Menopuase is defined as the permanent cessation of menses. While it is a normal process of aging, it creates a number of complications that require medical attention, such as vasomotor complaints (hot flashes), psychosomatic complaints, genital atrophy and osteoporosis. The issue of menopause is becoming increasing important because as most baby-boomers approach menopause at age 50, they are expected to spend more than 1/3 of their life in post-menopause since the life expectancy is now over 85 years.1 This update will discuss the optimal methods to address all of the changes that occur during menopause with both Western and traditional Chinese medicine.
Western Medicine Perspective
Menopause is not a disease, but a normal process of life. Still, it does create conditions and complications that may require medical intervention. Vasomotor complaints (hot flashes), psychosomatic complaints, genital atrophy and osteoporosis are the four main medical conditions associated with menopause that will be discussed in this article.
Hot flashes may occur in 80% of menopausal women, and may last for up to five years. Vasomotor flush is the objective and visible flushing of blood of the thorax, neck and face, followed by increase in body temperature and profuse sweating. Hot flashes is the subjective sensation of intense warmth in the upper body, typically lasting for four minutes. Since hot flashes occur most frequently at night, it is not uncommon for these women to experience insomnia, restlessness, irritability and emotional instability. Many women will seek professional help when these changes begin to disturb their daily activities.
Genital atrophy is also common as it may occur in approximately 20% of postmenopausal women. Since many tissues in the genitourinary region are estrogen-dependent, post-menopausal women may experience atrophy of such tissues as lower vagina, labia, urethra and bladder trigone. As a result, there may be vaginal dryness; painful coitus; diminished libido; increased vaginal ulceration; increased risk and frequency of infection; dysuria; urgency; painful urination; and stress incontinence. Once again, genital atrophy may require medical intervention by health care professionals.
Osteoporosis is a disorder characterized by a reduction in bone mass.2 Osteoporosis is becoming one of the more common disorders in the West as the population continues to age and life expectancy continues to increase. Osteoporosis occurs mostly in individuals between 51and 75 years of age, and is six times more common in women than men.3 There are numerous risk factors for osteoporosis, including (but not limited to) aging, dietary habits, lifestyle and family history. Chronic use of drugs also increases the risk of osteoporosis, with thyroid supplements, corticosteroids and heparin among those drugs implicated. Likewise, exposure to ethanol, alcohol, tobacco and drug abuse are causative or complicating factors. The clinical implications of osteoporosis include fractures of bones after minimal trauma. Injuries often result from a (relatively low-impact) fall from standing height, subsequently leading to fractures of the vertebrae, wrists, hips, humerus and tibia.4 In frail patients, even a child's overenthusiastic hug can cause fractures. With bone fracture, there is severe pain, discomfort, decreased mobility, risk of infection and, in osteoporotic patients, prolonged recovery. In the elderly, decreased mobility can lead to further health complications, delaying recovery even longer. Amongst the conditions associated with menopause, osteoporosis is considered by many as the most severe and the most significant.
Many drugs are available for prevention and treatment of menopause and related conditions. Listed below are some of the drugs most commonly used:
Hormone Replacement Therapy (HRT)
The purpose of hormone replacement therapy is to supply the body with an external source of hormones, including estrogen and/or progesterone. While there are numerous forms, Premarin (conjugated estrogen) and Provera (medroxyprogesterone) remain the most popular brands. In fact, Premarin is the most frequently prescribed medication in the United States.5 This is an astounding number considering menopausal women are the only individuals who are prescribed this medication. As a group, estrogen is commonly prescribed for numerous purposes, including (but not limited to) menopausal signs and symptoms, osteoporosis and atrophic vaginitis. In addition to menopause, some early studies have hinted that the use of estrogen may be associated with the prevention of Alzheimer's disease. However, more recent data concluded that the beneficial effects of estrogen last only up to 16 weeks, after which no difference is observed between the placebo and the control group.
Unfortunately, despite the possible benefits, estrogen replacement therapy has many potential conflicts and controversies. One of the biggest disadvantages associated with the use of estrogen is the staggering number of side-effects, including (but not limited to) an increased risk of breast cancer, uterine cancer, ovarian cancer, endometrial carcinoma, malignant neoplasm, gallbladder disease, thromboembolitic disease and photosensitivity.6 Progesterone is prescribed with estrogen to minimize the risk of endometrial cancer. However, it can cause side-effects such as an increase in cholesterol levels, edema, weight gain and bleeding. Due to these adverse effects, many women cannot take hormone replacement therapy, and there are many who opt not to take HRT.
Biphosphonates for Osteoporosis
Biphosphonates are a class of drugs that includes alendronate (Fosamax), etidronate (Didronel), pamidronate (Aredia), tiludronate (Skelid) and risedronate (Actonel). These substances treat osteoporosis primarily by blocking the loss of bone mass. Biphosphonates such as alendronate may increase bone density by 5-10% if taken daily, continuously, for three years. Side-effects of these drugs include nausea, diarrhea, esophageal irritation and esophagitis. Furthermore, in laboratory studies, the use of biphosphonates is associated with the development of cancer (thyroid adenoma and adrenal pheochromocytoma) and fertility impairment (inhibition of ovulation and testicular and epididymal atrophy).7
SERM
SERM is the abbreviation for selective estrogen receptor modulator. Currently, Evista (raloxifene) is the only medication approved in this class. It works by facilitating the utilization of calcium for proper bone strength, and is therefore used for prevention and treatment of osteoporosis. Unfortunately, this medication is associated with an increased risk of venus thromboembolism and increased severity and incidence of hot flashes. It is also contraindicated in patients with liver problems, as it is metabolized hepatically.
Clonidine
Catapres (clonidine) is another option for the relief of hot flashes. It stabilizes the blood vessels by binding to the alpha-adrenergic receptors. It is rarely prescribed as it has significant side-effects such as postural dizziness, blurred vision, first dose syncope, and withdrawal hypertension.
Summary
There are numerous options available for the treatment of menopause and related conditions. Unfortunately, there is no consensus on how menopause should be treated with Western medicine. Despite all of the clinical and laboratory research, medical doctors cannot agree on when and under what circumstances to start the treatment of menopause. Some propose to begin treatment during perimenopausal years; others prefer to initiate treatment only after menopausal symptoms and signs have begun; and still others discourage the use of drugs since the risks outweigh the benefits. Until more information is available, the best conclusion that can be drawn at this time is that the treatment should be individualized, with the doctors and patients in complete understanding of what is at risk and what is to be accomplished.
In part two of this series, we will discuss the diagnosis and treatment of menopause from the perspective of traditional Chinese medicine.
References
- Beers M, Berkow R. The Merck Manual of Diagnosis and Therapy, 17th edition, 1999.
- Dorland's Illustrated Medical Dictionary, 28th edition, 1994.
- Berkow R, et al. The Merck Manual of Diagnosis and Therapy, 16th edition, 1992.
- Fauci A, et al. Harrison's Principles of Internal Medicine, 14th edition, 1996
- Buckley B. 34th annual top 200 drugs. Pharmacy Times, April 1999.
- Estrogen supplements. Drug Facts and Comparison, 1999.
- Facts and Comparison, Jan. 2000.
