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Menopause occurs when a woman’s ovaries naturally reduce and then stop their production of estrogen. For most women, menopause occurs between 45 and 55 years, with an average age around 51. Menstrual periods stop because without estrogen, the endometrium (inner lining of the uterus) does not become engorged with vascular tissue (in anticipation of receiving a fertilized egg/human embryo). Of course, women who have had uterine procedures like hysterectomy or uterine ablation often will stop having periods sooner. The lack of estrogen may cause other symptoms such as hot flashes and night sweats (referred to as vasomotor symptoms). About 75% of perimenopausal women get vasomotor symptoms, which may be disabling. Other symptoms include vaginal burning or dryness as well as urinary frequency or burning, referred to as genitourinary symptoms of menopause.

Estrogen, and sometimes progesterone, are the two hormones used to reduce many menopausal symptoms. Progesterone is added to reduce the risk of uterine cancer from estrogen, unless the uterus is already removed. Hormone therapy can either be systemic (absorbed into the bloodstream) or delivered via low-dose vaginal preparations. Systemic estrogen is either taken orally or absorbed via a patch or gel. Low-dose vaginal estrogen can be delivered using inserts or cream and is not highly absorbed into the bloodstream. Progesterone is usually taken in pill form, either separately or in a combination pill with estrogen. In most cases, the discussion of hormone therapy focuses on systemic estrogen.

Studies have shown that systemic hormone therapy is effective for treating vasomotor symptoms. This treatment is also effective at treating the genitourinary symptoms. However, in cases of urinary or vaginal symptoms without vasomotor symptoms, low-dose vaginal estrogen is preferred. The risks of systemic hormone treatment are low in women younger than 60, although both estrogen and progesterone therapies are associated with a slight risk of breast cancer or blood clots. Just as in oral contraceptive therapies, the risks of blood clots (and breast cancer) rise significantly if the user smokes cigarettes.

There is also some evidence of a possible risk of heart disease from estrogen therapy, but the evidence is not conclusive and is still under study. In general, women who have vasomotor and/or genitourinary symptoms due to menopause that negatively affect their sleep and/or quality of life and who are not at high risk for blood clots, breast or uterine cancer, or heart disease may be good candidates for systemic hormone therapy. Because menopausal symptoms are usually more severe during early menopause, and the risk of adverse effects of hormone therapy rises with age, many clinicians prefer to prescribe hormone therapy only in those younger than 60 years who are within 10 years of menopause onset. Naturally, like all medical decisions, the decision to treat is made on an individual basis.

For more information go to the Endocrine Society at:

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 By Peter Galvin, MG

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