MENOPAUSE CONTINUED

By 1940 the medicalization of menopause became popular, they prepared drugs from the urine of pregnant women and pregnant female horse's(Premarin). These drugs were available in the USA in high doses such as 1.25mgs.


Further down the track by 1948 smaller doses were available such as 0.625 mgs and 0.3 mgs.
In 1950 Ayrest Laboratories funded a big campaign to educate women on menopause, what it is and how it can be helped. After their public relations exercise's, Premarin become the number one drug dispensed in the USA.


This got further promotion when gynaecologist Dr Robert Wilson in 1964 published an article on menopause called" Menopause" and a book called" Feminine Forever".
He did very extensive PR on the value of HRT, however by 1968 the side effects of oestrogen replacement therapy started to become obvious, such as endometrial cancer, breast cancer, deep venous thrombosis and the lack of any benefit to heart disease. There were some benefits, such as the prevention of osteoporosis and fractures.
Because of these complications several studies were set up to assess the benefit risk ratio of HRT(Oestrogen and Progesterone).


The main study was set up by the national institute of health , called Women's Health Initiative(WHI).
This was started in 1991 and to be completed in ten years on 160,000 women.
There were four arms to this study , one of them was a continuous oestrogen progesterone with an intact uterus, however this had to be stopped after 7 years due to increased risk of breast cancer , heart attacks and deep venous thrombosis.
This group had women of all ages from early menopause to late. They were more useful in younger women who took the HRT at the start of menopause.


The conclusion drawn from these controlled trials there was clear evidence of deep venous thrombosis, there was no clear benefit of cardiac disease and there was no increase in coronary disease in women less than 10 years post menopausal.


After this study and many others the oestrogen was on trial and it seemed that the benefits of oestrogen were less beneficial than the side effects, this created a fear amongst women particularly the increased risk of breast cancer.
All of a sudden the sale of HRT plummeted , the stock market fell by nearly 20% and the sale of drugs from Wyeth namely Premarin fell from 1.2Billion to 984.Million.
People started to believe that these tablets were no more the magic bullet.
One of the problems with this study was that they included women of all ages and even those who had no symptoms.
As a result of this fear, millions of women suffered from severe hot flashes and problems with their sexual life. Their husbands also suffered during this period from their wives' mood swings, bad temperament and were devoid of any sexual pleasure with each other.
We have recently worked out that Pre menopause, Peri menopause and Menopause is a continuum of the same biological problem, which is the lack of oestrogen due to the end of the biological cycle for women. This is now referred as Peri-Menopause, Menopause and Post Menopause. This has been studied under stages of reproductive aging, this makes it easier to understand women's menopause.
This period lasts for several years and that's why is was called "Climacteric". This in Greek meant seven years.
Currently we call it Menopause transition.


During this time some women have variable menstrual cycle both in duration and amount of bleeding, some of them still ovulate and can get pregnant. One of the hormones called F.S.H which comes from the brain increases. Please refer to earlier posts in relation to menstrual cycle.
Later on in menopause transition the menstrual cycles are delayed up to sixty days or more, F.S.H increases further. Its called menopause when you have not had a period for one year.


During this time of menopause transition women suffer symptoms of menopause, such as hot flashes, lack of sleep, mood swings, irregular bleeding and many others.
During this time we need to treat them and also offer contraception.
Recently the Women's Health Initiative has published a new update on women's health along with the British Menopause Society , North American Advisory Committee and Royal College of Gynaecology have all published new guidelines on HRT, so we have come full circle.
WE should not let women suffer from any fear from menopause or HRT, always consult a professional and not be guided by the media frenzy about this subject.


The original WHI created a lot of confusion, the reasons being the selection of women for the study was incorrect. 160,000 women were selected with no consideration of their age, their symptoms, their medical history, obesity, smoking, and poor lifestyle factors. They mainly focused on the long term benefits of HRT, no attention was paid to their initial symptoms such as severe hot flashes, urinary symptoms, lack of sleep, mood swings, and many other annoying problems.


The results were also analysed and expressed very poorly , for example they said that breast cancer risk increased by 26 per cent( 30-10,000 to 38-10,000 ), this frightened the life out of women and their care providers, they could have easily said, one extra patient in 1250 women who had been on HRT for 5 years was at risk.
The next worst thing was that these results were given to the media before they were published in any medical journal and analysed by the experts.
Many experts felt that the WHI conclusions needed a complete reassessment.
It is after ten years of muddy conclusions and many research trials the cloud over HRT has cleared.
We cannot say that HRT has no side effects , but the benefit risk ratio is in favour of the benefits.


The most important thing is to remove the fear in the mind of women and their care providers, the next important thing is the timing of HRT, the sooner it is started near menopause or menopause transition the better it is.
If we start after women are over 60 or ten years after menopause, the aging effects have already influenced their bodies.
HRT should not be offered for prevention of chronic disease except for osteoporosis, it is useful in women before the age of 60 who have the risk of osteoporosis.
This fear of HRT has been fuelled by an aggressive alternative medicine industry, the media, some non clinical groups seeking publicity for funding and the Therapeutic Goods Association has not revised the inaccurate conclusions of the WHI.


In general the conclusions on HRT are:
1- Do not let the women suffer who need HRT for their symptoms.
2- Can be an appropriate treatment for women with osteopenia, or osteoporosis.
3- Local oestrogen therapy is very useful with women who have a dry vagina and associated poor sexual life, and in fact it puts the smile back on their faces, and they can enjoy sexual pleasures for further years.
4- Women who have had a hysterectomy only need oestrogen alone and this has no increased risk of breast cancer.
5- In women who have a premature menopause, HRT is very essential until at least the normal age of menopause.
6- The recent trials suggest that the lowest dose of oestrogen should be used.
7- It is useful to use transdermal oestrogen( on the skin )  as it prevents vascular complications, eg: Deep venous Thrombosis.
8- The dose and duration of HRT and safety issues should be discussed in individual circumstances.
9- The use of custom-compounded bio identical hormone therapy is not recommended.
10-Current safety data do not support the use of HRT after breast cancer. If you have to have it then you need to have a detailed consultation with your Oncologist.


The other things we will need to discuss about menopause are, Anatomy and Physiology of Menopause, Assessment of Menopausal Women and current treatments available.