P.39 organsupporting defects in the pelvis can restore sexual functioning and with it, a woman's sense of vitality and feminine allure.
P.40 premenopausal women, heart disease is the most frequent cause of death in women over the age of 50. Since 1984, the death rate from CVD in men has decreased, whereas the death rate for women has increased.
Numerous epidemiologic studies support the long-term benefit of estrogen in preventing CVD. Observational studies, such as the Postmenopausal Estrogen/Progestin Intervention Study sponsored by the National Institutes of Health, revealed that HRT can increase high-density lipoprotein cholesterol and decrease low-density
lipoprotein cholesterol. The Nurses' Health Study demonstrated a reduction in the risk of CVD of up to 50%
among current HRT users. Women who use estrogen have significantly less coronary artery stenosis than do women who do not use it. Takahashi et al. found that longterm HRT (for more than 2 years) may delay carotid intimal-medial thickness in healthy postmenopausal women.
Moreover, patients with the most advanced coronary artery disease experience the most benefit from HRT. Only 35% of women surveyed were aware of the connection between heart disease and menopause.
Current theories indicate that estrogen has extraordinarily complex biologic effects that translate into a variety of actions in diverse tissues. There is growing scientific evidence that estrogen exerts its beneficial actions on tissues of the skeletal, urogenital, digestive, cardiovascular, ocular, and nervous systems.
HRT is also first-line therapy for osteoporosis for most women, and treatment should begin as soon as possible after the menopause. Enough time has elapsed since the WHI media scare and cessation of estrogen therapy by users that a marked and rapid loss of bone density is being noted in those who stopped their replacement
therapy. Yates and Barrett-Connor studied the association between HRT cessation and hip fracture risk.
Concurrent with WHI, women in National Osteoporosis Risk Assessment currently on HRT had a 40% lower incidence of hip fracture compared to those who had never used HRT. Women who stopped using HRT more than 5 years earlier had similar hip fracture use to women who had never used HRT. Preliminary data suggest that even the elderly respond to estrogen replacement. However, there are therapeutic alternatives and lifestyle modifications (diet and routine exercise) that perimenopausal women must be counseled about to create a comprehensive prevention program. Such an effort can have a significant impact on long-term morbidity and mortality associated with osteoporosis.
Because one of their jobs is to find every needle that gets lost in the proverbial haystacks of their homes, women have phenomenal memories. When they become less adept at remembering where they and other people put their things, they fear the worst—that they are losing their minds—and this fear is not illogical. Women constitute 72% of the population over the age of 85 years, and roughly half of this group has Alzheimer disease (AD). Not only do women constitute a greater proportion of this older population, but AD is expressed earlier in women than men. This may be related to the estrogen loss that occurs with menopause. Hammond cites a study that found women who took estrogen for more than a year experienced a dramatic delay in AD onset. But even the group of women who averaged only 4 months of estrogen therapy, and most likely took the medication to control
symptoms such as hot flashes, experienced a delay in AD onset. It has been speculated that a brief exposure to estrogen influenced AD expression 20 to 30 years later by preventing an irreversible loss of neurons associated with the occurrence of hot flashes. Research is ongoing, but one study found that estrogen replacement therapy in postmenopausal women is associated with a 50% reduction in the risk of developing AD because it slows the decline of visual memory. Lebrun's study in clinical endocrinology supports findings that endogenous estrogens protect against cognitive decline with aging.
Colon cancer occurs more often in women than men and is a leading cause of cancer incidence and deaths in women.
Even though mortality rates for colon cancer have decreased 25% among women in the last 20 years, it remains the third leading cause of cancer deaths in this group. The concept that postmenopausal estrogen replacement therapy may decrease the risk of colorectal cancer has received considerable attention, even though the
hormone has no indication for this use. Multiple epidemiologic studies have been published that examined this relationship. The majority of these suggest an inverse, protective effect for estrogen, particularly with current use. Although the precise mechanism by which estrogen reduces colon cancer risk is unknown, it has been hypothesized that it affects bile acid metabolism or promotes tumor suppressor activity. The inclusion of estrogen as a measure to prevent colon cancer should be part of the discussions between menopausal women and their physicians. Counseling should include the American Cancer Society recommendations for annual digital rectal examination and fecal occult blood testing as well as a flexible sigmoidoscopy every 5 years or colonoscopy every 10 years.
