Menopause

A woman enters her reproductive "life" at the onset of the first menses or about twelve years of age. Usually, fertility peaks in the late teens or early twenties and most women experience a decline in fertility in their thirties. Menopause is a natural event in the aging process and signifies the end of the reproductive years with cessation of cyclic ovarian function as manifested by cyclic menstruation. The hormonal markers of menopause include:

1. A low estrogen level, which has consequences on many organ systems apart from the reproductive system.
2. High FSH and LH levels
3. Low testosterone level

Perimenopause is the transition period from the childbearing years to menopause, which may last from several months to several years. Menopause is defined as the final cessation of menses. The average age of menopause is 51 and less than 1% of women experience it before the age of 40. Some women undergo premature menopause at a very early age affecting their ability to have children.

Causes of Menopause

• Physiological (a normal part of every woman's reproductive life)
• Surgical (a result of removal of the ovaries)
  
• Chemotherapy or high dose radiotherapy related to cancer treatment
• Premature (may be an immune process)

Symptoms of Menopause

• Hot flashes
• Vaginal dryness
• Irritability and mood swings
• Loss of libido (sex drive)
• Depression, anxiety
• Fatigue and inability to concentrate
• Headaches
• Loss of skin elasticity with reduction in breast size

Menopause is a normal part of a female's life and, with expert management; she should experience an excellent quality of life. Of course, this is a time of intimate change, and change is always associated with anxiety and trepidation. The following are not necessarily true about the menopausal years and the reader should be reassured that:

• Weight gain is not inevitable.
• Hormone replacement therapy is not deleterious when administered properly.
• Sexual enjoyment and gratification may continue for many years.
• Hysterectomy is not an automatic consequence of menopause.

With a proactive approach, as advocated by Dr. Kustin, including a strong emphasis on preventative care and the use of hormone replacement therapy (HRT) in appropriate cases, the menopausal years may indeed be the golden years of a women's life. Dr. Kustin develops a customized regimen for each patient.

Estrogen Deficiency

1. Menopausal syndrome (described above)
2. Atrophic vaginitis and urethritis which may lead to discomfort during intercourse and incontinence of urine. The pelvic musculature atrophies with the decline of estrogen production leading to a loss of pelvic tone and possibly prolapse (descent of the uterus, bladder, and rectum).
3. Osteoporosis due to bone loss with an increased risk of sustaining fractures especially of the hip and spine.
4. Athelorosclerosis (hardening of the arteries) with resulting cardiovascular disease.
5. Hot flushes are an integral part of the transition into the menopausal years. They are related to a low estrogen level and to the pulsatile episodic release of hormones from the pituitary gland because of a failing ovary. These hormones increase the blood flow to the skin of the upper body causing a flushing sensation. Because of the diminished secretion of estrogen and testosterone, women may experience a distressing alteration in sexual function. This may take several forms:
   
   
   • Diminished sexual responsiveness.
   • Dyspareunia (painful sex)
     
   • Decreased sexual activity and desire.
     
   • Associated dysfunction in the male partner.

Osteoporosis

Osteoporosis is a common condition in which the skeleton is sufficiently compromised by reduction in the mass per unit bone volume such that there is a significantly increased risk of skeletal failure (fracture) even in the absence of trauma.

The loss of estrogen at the time of menopause may increase a woman's propensity to develop bone loss. There are other uncontrollable risks factors including:

• Family History
• Low bone mass at the onset of menopause
• A slender slight build
• Caucasian race with a fair complexion
• Premature menopause or early surgical menopause
• Treatment with certain steroid drugs

Controllable risk factors for the development of osteoporosis include the following:

• Lack of physical exercise
• Insufficient dietary calcium
• Smoking
• Alcoholism
• Excessive caffeine intake
• Estrogen deficiency

The continued loss of bone mineral is termed osteopenia until the bone mineral mass reaches a critical low level termed the fracture threshold. At this point the patient is suffering from osteoporosis and has an increased fracture risk.

