Update 2015: Menopause and Hormone Therapy

by Louis A. Klein, MD


The menopause and hormone overview I write is an update of what I had written several years ago, which I home will be of some help as you wade through the conflicting and potentially harmful well meaning but erroneous recommendations too often provided by so many sources.  I recommend you read through the informative frustrated appeal of Dr. Robert Nelson, another East Bay physician specializing in the treatment of menopause.  His article, "Menopause, A Misunderstood and Managed Endocrinopathy", reviews some of the current updates that should be considered in the management of menopause. There remains some dispute as to whether menopause should be considered an “endocrinopathy” or disease in all women and whether all women should be placed on hormone replacement therapy; indeed, one of the obvious “advances" in the world of menopause has been the replacement of the term "hormone replacement therapy" by "hormone therapy".  This change reflects the confusion within the medical profession as to whether menopause should be considered a hormone deficiency disease or a “natural” change of life; it also reflects an appreciation that many women do well without in the “replacement” of hormones no longer produced at menopause and the there are medical concerns that may be associated with the use of the hormones in menopause.


Let me summarize and comment on the takeaways of my prior paper on menopause:


  • Women are “designed” as reproductive units significantly controlled by hormones and hormone modulators that circulate within the circulatory or blood systems.


  • The major source of these hormones is the ovary.  At menopause the ovary “retires” and stops producing the major female hormones, which include estrogen, progesterone, and testosterone.


  • These hormones function like “keys” that circulate within a woman's body, looking for “locks” or receptors that they fit into and turn associated “engines” on or off.  Much of the current research today (and its attendant new treatment options) relates to how hormones or SERMs (selective estrogen receptor modulators) affect receptors in the different areas of the body.


  • Estrogen is considered the primary hormone in women, affecting many reproductive and non-reproductive body functions. Estrogen thus has effects on many body functions other than just the ability to become pregnant.


  • Starting estrogen around the time of menopause and continuing it has been found to have beneficial effects on important body functions.  Dr. Nelson summarizes current thinking on how these effects can prevent heart disease (the major disabler and killer of women), Alzheimer’s disease, diabetes, colon cancer, osteoporosis and even breast cancer. Discontinuing hormone therapy in turn reverses many of these protective effects.


  • As we and our bodies age, we are affected by the ravages of time and disease processes we develop or are genetically susceptible to.  Hypertension, diabetes, lupus, lipid abnormalities and other body processes affect the vessels within our bodies. These effects result in distortions of the blood flow within our blood vessels. The distorted blood flow can become associated with clot formation, which can be exacerbated by the presence of estrogen and other factors.  Clots formed adhere to blood vessels or may break off and travel through the normal blood flow pathways to finally lodge within smaller vessels and obstruct them, thus producing potential stroke, heart attack, pain and dysfunction. The risk of these occurrences seems related to the severity of the associated disease or aging process, the dose and route of estrogen administration, other potential contributing medications and “karma”.


  • Many other associated direct and indirect issues related to menopause can produce significant disabling concerns.  For example, common menopausal flushes often affect work and general function and results in sleep disturbances that can in turn affect ability to function, similar to the effects of sleep apnea.  As noted by Dr. Nelson and myself, menopause is a new “paradigm” our generation is working through.  Women now spend over a third of their lives in menopause rather than being eaten by dinosaurs… This is a time that can be influenced by disease, death, stress, financial and relationship changes and identify crises.  How we each deal with these transitions are in turn associated with factors such as self esteem, prior history, genetic endowment, support factors, relationships, education, financial security, identity, hobbies, interests, etc., etc.  I am reminded of the 60 Minute episode where a gentleman celebrating his 100th birthday was interviewed: the spry and chipper youngster was out on the dance floor at the “home”, hitting on the 70-80 year old ladies. He had a scarf draped around his neck and a cigarette dangling from his mouth.  When asked to what he attributed his longevity, he smiles and commented, “good genes…”


  • While instituting hormone therapy seems to be beneficial in many to most women, ongoing evaluation and adjustments need to be monitored regarding general health, diseases such as those listed above, hormone levels, other medication and holistic usage, delivery method and options, lifestyle and plans.  A woman with a strong personal or family history of breast cancer with positive estrogen receptors warrants different considerations than a woman with a strong perison  or family history of osteoporosis.  The adage that “Life is a Suicide Mission” needs to be considered along with rational “Quality vs. Quantity” issues.  While the Korean “Short Fat Life” is not ideal, neither is a lack of consideration regarding how each of us appreciated and elects to deal with the generally unknown time we each have to experience what the miracle of life offers us…


As noted, there is significant current research in progress defining how hormones affect receptor sites throughout our bodies, and how these effects can be modified.  Recall how the use of unopposed estrogen resulted in the increase in uterine cancer, and how this increased cancer risk was ameliorated by the addition of progesterone to the menopausal recipe.  Medications now exist that can product the positive effects of estrogen while containing SERMS that can specifically “turn off” stimulation of the uterine lining, thus eliminating the need for progesterone and its side effects many women dislike.  These SERMs also turn on and off or moderate hormonal effects on the brain, bones, vascular system, breast, vagina, hair and skin.  Indeed, the issue of the year is now how estrogen deficiency can be associated with vaginal dryness and associated with sexual and urinary concerns. Such concerns have obvious effects on self image, self esteem, relationships and general functioning.  Menopause does not have to mean the end of sexuality and personal development.  Please review the article by Dr. Alexander.  The menopausal period of life should not be looked at as an end, but rather as another “new beginning”.


I am grateful to Drs. Nelson, Kagan, Altman, the National American Menopause Society (NAMS), and to the others who have worked and continue to work on helping women understand and work through their individual menopausal questions and concerns.  I would feel remiss if I did not comment on the recent tragic and premature loss of Dr. Sandra Altman, a true physician who worked hard on helping women understand and safely progress into and through menopause.  She left a large hole that can never be fully filled.  I personally look forward to continuing to monitor, learn, and counsel and share the developing understanding of this  challenging period in women’s lives.


Louis Klein, MD


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