We the
clinicians as well as the women, all worry about hot flushes , night sweats ,
bladder problems, insomnia and mood swings, but do not think about heart
problems in peri and post menopausal women .
However the fact remains that the highest cause of death in women after
50 is cerebrovascular disease (CVS) and stroke. These account for 75-76% deaths
in western society as compared to deaths due to breast cancer which is 6-8%.
Out of every 3 deaths in women 1, is due to CVS. We have to start paying
attention to this and prevent them, from happening. There is a 10 years lag
time when this happens in women as compared to men, unless women have a
premature ovarian failure, premature menopause or early surgical menopause.
Women lose oestrogen, this causes the blood vessels to become stiff, lose their
elasticity, blood pressure increases and this increases the strain on the heart.
The LDL (Low Density Lipoproteins) and Triglycerides (bad cholesterols) increase.
HDL decreases (good cholesterol). Insulin resistance increases leading to, pre diabetes
and diabetes as time goes on. Oestrogen also effects fat stores slows
metabolism, this leads to weight gain and an increase in BMI and increase in
abdominal girth. These are not ideal to prevent heart disease. The coagulation
factors are altered, such as antithrombin3, factor 7c and plasma fibrinogen are
all increased, leading to increased risk of thrombosis. So the risk of heart
disease becomes multi factorial, there is increased blood pressure, strain on
the heart, diabetes, obesity, changed cholesterol, increased thrombotic factors
and increased sympathetic tone. All these lead to, metabolic syndrome and CVD. Some
research has indicated that changes in cholesterol, apoproteins B, happen
within the one year after the final menstrual period where as most other
changes are related to chronological age.
What are the
symptoms of CVS and heart disease? Heart Palpitations, Shortness of Breath, Light
Headedness, Headaches, Diabetes, Swelling of the Feet, (change in the rhythm of
the heart) Fibrillation, Pain in the Chest and Stomach. Women often do not have
a chest pains when they have a heart attack. For neurological problems (Stroke);
a women may not be able to smile put her tongue out and cannot lift her arms
above her head (these are very simple test for the public to work out what is
happening). Take them to a hospital immediately if this is happening. If stroke
sufferers are treated within 4 hours they suffer very little residual damage. It
has been shown that if treatment for prevention of long term CVS is started
soon after menopause or within 10 years of menopause, these can be prevented. Most women need
treating for hot flushes, night sweats, lack of sleep, mood swings, dry vagina
and psychosexual problems, why not give them MHT (Menopausal Hormone Treatment)
and not let them suffer and also prevent them from long term effects of oestrogen deficiency such as increased
risk of CVS and osteoporosis. This early period of menopause is called Xperiod
of opportunity. Later on after many years of menopause, changes in women’s blood
vessels have already occurred and oestrogen is not helpful. If a woman has a
uterus and she needs oestrogen, she needs progesterone as well for uterine
protection from cancer; a form of progesterone called micronized progesterone
is recommended. This has fewer side effects and is better tolerated. For
prevention of thromboembolic problems, dermal oestrogens are prescribed in the
way of oestrogen patches and or jelly. Women should watch their weight, abdominal girth,
exercise, nutrition and quit bad habits such as smoking, excessive drinking of
alcohol and soft drinks and being a couch potato.
It is very
important to start MHT (HRT) during the WINDOW of OPPORTUNITY to prevent cardiovascular
disease, which is the main cause of death in older postmenopausal women. The
window of opportunity is considered to be within 10 years of menopause, or
under the age 60.
There are many
ways in which a woman can be relieved of her peri menopausal problems during
the transitional phase or post menopausal phase. The most important thing is do
not suffer in silence or follow the odd or non scientific, unauthorised,
unproven solutions. MHT or HRT is probably the best solution for a long time or
for the future prevention of complications and deaths from CVD or complications
of Osteoporosis. Women who want to self manage their peri menopause can do this
to some extent. They can watch their lifestyle factors, diet, exercise and
yoga. Some selected antidepressants also help with hot flushes and sleep
disturbances, these also can be tried. They need medical input if there periods
are all over the place, too heavy and they are worried about contraception.
