic fractures of her spine.

Loss of estradiol at the menopause is frequently associated with other distressing personal problems such as insomnia, poor verbal memory recall, dementia, psychological or emotional disturbances, increasing urinary frequency, a dry vagina and loss of libido.

During the post-menopause, a woman may continue to suffer from a variety of distressing symptoms such as flushes and sweats, emotional and psychological depression or discomfort during sexual intercourse (sometimes leading to rejection by a partner). She may also develop some disfiguring physical changes (a dowager’s hump) or premature skin deterioration (wrinkles, fragile skin) and, because of these changes, she often experiences social humiliation and isolation.

Until the middle of the 20th century, life for many post-menopausal women was bleak and depressing, with little reduction in the progression towards crush fractures of the spine due to osteoporosis with subsequent immobility; memory loss, Alzheimer’s dementia, or premature death from heart attacks. Many women continued to experience the peri-menopausal symptoms of distressing flushes, sweats, insomnia and marked sexual problems into their advanced age.

With the availability of relatively cheap commercial quantities of sex hormones (estradiol, progesterone and testosterone) the situation for a woman has changed and she now has access to reliable hormone treatment options.

For all women it is vitally important that the normal function of cells in the brain, bones, muscles, the heart and other vital organs is maintained. There are many therapies, both medical and non-medical, which may help to maintain the vitality of a post-menopausal woman. These include regular exercise, the maintenance of normal weight, the stimulating of brain function with mental exercise programs and to give up smoking.

Hormone therapy can also help with this maintenance. There are hundreds of hormones