25 February 2010

Menopause is a natural event occurring in a woman generally between the ages of 45 and 55 and is associated with the decline of the hormone estrogen. The signal event in this occurrence is the absolute cessation of her menstrual periods, indicating an end to reproductive potential. For technical purposes, menopause is deemed to have occurred if there have been no menstrual periods for 1 year.

If during the years before and after menopause there occur a number of uncomfortable and disturbing symptoms, then this period is referred to as perimenopause. This transitional period may evidence symptoms such as “hot flashes” and “night sweats” which are pathognomonic of this condition. The list of symptoms associated with menopause can be quite exhaustive and may include any number of disparate maladies. Post-menopause, symptoms may persist for up to 5 years, but are usually more disconcerting in the initial 2 years after the cessation of menstruation. Gradual estrogen decline as in natural menopause allows the body to better adapt to the change. On the other hand, sudden drop in estrogen levels as precipitated iatrogenically via surgery, chemotherapy or radiotherapy usually initiates severe symptomatology.

In the long term, however, other more permanent and established features such as wrinkled and dry skin, problems with micturition, joint aches and joint pains may occur. We have also been told of the likely occurrence of conditions such as cardiovascular events, dementia and colon cancer.  Needless to say, the presence of such symptoms and possible long term complications can be life changing, driving many patients and health care professionals towards alleviation therapy. In the past, not only has this form of therapy been clinically advocated, but even positioned as a necessary requirement for a healthy life.

Although initially approved by the US Food and Drug Administration (FDA) as early as 1942, replacement therapy really took off in 1966 with the publication of a book titled “Feminine Forever” by gynaecologist Dr Robert Wilson. In his text, Dr Wilson upended the prevailing idea of menopause as a normal stage of life event, and disparaged it by classifying it as a degenerative disorder. He further stated that this “disease” could be prevented by using hormonal medications. In the subsequent years and decades, numerous television and print advertisements involving popular actresses and men in white coats  would go on to propagate the necessity to inhibit the effects of age on women using “Hormone Replacement Therapy” or HRT. In time, the medical community came to “believe” in the protective benefit of estrogen, with rampant prescription to a multitude of women. To say that these efforts were in the majority motivated and funded by the pharmaceutical industry would be understating the fact.

Since that time, large sums of money have been spent on influential physicians, medical societies, medical courses and scientific journals with positive reinforcement of the benefits of HRT. Not all were deceived though. Clinical studies provided glimpses of ineffectiveness, and worse, side effects. However, countered by a general financial feel good factor coupled with clandestine subversion of such evidence, these findings remained buried until mounting evidence rocked the foundations of this billion-dollar industry.

First in the 1970s association of HRT with endometrial cancer, and then in the 1990s with breast cancer, there was enough evidence from research to finally subdue this blind belief in the benefits of HRT. Reports in The New England Journal of Medicine in 1975 positively linked continuous usage of estrogen to the development of endometrial cancer. Although this, and subsequent FDA action, resulted in a sharp decline of estrogen prescription, sales of the drug rebounded when its efficacy and safety were shown in hysterectomised patients. Clever repositioning of HRT in preventing heart disease, Alzheimer’s disease and stroke as well as wide ranging health benefits, with the aid of several studies lead to renewed interest in the medication, albeit in combination form with progestins for protection against endometrial hyperstimulation. Although numerous studies later showed an increased risk of breast cancer with such treatment, these were dismissed due to their observational nature and the belief that this risk was outweighed with the larger benefit in preventing cardiovascular and neurological problems. The publication of The Women’s Health Initiative in 2002 put paid to that. This randomized study, the largest ever clinical trial into women’s health, displayed an increased risk of breast cancer, myocardial infarction, stroke and even dementia among women who took certain combination hormone therapy. HRT use around the world declined, followed by a drop in breast cancer cases.

Branding the use of estrogen around the time of menopause as “Hormone Replacement Therapy” can be misleading. “Replacement” would imply that women require hormone drugs to stave off the undesirable aspects of ageing after menopause. In its place, the term “Menopausal Hormone Therapy” has been advocated by the National Institutes of Health in the US. Abbreviated to MRT, this term is more current and does not carry any implications associated with the afore-mentioned one. Use of hormones in and around the menopause should be an informed choice for women with symptoms. Knowledge of the benefits and side-effects of these drugs, surveillance against adverse effects as well as alternative treatments should be mandatory prior to commencement of such therapy.

Today, hormone therapy has been shown to be very effective for treating hot flashes, night sweats and other early symptoms of menopause. This symptom management together with the full risk disclosure and proper clinical vigilance can lead to a very satisfying transitional period for women. Menopausal hormonal drug use should be limited to those women with symptoms and with low doses for short durations. It should not be positioned for health improvement or anti-aging.

Hanifullah Khan
Consultant O&G & Laparoscopic Surgeon, Lumut, Malaysia

MEMS Council Member 2009/2010.