Dr. Kustin has advanced training as a reproductive endocrinologist and is very familiar with the management of difficult menopausal problems including hormone replacement therapy.

His philosophy includes the fact that the patient must be an informed partner in making decisions regarding therapy. Preventative care is paramount in the successful management of the menopause. Treatment protocols must be individualized for each patient depending on the clinical setting, symptoms, and side effects.

Dr. Kustin encourages every woman attending for menopausal care to undergo the following evaluations:

1. General medical checkup including colonoscopy when indicated.
2. Gynecological evaluation including mammogram and possibly endometrial biopsy to exclude a pre cancerous condition in the uterus.
3. Gynecological ultrasound as a screening test for ovarian cancer, which is a deadly disease when diagnosed in its advanced stages but very treatable in its early stages. Ultrasound detection of early ovarian cancer may save lives.
4. Blood work
5. Screening for osteoporosis when indicated with a dexascan (bone density study or urine and blood tests).

Having completed this initial evaluation, a personalized treatment plan is developed and progress closely monitored.

Treatment of Menopause

This may take the form of the replacement of estrogen, progesterone, and occasionally testosterone. There are many protocols for the safe administration of HRT, which may be accomplished with pills, or skin patches administered continuously or cyclically depending upon the clinical setting. Many of the changes of menopause may be reversed with hormone replacement therapy but this approach may not be indicated in every case.

There are potential advantages of skin patches compared to pills. These are:

• Ease of use with continuous low dose delivery
• Minimal nausea
• Minimal effects on the liver and gall bladder
• Less risk of hypertension

Estrogen therapy has several benefits including:

• Alleviation of menopausal syndrome
• Prevention of osteoporosis
• Improved lipid profile
• Lower cardiovascular risk
• Improved sexual function

• Episodic uterine bleeding (this may occur as a result of the addition of progesterone to remove an increased risk of the development of uterine cancer if estrogen is taken alone).
• Periodic endometrial sampling
• Side effects of estrogen and progestins
• Long term commitment to taking medications

Estrogen Contraindications

Certain patients should not be prescribed estrogen. These include those with the following conditions:

• Acute vascular thrombosis
• Acute liver disease
• Undiagnosed vaginal bleeding
• Impaired liver function
• Carcinoma of the breast or reproductive system
• Pregnancy or active pregnancy complication

Other patients need very careful evaluation and close monitoring before taking estrogen. This includes those with the following conditions:

• Hypertension
• Vascular disease (including phlebitis)
• Benign breast disease (fibrocystic)
• Uterine fibroids
• Migraine headaches
• Endometriosis
• Gallbladder disease

Estrogen Side Effects

• Mastalgia (breast tenderness)
• Fluid retention and bloating
• Resumption of menstruation
• Nausea
• Hypertension
• Gallstones
• Phlebitis

Hormone replacement therapy is certainly associated with many benefits and many women experience profound relief from menopausal symptoms because of this therapy. However, there may be risks:

1. Endometrial (uterine cancer)- There is a marked increase in the incidence of uterine cancer in women who are prescribed estrogen without progesterone (in women without a uterus estrogen is usually prescribed alone). However, combination therapy has been shown to eliminate this risk. Careful monitoring of patients on HRT is mandatory.
2. Breast cancer- Many studies have been published regarding the links between breast cancer and HRT. At this time, there is no consensus as to causation. Regular surveillance with mammography is mandatory.

There is much discussion in the lay press concerning the side effects of HRT therapy. While side effects can be serious, the benefits of therapy usually outweigh the risks. The best chance for successful treatment results when a trained specialist such as Dr. Kustin is consulted.

There is also abundant lay literature concerning the use of natural products to control the symptoms of menopause. Many plants contain "naturally occurring estrogens" or phytoestrogens that may alleviate some of the symptoms of menopause. The major difficulty with these products is the lack of adequate studies documenting effectiveness and the variability of concentrations of hormones found in plant material. The hormonal components of prescription products are precisely measured and controlled for optimal effect with the least chance of side effects.