Coping with "the change"
by Vicki Wood

Clarifying the role of hormone replacement therapy for women in menopause

It's miraculous how efficiently the human body is designed for the functions it will perform in life. This is most evident in the reproductive system of a woman. As she enters puberty, her body begins to adjust to the monthly reproductive cycle and she starts menstruating. Throughout those years, the female body regularly produces estrogen and progesterone, hormones which help make it an ideal environment for carrying and bearing children. During the natural childbearing years (usually from early teens until the early 40s), our bodies continually and consistently prepare for this monthly window of opportunity to conceive.

Once those prime natural childbearing years pass, often from the mid-40s to early 50s, our bodies prepare for moving into the next life phase. For most women, this stage, perimenopause, is a time during which periods may become irregular: either heavier, lighter or less frequent than usual. Our bodies start producing less estrogen and progesterone. We may or may not notice the effects of this physical transition. For some women, perimenopause may usher in a time of mood swings, frequent headaches, occasional forgetful spells, vaginal dryness and loss of interest in sex. Others breeze through this period with no noticeable effects.

At some time in her late 40s to mid-50s, a woman's body embarks upon a time of major change. Menopause, the name given for this life phase (the word means last period), is actually a defined point in time. A woman is officially in menopause one year after her last menstrual period, whether this occurs naturally or is caused by surgical procedures such as removal of the ovaries.

It's no wonder that this life stage is often referred to as "the change of life." For many women, the end of monthly periods is just one of the changes she'll notice during menopause. As her body adjusts to this change, a number of accompanying phenomena may make life at this time uncomfortable.

The decreased and irregular production of the two hormones - estrogen and progesterone - which had been produced regularly throughout the reproductive years can cause some pretty uncomfortable symptoms. Estrogen, in particular, is a hormone that performs some basic, but essential maintenance duties in our bodies. Among other things, it helps to regulate body temperature, keeps skin and tissues primed with fluids and elastic, helps the body use nutrients such as calcium (the bone builder) more efficiently, and helps keep blood vessels healthy. It's no wonder that some women's bodies experience "estrogen withdrawal" symptoms at menopause!

The symptoms
Among the most common (experienced by 75 per cent of women) menopausal symptoms are hot flashes and/or "night sweats" - brief (usually 30 seconds to five minutes) periods during which a woman may feel very hot and perspire excessively, and immediately afterwards, feel chilled.

A woman in menopause may also find that she feels irritable, tired, nervous or unable to sleep. The same changes can cause headaches, dizziness and rapid or irregular heartbeat. The lack of estrogen also affects the skin around the vagina, making it thinner and dryer, possibly leading to vaginal itching or pain during intercourse. The skin that lines the bladder and urinary tract is also affected; this explains why loss of bladder control often occurs during menopause. Sometimes women also experience painful muscles and joints.

Every woman is different - as with every other important phase in her reproductive life (puberty, pregnancy, childbirth, perimenopause) - some women will find that they pass through the menopausal years with little discomfort. But many women experience problems severe enough to require help. And there is help available.

To replace or not to replace?
Since the cause of most menopausal symptoms is a lack of important hormones, it makes sense that the most common treatment for menopausal symptoms is hormone replacement therapy (HRT). HRT is available in two formats: estrogen only and estrogen combined with progestin (progesterone). The combined products are usually given to women who have not had a hysterectomy, because progestin has been shown to prevent cancer in the endometrium (uterine lining).

If you and your doctor decide to try hormone replacement therapy, there are a number of possible approaches. First, there are two types of HRT - natural and synthetic. Natural hormones are identical in structure to the hormones produced by the body. Synthetic hormones have a different structure, but they mimic the actions of hormones in the body. Since the side-effects of synthetic and natural estrogen and progesterone vary, you and your doctor will have to decide which form of HRT your body will best tolerate.

HRT also comes in different "delivery" formats. The most commonly prescribed form of HRT is a pill. Most private and public drug plans cover a range of oral HRT products. HRT is also available in patch form (like a small plastic bandage that's applied to the skin), as a cream or gel, or as a vaginal supplement or ring. If drug plan coverage is an issue, check with your insurance company; some of the newer HRT forms may not be covered or may be partially covered.

There are also two different ways to take hormone replacement therapy. In cyclic therapy, estrogen and/or progesterone are taken on certain days of the month, and women will experience light monthly bleeding, like a period. When HRT is taken daily, no bleeding occurs, but your physician will adjust dosage every few months to induce bleeding in order to prevent the uterine lining from building up.

Like any medicine, HRT can cause its own side-effects (which range from mild bloating to headaches and high blood pressure) and is not recommended for every woman. For example, HRT can reduce the effectiveness of certain medications (e.g. blood-thinning agents, medication for high blood pressure, or diabetes medicines).

If, however, HRT is helping severe symptoms, ask your doctor about working with a specialist pharmacist who can create a customized HRT product for you. This can be more expensive, but a pharmacist can often produce a therapy that contains the right doses of hormones without the additional ingredients that may cause you trouble.

