Advice to Patients in Perimenopausal Phase

This spring I attended the Advanced Curriculum on Women's Health, presented by the American Medical Women's Association. This was the second iteration of this curriculum, chaired by AMWA leader and women's health expert Dr. Lila Wallis, MACP. She has also edited the new Textbook of Women's Health, Lippincott - Raven 1997, which I highly recommend. Both the curriculum and the textbook utilize a life stage approach to women's health. In many circumstances this is the most helpful way to be sure that your individual patients have all bases covered in terms of their important health needs.

One of the most complex stages is the perimenopause. New research is gradually stripping away old myths and adding new knowledge about the best ways to preserve health and function in the postmenopausal years.

We all know that the most crucial fact of menopause is the absence of high levels of the hormones estrogen and progesterone, and the replacement of estrogen in particular appears to reverse or stabilize many of the degenerative processes occurring postmenopausally. What we have all learned, sometimes through painful experience, is that the majority of women do not take hormone replacement therapy(HRT). If started on HRT, many of them simply stop it on their own.(1) The most commonly cited reason that I hear is the increased risk of breast cancer. All our talk about the amount of risk, a percentage point above the expected in a woman in her fifties, or the likelihood of early detection and cure, or the effectiveness of estrogen on decreasing risks of death from heart disease or disability from osteoporosis, seem to fall on deaf ears.

My own feeling is that I have to listen very closely to that fear of breast cancer. If I persuade a patient to try HRT, the next time I see her I have to find out if she is really taking it. There is a very strong possibility that she is not.

That said, I have found that the most useful approach is to evaluate the various risks and problems my patient is experiencing and then to use the current best regimen that is most satisfactory to her. This means explaining the changes and consequences and determining her individual risk. It also means explaining what are NOT inevitable consequences of menopause.

Depression and Other Mental Symptoms

I see women daily who are convinced that significant mental problems are inevitable in menopause. Depression is common in women, more common than in men. About 10 percent of the female population can expect to have serious depressive symptoms or illness during their lifetime. Among those women, menopause can precipitate a major depression. On the other hand, 90 percent of women are not at that risk.

No precise determination has been made of the degree to which hormone changes are responsible for the reputed mood swings of menopause. A very common cause of irritability and lability is sleep deprivation due to nocturnal hot flashes. Simply relieving this vasomotor activity can reverse all the symptoms. Estrogen replacement is most effective. Phytoestrogens (soy, yams) and vitamin E can be helpful.

Sexual Activity

Another untrue assumption is that, at menopause, sex life is over. Just renouncing this assumption goes a long way to maintain sexual function. The hormonal milieu is probably the least important factor. Urogenital tract changes do occur with thinning of the pelvic and vaginal lining. Continued regular sexual activity will maintain vaginal tone and glandular secretions. Several OTC products like Replens^® and Astoglide^® can solve problems with lubrication.

Urogenital Health

The atrophy that affects the vagina also affects the urethra and supporting tissues of the bladder. The urethra loses its spongy epithelial lining and appears more like a hollow tube. It is less able to stop urine flow at the end of urination and can contribute to an increased susceptibility to ascending organisms and bladder infection. Urinary incontinence can also become a significant problem at this time.

Hormone replacement, which can be either systemic or local, in the form of a vaginal cream or ring, can reverse vaginal and urinary tract changes. The pelvic floor, or Kegel exercises are a must, particularly for women with urinary incontinence.

Osteoporosis

We are all aware of the many factors that can put a woman at risk for osteoporosis and its complications. Genetic predisposition, dietary and exercise habits, use of tobacco, alcohol, and medications, as well as specific illnesses can all contribute. I am continually impressed by the long-standing inadequate calcium intake by most women. Three servings (1000mg) of dairy product premenopausally and five servings postmenopausally (1500mg) are required to insure enough elemental calcium. Calcium supplements have to be calibrated according to their elemental calcium content. Consult labels! Unless a woman is motivated to be on a very compulsive regimen, ingestion tends to be very sporadic.

Adequate intake of vitamin D is also important. Current recommendations may not be adequate. Women 50 to 70 years old should get 400 IU and perhaps more.(2)

Although I do inquire about risk factors, I have a very low threshold for simply going ahead and ordering a bone density study to find out where my patient stands. The current best procedure is the DEXA (Dual Energy Xray Absorptiometry). The reports you receive back on these tests can be daunting. I go straight for the "T score" or the comparative reading with young normals. The "Z score," which compares the patient with her peers, is actually comparing her with a group with declining bone density, which in the oldest individuals is at the fracture threshold. It is helpful to get a DEXA two years in a row to see if the T score is declining rapidly. This can influence your decision to treat. My goal is to maintain a patient at or around 100% T score.

We all know that bone density per se is only part of a woman's risk for fracture and deformity. Physical conditioning and balance are crucial factors in preventing falls, and the elderly respond remarkably well to training programs. Persuading your patient to stop excessive alcohol drinking and helping her to quit smoking are measures that incur widespread benefit.

Cardiovascular Disease

I always review the five major risk factors for coronary heart disease: smoking, abnormal lipids, hypertension, diabetes, and family history. The postmenopausal status is another risk factor. The two important beneficial effects of estrogen -- protection of the vulnerable vascular epithelial lining and the induction of a favorable lipid profile -- are lost at menopause. The more risk factors a woman carries, the more I am inclined to recommend estrogen replacement to counter risk. This is much less of an issue for women with no major risk factors whose lipid profile does not fall into a risk range after menopause.

Treatment

For both osteoporosis and cardiovascular disease, estrogen replacement therapy confers the most significant benefit. As I mentioned at the beginning of this Cyberounds^®, many women simply will not take estrogen. Estrogen is agonistic on both breast and uterus, so it increases the risk of cancer in both. Adding progesterone obviates the risk on the uterus without diminishing the benefit. The risk to the breast remains, and we know this is a major deterrent for many women. There are now some new alternatives.

The newest bisphosphonate, alendronate, stabilizes and increases bone density and has a much easier dosing schedule than etidronate,(3) which had to be taken on a periodic schedule. The main problem with alendronate is its poor absorption, which requires dosing on an empty stomach, and the risk of esophageal irritation, which requires the upright posture. I tell my patients to take their pill and go out for a morning walk. (4),(5),(6),(7)

The newly released SERM (selective estrogen receptor modulator) raloxifene shows promise for a number of reasons. It does stabilize and increase bone mass. It confers cardiovascular protection.(8),(9) It is antagonistic on uterus and breast, so it does not increase the risk for uterine polyps or cancer and may be found to prevent breast cancer, like tamoxifen. The latter has just been found in a large American study to prevent breast cancer in women at risk.(10) Tamoxifen has long been used to treat women with breast cancer. Both alendronate and raloxifene have the disadvantage of not antagonizing and probably increasing vasomotor symptoms.

Conclusion

Assessing the health risks at menopause in a step by step fashion can result in much more accurate and appropriate treatment for individual women.