Menopause is a naturally occurring biologic process in females, generally occurring in from age 45 to 55. Menopause occurs after the last ovulation marking the end of the fertile period of a female’s life. It is defined as the permanent end of menses and fertility occurring 12 months after a patients last menstruation. During menopause the body regulates itself to acquire a new hormonal balance, spanning for the rest of the lifespan of the female.
When a female goes through menopause the ovaries stop producing eggs and fewer hormones (estrogen and progesterone); menstrual periods generally become either more closely or more widely spaced, but may even come to a sudden stop. This reduction in potent and active sex hormones, and their downstream biological effects, cause a plethora of changes in physiological processes. An irregularity in menstrual cycles can occur for one to three years. Even though a natural process and not a medical illness, it still can have dramatic effects on a women’s mental and physical health. These effects vary dramatically from one patient to another and are primarily caused by the changes in estrogen and progesterone.
The effect of the underproduction of hormones, and other biological molecules, by the ovaries manifest in several unpleasant symptoms. These symptoms can be divided into two categories physical and psychological. Physical symptoms include irregular menstrual periods, hot flashes, night sweats, heavy sweating, fatigue, muscle aches, heart palpitations, headaches, dizziness, sore breasts, sensitive skin, dry hair, hair loss, prolapse, vaginal drying, painful sexual intercourse, vaginal discharge, loss of libido, urine tract infections, urinary incontinence, and an increase in osteoporosis. Psychological symptoms include mood swings, fatigue, apathy, anxiety, and depression.
A common treatment used for the symptoms of menopause is hormone replacement therapy 1. Hormone replacement therapy mimics the human body’s natural production of those hormones in order to reduce the symptoms associated with dramatic swings in hormone concentrations during menopause 23. Since these treatments are patient specific and vary from patient to patient many different formulations of hormone therapy can be made by compounding pharmacies to meet these individual needs. Hormones of all strengths and concentrations can be put into oral capsules, topical creams or gels, vaginal creams, suppositories, injections, and sublingual lozenges 4. There are also other prescription alternatives to hormonal therapy that may work for some women. Patients have found benefit in reduction of symptoms with the use of anti-depressants, anti-hypertensive and also anti-seizure medications 56.
The treatment of these symptoms can be accomplished by replacing the hormones that the underperforming ovaries fail to produce 7. This therapy is referred to as hormone replacement therapy (HRT). The body naturally stops producing these hormones because its genetics dictate the time for reproduction is over. Even though the body is programmed this way, replacing hormones in the appropriate amounts can maintain a comfortable balance that is beneficial to the female.
Vasomotor symptoms are usually described as night sweats, hot flashes, and flushes. Hormone replacement therapy can reduce these vasomotor symptoms in postmenopausal and perimenopausal women by 65% and 90%, respectively 8.
The lack of hormonal signals, and in balance initiates the biological processes that produce the symptoms mentioned above 10. Therapies to treat and replace the hormonal signals are readily available from qualified physicians.
Therapy includes mono or combination therapy of the hormones progesterone, estradiol and in some cases low dose testosterone. Even though estrogens are referred to as the female hormones, every female also is genetically set to produce testosterone in small amounts. Serum levels of testosterone also drop as estrogen concentrations decrease. Hormone replacement therapy replaces the hormones that the ovaries fail to produce naturally. Generally, if the risk reward ratio of hormone replacement therapy is in the favor of the patient’s health, due to the disruption from menopausal symptoms, hormone replacement therapy might be considered by your physician 11.
Hormone replacement therapy is not for all patients, many patients with pre-existing conditions should consider alternatives if concerned with adverse effects. The benefits of a comfortable and healthy lifestyle should be weighed against the adverse side effects of hormone replacement therapy by your physician.
In recent news, hormone replacement therapy has become the subject of debate among medical communities 12. A large shift in prescribing patterns recently occurred in the general physician prescribing population. When hormone replacement therapy was first prescribed to treat menopausal symptoms, it was generally regarded as safe for all, almost equivalent to consumption of over-the-counter daily vitamins and supplements. Generally, physicians prescribed hormone replacement therapy because of the dramatic effect on the mood and well-being 13. However, dramatic psychological and physical beneficial effects came at a large cost to some. Few women prescribed hormone replacement experienced moderate to severe side effects. These effects did not occur in the large majority of women, but were at a large enough percentage to warrant other drugs with less side effects as treatment for the symptoms of menopause. Many women continue to take hormone replacement therapy for treatment of menopausal symptoms.
Predisposition to disease plays a large part in determining if a patient is an appropriate candidate for hormone replacement therapy 14. Additionally, lifestyle and dietary changes are considered the first line of treatment for healthily undergoing the changes of menopause.
Secondarily, medications with outstanding safety profiles are considered for the alleviation of menopausal symptoms before hormonal therapy is considered. However, contrary to popular prescribing patterns, some physicians prefer to utilize hormone replacement therapy as a primary treatment for menopausal symptoms, these physicians generally approach cautiously. Physicians using hormone replacement therapy as a primary treatment thoroughly evaluate a patient’s pre-disposition to adverse side effects, determine precise hormone dosages, and closely monitor the patient during initiation and continuation of therapy. These measures increase the safety of hormone replacement therapy, a knowledgeable physician can monitor a patient and determine physiological changes occurring from the hormones administered. If physiological changes are determined to be dangerous to the patient’s health the prescribing physician can cease hormone therapy. The serum markers indicative of adverse effects should be monitored by a prescribing physician. Generally, these biomarkers include cardiovascular 15, liver, and general metabolic proteins and small molecules associated with the adverse side effects of estrogen, progesterone and testosterone administration. Negative effects on inflammatory markers biomarkers include, E-selectin, cell adhesion molecules, monocyte chemoattractant protein-1, and tumor necrosis factor-alpha, inconsistent effects on interleukin-6, and stimulatory effects on vasoprotective cytokine, such as the transforming growth factor-alpha 161718. However, women who receive 2-3 years of HRT after menopause do not have increased mortality, in contrast cardiovascular benefits are apparent when compared to those who had not been treated with HRT 19
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