Is it safe?
It is fascinating to see how the perception of HRT has changed throughout recent history. Early promotional campaigns hinted at the benefits of hormone replacement to help keep women younger-looking and more active. In recent decades, protection was the keyword: HRT, specifically the estrogen/progestin combination has been scientifically proven, not only to help the menopausal symptoms described above, but also to help prevent bone loss and aid in bone building.

As well, early studies had suggested that HRT would also help to protect women against heart disease, but that claim has recently been refuted by a much-publicized study which has caused women and the health profession to revisit the value of and/or need for HRT.

The U.S. Women's Health Initiative study launched worldwide headlines in the summer of 2002 when the part of the study which examined the use of combined HRT was abruptly halted after researchers found that women taking combined HRT, particularly those taking it for five years or longer, were slightly more likely to develop coronary heart disease, stroke, blood clots and cancer.

As a result of this study, Health Canada and health experts have changed their guidelines for combined HRT. Specifically, new guidelines state that HRT is no longer recommended for long-term use. And doctors should no longer prescribe HRT therapy solely with the goal of preventing osteoporosis or heart disease.

While the risk for occurrence of any of these serious health events is still quite small, it is significant. Experts have concluded that even that small risk outweighs the comparative benefits of long-term combined HRT.

While long-term HRT use is no longer standard, the new guidelines do state that for women with severe menopausal symptoms who obtain relief while taking HRT, a shorter course of therapy is still beneficial. However, they now strongly advise using HRT for short periods, and under close supervision by a doctor. Your physician should closely monitor your progress throughout treatment and, every year or two, re-evaluate your need to continue therapy.

Experts advise women never to discontinue HRT suddenly, or without consulting a physician. If you and your doctor agree that it's time to stop taking the hormones, your doctor can set up a safe and graduated withdrawal program.

Try a change of lifestyle

New medical guidelines suggest that many bothersome menopause symptoms may be helped, or even alleviated through simple lifestyle changes.

The Society of Obstetricians and Gynaecologists of Canada (SOGC) suggests that "menopause is an ideal time to re-evaluate your lifestyle and make the necessary changes to improve your quality of life." For the most part, the steps you can take to boost your chances of a healthy menopause are the same ones that make us feel better overall: get regular exercise, quit smoking, eat a balanced diet and reduce alcohol consumption.

Women in the menopausal years are at greater risk for osteoporosis, so if you are not taking HRT, it's a good idea to increase your intake of calcium-rich foods, participate in regular weight-bearing exercise, and talk to your doctor about calcium/vitamin D supplements. If your bones really need a boost, you may be a candidate for one of the bone-building prescription therapies.

The respected Mayo Clinic in the U.S. adds that caffeine, alcohol, spicy foods and hot beverages can trigger hot flashes. Although it has not yet been clinically proven, some researchers believe that eating plant-based estrogens (found in soybeans, chick peas and other legumes) and lignans (found in flax-seeds, whole grains and some fruits and vegetables) may also help.

Other tips for coping with "thermostat" problems include taking a cool bath before bedtime and wearing light layers of clothing, getting regular aerobic exercise and practising deep breathing.

Consider the alternatives

Black cohosh, evening primrose oil, wild yam, and numerous vitamin, herb and mineral combinations marketed as "natural HRT" have been used for years to treat menopausal symptoms, however few have been scientifically tested or clinically proven. Alternative remedies may well provide relief, however it's strongly recommended that before trying to treat your own symptoms, you see your doctor for a complete checkup and a discussion about your options. The SOGC publishes guidelines on alternative therapies for menopause (visit www.sogc.org and click on Consumer Information).

A woman's best bet for going through menopause as comfortably and happily as possible is to develop a close and open relationship with a physician or gynaecologist who is knowledgeable and informed about this quickly changing specialty. It also helps to become informed yourself.

Below are a number of recommended sources of information on menopause and hormone replacement therapy. Read up, and then talk to your doctor about the issues that interest and concern you.

Women's Health Matters
a consumer information site produced by Sunnybrook and Women's College Health Sciences Centre www.womenshealthmatters.ca

The Society of Obstetricians and Gynaecologists of Canada www.sogc.org

It's Your Health a Web site for Canadians covering a wide range of health topics
www.hc-sc.gc.ca/english/iyh

The North American Menopause Society - www.menopause.org

Superfoods for the menopausal years
It's always a great idea to eat healthy foods and to exercise, but never more so than during the menopausal years. For a healthy "change," try boosting your intake of some of these nutrient-rich foods:

• Make mine extra virgin. Extra virgin olive oil, canola and peanut oils contain the so-called "good" monounsaturated fats that lower blood cholesterol levels.
• Get the flax. Flax-seed oil, ground flax seeds and walnut oils contain essential fatty acids believed to lower risk of heart disease.
• Go fishing. Fish are also full of "good" omega-3 fats. Choose oily fish such as salmon, sardines, tuna, herring and mackerel.
• Act like a nut. Studies have shown that regularly eating small amounts of nuts can help prevent heart disease.
• Try soy. Soymilk, tofu, soybeans and soy-based vegetarian foods contain isoflavones, which have been shown to affect the body like a mild estrogen.
• Choose the brown. Whole-grain breads, cereals and pastas contain magnesium and the antioxidant vitamins believed to protect the heart.