Menopause

Menopause is a natural biological process in which the menstrual cycle is permanently terminated and marks the end of women’s fertility.

It is a transitional period in a woman’s life, during which her ovaries essentially stop producing eggs, her body produces less oestrogen and progesterone, and her menstrual periods become less frequent and eventually stop.

Menopause usually occurs in a woman in her 40s or 50s.

Statistically it has been shown that the average age at which it occurs is set at 51 years. However, the menopausal period can last several months or even years, and may present several physical and emotional symptoms, including sleep disturbance, hot flushes, reduced energy, anxiety and feelings of sadness and loss.

Hormonal replacement therapy and its effects

It is a common doctrine that hormones should be replaced if a significant biological hormone deficiency is documented. Following this principle, but also in accordance with the results of various observational studies, it was common practice, until the early 2000s, for women entering the menopause to receive hormone therapy. In 2002, however, a large randomised study was published in America, the WHI, which caused concern among both women and doctors themselves and resulted in an 80% reduction in the use of hormones in post-menopausal women. The first part of this study showed that long-term use of estrogen hormone therapy with progesterone may slightly increase the risk of breast cancer. Also, in the same age group of women (mean 63 years), the co-administration of oestrogen and progesterone was also found to increase the risk of cardiovascular events and on the other hand to reduce the risk of fractures and colorectal cancer. The second part of this study in women who had already had a hysterectomy showed that long-term estrogen alone, without progesterone, did not increase the risk of breast cancer. Of note, women who have had a hysterectomy do not need to take progesterone. The average age of the women in this study was 63 years old and only 3.5% were between 50 and 54 years old, the age at which the decision should theoretically be made whether or not to give hormone therapy. Given this, a great deal of controversy has erupted as to whether and to what extent the results of this study can be a guide to the use of hormone therapy in young women just entering menopause. Indeed, the data from the newer studies focusing on this group of women just entering menopause are encouraging in terms of the benefits, but also reassuring in terms of the risks of hormone therapy.

Latest data – What the latest studies tell us

Currently, the majority of women who start hormone therapy do so in less than 10 years from the time of menopause. Newer studies are focusing on this category of women.

The benefits

Up to 59 years of the WHI study shows that estrogen-only supplementation not only does not increase the risk of heart disease, but instead reduces it. Similarly, co-administration of estrogen and progesterone in the above category of women does not increase the risk of cardiovascular events. The co-administration of oestrogen and progesterone may reduce the risk of diabetes mellitus and is accompanied by less fat deposition, particularly in the abdominal region, which usually occurs during menopause. Also, numerous studies show that hormone therapy in recently postmenopausal women increases bone density and reduces the risk of fractures. Finally, for the symptoms of menopause which affect all women to a greater or lesser extent, such as hot flushes, night sweats, dryness of the vagina, painful sexual intercourse and mood swings, nothing is more effective than the administration of hormones.

The risks

The individual analysis of the data from the WHI study for this group of women shows that the administration of oestrogen alone (in women with hysterectomy) and for less than 5 years does not increase the risk of breast cancer. It is worth noting that recent randomised trials have shown even a small reduction in breast cancer risk after estrogen administration and for up to 5 years. Also, recent randomized studies show that co-administration of estrogen and progesterone for up to 5 years in young postmenopausal women does not increase breast cancer risk, although data from the subgroup analysis of the WHI study showed a small increase.

The symptoms of menopause can be treated in two phases.

During the first period (up to 5 years), the prevention of bone loss (osteoporosis), along with the specific symptoms of menopause, such as hot flushes and vaginal dryness, can be treated with estrogen administration. The American Food and Drug Administration recommends that estrogen be given at the lowest possible effective dose and for a period of no more than 5 years. After the first short phase of menopause, women should discuss with their doctor the potential benefits and risks of continuing hormone therapy. It should be remembered that the goals of short-term treatment after menopause are different from long-term goals. In the short term, the goal is to relieve the symptoms of menopause, while in the long term, the goal is to prevent osteoporosis and fractures. If you take hormone therapy for three to five years, the risks are relatively small. If you are concerned about developing osteoporosis and are considering continuing hormone therapy for more than five years, consult your doctor, who will indicate whether hormone therapy or another treatment is better for you.