When a medical care giver starts to look after peri and postmenopausal problems
he/she takes a history in detail. This includes age, period history, your
personal history of any medical disorders, DVT, CVS, liver and kidney disease,
any operations, does she have a uterus or ovaries, does she need contraception,
any family history of problems such as CVD, DVT or cancer. There will be a focus
on women’s symptoms, irregular bleeding, anxiety, hot flushes, night sweats,
sleeping problems, lack of interest in sex, dry and painful vagina, urinary
problems such as urgency, incontinence and or repeated bladder infections. The
clinician will do a detailed clinical assessment and look at a woman’s stature,
walking,
vision and hearing. This can all be observed as she enters the clinic and says
hello. He /she will take your weight, blood pressure or may be test your blood
sugar. A breast examination is done, along with listening to the chest,
abdominal examination and above all a vaginal / pelvic examination to find or
exclude any local problem. Not many tests are required to make a diagnosis of
menopause except in situations where there is a question of premature ovarian
failure. It is not very rare if women came to you with a diagnosis of early
pregnancy, (before the advent of such good pregnancy tests) ,the care giver
finds, the woman in fact is not pregnant
and is suffering from premature ovarian insufficiency (PIF). These situations are extremely distressing
both for the care giver and the woman. Some of the tests that are ordered in
peri and menopausal are to assess ,her health
such as FBE , ferritin (iron level in the blood), cholesterol ,thyroid function
tests, liver and kidney function, mammogram, blood in stool, human papilloma virus, now instead of a smear test, pelvic ultrasound
and any other tests if required in particular cases. With all this information
the care giver is in a very good situation to discuss MHT with a woman
depending on her wishes and symptoms. If you are under 60 or within ten years
of menopause, this is what is called window of opportunity. It is the best time
to start MHT if you so desire. It helps with your initial symptoms and prevents
future problems such as CVD, osteoporosis and genitourinary syndrome of
menopause. If a woman has had a hysterectomy the MHT (HRT) is easy to prescribe
and take. Normally women need two
hormones, oestrogens for symptom relief and long term protection from CVD, osteoporosis
and late onset genitourinary problems and progesterone is required for protection
of the uterine lining the endometrium from cancer. Progesterone can be difficult
to take for many women because of side effects, and it also increases the risk
of breast cancer. When there is no uterus, progesterone is not required. It is
easy to take oestrogen only. It can be used as oral, transdermal (on the skin) as
a patch or jelly. It can also be used as an implant. Implants (deposited just
under the skin for slow release) are used 6monthly or 12 monthly depending on
the strength as to how long they will last). Transdermal methods are very good if there is
any history or risk factors for thromboembolic problems. In the early pre
menopausal phase, if a woman needs MHT and her period is overdue always exclude
pregnancy. One of the best MHT is combined oral contraceptive pill, especially
if contraception is required and if there are no contraindications, for the
pill such as high blood pressure, history of thromboembolic (DVT) problems or
smoking. They come in different strengths depending on what is required to
relieve a woman’s symptoms safely. For progesterone, what is currently used is
called micronized progesterone. This progesterone is very safe and easy to tolerate.
It decreases the risk of breast cancer. It can be used orally or vaginally, either
continuous or 12 days in each cycle. However this regime is not a contraceptive
and also does not help if a woman’s periods are heavy. For these situations an oral
contraceptive pill which is good. If oral oestrogens are not suitable, transdermal
oestrogens combined with a progesterone realsing intrauterine device is used,
releasing a progesterone called levonorgestrel . This stops heavy periods or in
fact periods all together and is a contraceptive as well. It is cost effective.
This does not help with cyclical symptoms such as PMS, mastalgia, mood swings
and fluid retention.
This works
for nearly 5 years. For more information
on these you can refer to my previous post on bleeding problems, and contraception
after 40. Women, who have early menopause, benefit from MHT. If they have an intact
uterus, MHT with different types of Oestrogens and Progesterone is required, as
already explained.
Combined
oestrogen and progesterone patches are also available in varies forms. They are useful if transdermal oestrogens are
required. They can be cyclical or continuous.
Tibolone is another
HRT often used for treatment in post menopausal women. It should not be used if
a woman has not had a period for at least 1 year. It is a synthetic drug made
from the Mexican yam. It can be used both in women with or without a uterus. It
has oestrogenic actions on the brain relieving hot flushes, on the bone
preventing bone loss and fractures and on the vagina improving vaginal dryness.
