Experts debate options for menopause symptom relief

Will Astor//April 29, 2005//

Listen to this article

Demographics tell the story.
It is a particular twist on the familiar post-World War II baby boom tale. Most currently practicing obstetrician/gynecologists are out of necessity increasingly focused on menopause.
As baby boom women continue their trek from cradle to grave, they are now either about to leave their childbearing years, already past childbearing age or in the middle of a transition between those stages.
The age at which women’s reproductive careers end can vary from roughly 42 at the early end to the late 50s at the upper end. Data published by the North American Menopause Society states that women experience menopause at an average age of 51.4 years.
More than 42 million American women were 50 or older in July 2000 and nearly 40 million of those women were post-menopausal. In the 12-month span between July 1, 1999, and July 1, 2000, more than 1 million U.S. women entered their 50s, U.S. Census Bureau data show.
In Monroe County, says Albert Jones Jr. M.D., department chairman of ob/gyn at Unity Health System’s Park Ridge Hospital, the population of post-childbearing-age women has over the past few years remained more or less stable while the number of childbearing-age women has not increased.
Unless they run fertility clinics, Jones says, that means that local ob/gyn specialists now typically see more menopausal women than childbearing-age patients.
To be precise, menopause is not a disease, notes Vivian Lewis M.D., director of the Strong Health and University of Rochester Medical Center division of reproductive endocrinology. Lewis is also an infertility and menopause expert.
The cessation of reproductive capacities is a stage of life all women who live long enough will experience, she says. Still, menopause has medical consequences.
Menopause means the permanent cessation of menstruation, which in turn is a consequence of a drop in the body’s production of the hormone estrogen. In addition to ceasing to signal the female body’s monthly menstrual cycle, a drop in estrogen production also can lead to ill effects such as loss of bone density, or osteoporosis, a condition sometimes called brittle-bone disease.
Most women who seek treatment specifically for menopause do so not to forestall osteoporosis, Lewis says, but because they are experiencing symptoms associated with menopause-sudden swings in body temperature or hot flashes, mood swings and sexual side effects, such as loss of libido and painful sexual intercourse.
Not all women experience such symptoms, Lewis says.
And while the reasons why those who do seek to alleviate them vary, medical researchers still do not know whether women who experience hot flashes and other menopausal discomforts are at greater or less risk of more serious medical consequences than women who experience symptom-free menopause.
For a decade or more prior to the mid-1990s, medical science thought it had found an antidote not only to menopause’s unpleasant side effects but one that seemingly could halt the aging process in its tracks. Called hormone replacement therapy, or HRT for short, the treatment put women on a regimen of pharmaceutically manufactured estrogen to replace the hormones their bodies no longer produced.
Early studies showed HRT to alleviate hot flashes and other menopausal symptoms and in a bonanza of benign unintended consequences to also allay the onset of breast cancer, colon cancer and heart disease.
“The problem with those early studies was that they had a healthy bias,” Lewis says.
Researchers in those studies unwittingly selected subjects from a population of women whose general state of health was above average and whose lifestyles were on the whole more healthful than average. Results that showed women on HRT to have lowered incidence of heart disease and breast cancer were due not to the benefits of HRT but to the fact that test subjects were healthier to begin with.
That in itself would not necessarily have torpedoed HRT. But a long-term study following some 10,000 women on HRT called the Women’s Health Initiative did much to discredit the treatment. Researchers found that women in groups receiving replacement hormones in the study had higher incidences of breast cancer and heart disease than their sisters in control groups.
“They actually had to stop the study. They considered it too dangerous to continue,” Lewis says. HRT still could be appropriate for some but after the WHI flap, physicians “are no longer giving it carte blanche.”
Science so far has not come up with alternatives that offer as complete or easy relief from menopause symptoms, Lewis says.
And she says a plethora of over-the-counter remedies and food supplements do not entirely live up to their hype. Over-the-counter medications and supplements are not rigorously tested and women are probably well-advised to avoid them, Lewis believes.
Researchers including herself are now doing clinical trials on drugs that could replicate what were thought to be HRT’s benefits, but there are no conclusive results in that area yet.
Lewis calls the drug study she is working on “estrogen lite.” If the trial proves out, she says, it could usher in medications that would be effective in reducing menopausal women’s risk of osteoporosis and breast cancer.
A locally based UR-associated firm called PharmaNova LLC is working on a non-estrogen drug to alleviate menopause symptoms. PharmaNova president Rodney Brown told the Rochester Business Journal last year that the company could be as close as two years away from marketing Xenolev, a drug that would turn a substance currently used to treat epilepsy into an alternative to Premarin, a widely used estrogen therapy drug.
Until such remedies prove out, Lewis says, the best counters to menopausal symptoms and preventatives against heart disease and cancer could be such simple measures as good diet and adequate exercise. However, she concedes, many see such measures as time-consuming, strenuous and unappetizing and would vastly prefer “to take a pill.”
But while many women’s health specialists have virtually stopped prescribing HRT, not all see the decision to halt the treatment WHI study wise or view the dangers the study is supposed to have uncovered as real.
“Statistically, the study should never have been reported,” Unity Health’s Jones insists.
No one disputes that HRT alleviates hot flashes and other unpleasant effects of menopause, Jones says.
And researchers who revisited the WHI results since the study’s cancellation found that women on HRT actually have a slight but “statistically significant” reduced risk of colon cancer.
While Jones concedes that women with estrogen-dependent breast cancers should definitely not be on HRT, he says that the therapy has no meaningful effect on heart disease or non-estrogen-dependent breast cancers.
Cardiovascular effects of HRT are neutral, Jones says. Women on replacement estrogens see no heart-health benefits but also do not suffer any greater risk of heart problems.
In addition to alleviating discomforts associated with menopause, HRT improves skin tone, a benefit that has more than cosmetic value. The skin provides one of the body’s most basic, front-line defenses against foreign disease-causing organisms.
Perhaps most significant, in Jones’ view, are the benefits HRT brings in preventing bone loss in menopausal women. The supposed dangers of HRT in promoting breast cancer or heart disease are unproven, Jones believes. But neither one is the leading cause of death among elderly women. More die of complications from hip fractures.
Jones is not alone.
“Significant damage has resulted from the way WHI results were originally reported. Women have walked away from treatments often necessary for their health and well-being and lost trust and confidence in their health care providers and the care they recommend,” wrote North American Menopause Society executive director Wulf Utian M.D. in a recent paper on WHI findings.
Citing the same new findings as Jones, Utian concluded in a “personal analysis” that physicians who have rejected HRT should reconsider the therapy and consider prescribing the regimen to pre-menopausal women for alleviation of symptoms and to women who want HRT as a preventative against future ills such as osteoporosis.
Jones already has taken Utian up on the recommendation. Many of his patients who dropped HRT after the WHI called off its study later asked to go back on hormones, Jones says. And, he estimates, 60 percent to 70 percent of menopausal women he is currently treating are on HRT.
([email protected] / 585-546-8303)