Age-related macular degeneration (AMD) may be reduced by estrogen administration. This disease is the leading cause of legal blindness in the United States, accounting for as many as 60% of all new cases. There is no medical treatment, and surgical management in the form of photocoagulation is effective in only a small percentage of patients with the wet type of the disease. In the Rotterdam study, women who experienced
menopause at an earlier age had a 90% increased risk of exhibiting signs of late AMD compared with those who experienced menopause at a later age. These data suggest that HRT reduces the risk of developing AMD.
Counseling women about replacement therapy must be combined with discussions about the importance of lifestyle changes, including the following:
Normalization of weight Dietary intervention Smoking cessation Regular exercise Control of hypertension Control of diabetes
Control of alcohol consumption Control of lipid elevations
Routinely, HRT counseling should go beyond simple symptom control to include both short- and long-term benefits, contraindications, common patient concerns, and misconceptions.
The contraindications to estrogen replacement that have been established by the FDA include known or
suspected pregnancy or breast cancer, estrogen-dependent neoplasia, undiagnosed abnormal genital bleeding, and active thromboembolic disorders. However, ongoing research suggests that some of these contraindications may not be absolute. In the meantime, all of the relative contraindications must be carefully discussed and weighed against the risk of not prescribing HRT. This is also a good time to discuss the common concerns and misconceptions that women have about estrogen, even if patients do not raise them. For example, many women are concerned that estrogen may bring on the return of monthly bleeding, restore fertility, or produce weight gain.
When bilateral oophorectomy is anticipated in a premenopausal patient, HRT should be discussed before surgery, because one of the greatest fears of younger women is surgery-induced menopause. Patients should be told that estrogen therapy can be started immediately after surgery and that hot flashes and other
menopausal symptoms can be avoided. The natural conjugated estrogens do not cause hypercoagulability and are safe during the immediate convalescent period.
Parker et al., in a recent lead study in Obstetrics and Gynecology, recommend ovarian conservation until at least age 65 because of their benefit to long-term survival. With ovarian preservation, the need for exogenous
hormones is delayed.
P.41 The long-term benefits of HRT in preventing osteoporosis, CVD, and colon cancer are well established. The health of the vagina and lower urinary tract is also maintained. The Journal of the British Menopause Society says that various studies have demonstrated the efficacy of estrogen replacement in improving urinary and stress incontinence. The vagina lubricates more easily with sexual arousal, and intercourse is more comfortable with an estrogenic vaginal mucosa. Many women report an increased interest in and enjoyment of sex.
For women who do experience a loss of libido, even while taking estrogenic hormones, the new androgen therapies look promising as a way to improve sexual function and psychological well-being. Testosterone delivered via transdermal patches or gel bypasses the liver and has no negative effect on cholesterol. The skin serves as a constant reservoir; therefore, blood levels show fewer fluctuations.
However, there are physicians who believe hormonal balances induced by prescription medications should only be offered for relief of extreme menopausal symptoms and only for a short while. The author of Dr. Susan Love's Hormone Book and Dr. Susan Love's Breast Book is one such physician. She is a staunch supporter of eating soybean products and using herbal remedies such as black cohosh to maintain estrogen levels, the use of acupuncture and paced respiration for hot flashes, exercise, and using vitamin and calcium supplements. But even she admitted in an interview, “If my symptoms [for menopause] worsen, I may feel that I want to take some kind of drug. I certainly would be open to that.”
By 2030, 1.2 billion women will be menopausal or postmenopausal. Wu et al. reported that if the surgery rates for pelvic floor disorders remain unchanged, the number of women expected to undergo inpatient and outpatient procedures for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) will significantly increase. In 2010, records show 210,700 SUI surgeries performed. This number will increase over 47% by 2050. During the same time frame, POP surgeries will increase from 166,000 to 245,970.
The National Institutes of Health recommends human sexuality courses for all health care professionals in graduate schools. A majority of medical schools offer 3 to 10 hours of human sexuality instruction, usually embedded in other courses; this is not nearly enough to help a sexually dysfunctional patient. Even trained professionals who are members of the American Urogynecologic Society underestimated the prevalence of the problem. Only 22% of urogynecologists reported they had developed the habit of screening their patients for sexual dysfunction.
Professionals don't realize the tremendous societal burdens that the angst resulting from sexual dysfunction creates, as reflected in divorce, domestic violence, single-parent families, quality of life issues, and problems in forming enduring relationships. A few in the medical community are working for international standardization and continuing education and training in the area of sexual dysfunction. If successful, this will directly translate into greater competency and help for 50 million women in the United States alone.