It works like testosterone and improves sexual function and mood swings. There is
some controversy about its risk on breast cancer. It is best to have regular
breast examinations and mammograms. It has a slightly increased risk of stroke
in women over 60. It is best not to use it in women who are over 60 or have
risk factors for stroke eg: smoking, obesity, and high blood pressure.
IT should
not be used, in women with a history of breast cancer or, for cardiovascular
protection. Its data on LDL, HDL, and thrombosis risk are also inconclusive. Its
side effects are headaches, nausea and swollen feet. Some women may have some
bleeding in the initial 1-3 months, if it does not settle it should be investigated.
The role of Tibolone on breast cancer is still under research.
One of the
latest drugs approved by FDA for post menopausal women is a combination of combined
Estrogens
and Bazedoxifene. Bazedoxifene, is a selective oestrogen modulator (SERM), this
means that these oestrogens act differently in different organs. It is used for
vasomotor symptoms and osteoporosis. This drug cannot be used if a woman has a
heart disease, stroke, breast or uterine cancer, liver and kidney disease,
dementia, blood clot, eye problems, migraine headaches, epilepsy, risk factors
for coronary heart disease, thyroid function or high calcium levels in blood. Every
woman should discuss with her care giver in detail that it’s safe for her to
take this drug. Some side effects are diarrhoea, nausea, neck pain and upper
abdominal pain. One of the serous side effects reported is sudden loss of
vision. This is thought to be due to retinal vascular thrombosis. Breast, ovarian and endometrial cancer may
occur but this risk is unknown. Bioidentical hormones are promoted by many
people instead of MRT. But these are not truly tested. This may be a euphemism
for uncontrolled activity.
Non Hormonal
Treatments of menopause
Some recent
anti depressant called SSRIS (selective serotonin reuptake inhibitors, and
selective norepinepinephrine reuptake inhibitors) and SNRIS are found very
helpful for management of vasomotor symptoms of menopause, particularly in
women who cannot take oestrogens. These drugs help to increase our levels of serotonin
and noradrenalin in the brain; they are useful in transmitting messages from
one cell to another. They are useful for vasomotor symptoms and mood swings. There
are many such drugs. Your care giver will be able to give these to you. They
are venloxifene, escitopram, praoxitin, prebgablin and many others. These normally
are anti depressants, but when used for VMS of menopause they are used in a
much smaller dosage. There is another drug called Gabapantin which is very
helpful if there is pain as well with VMS. Normally it is used for chronic pain
and epilepsy. Side effects can be dizziness, light headaches and drowsiness. Clonidine is another useful drug, normally it
is used for blood pressure or migraine headaches. All these drugs are particularly
used for women who have suffered from breast cancer or any others cancers and these
are non hormonal. They can use local moisturisers for the vagina, they last
longer than lubricants. Silicone based lubricants are best.
There are
many plant based remedies and food, however women who have had a history of
cancer should stay away from them as they have not been evaluated. Other
helpful counselling can be on sexual problems, bone health, life style changes,
relaxation, no smoking and acupuncture is supposed to help some women. In very
difficult cases Stellalate Ganglion Block is done, by injecting sympathetic nerves
in the neck. A new class of drug is being studied in the Imperial College in London
which may revolutionise the management of menopause. There are many new
treatments for genitourinary syndrome of menopause, please refer to my previous
post on this. Women who have had breast cancer cannot use Ospemifene, a drug mentioned
there for dyspareunia. There are special situations when HRT should not be used.
These are Oestrogen dependent cancers, high risk of DVT/VTE, personal wish not
to use hormones, undiagnosed genital bleeding, severe liver disease, and untreated
high blood pressure. When any one uses a
drug always read the information on side effects.
CONCLUSION: This post discusses the prevention of CVD in older
post menopausal women, which is the main cause of death in menopausal years. Various
treatments of menopause are also mentioned. The most important thing is not to
suffer in silence. There is a lot of help available in various forms and it is always
discussed with every woman in detail. It is offered to women in total agreement
with them. The most important scenario is to start it during the window of opportunity.
Stay away from treatments which are not scientifically proven.
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