Menopause – The Change of Life
Menopause – a Journey
Menopause is a journey all women are predestined to pass that begins in the early forties and concludes with the cessation of menses when women become postmenopausal. The average age of the last menstrual period is around 51.
Menopause is caused by a gradual reduction of ovarian hormone production that is often the cause of menstrual irregularities and occasional hot flushes commonly seen in women during this time. The total loss of the menses characterizing the onset of the post-menopause is due to ovarian failure, meaning its complete inability to produce any hormones. This causes a profound change in life for women not shared by men. Men continue producing all their hormones but at a gradually decreasing rate as they age.
The monumental shift women experience as a result of a deficiency of multiple key hormones is dramatic and affects all aspects of her life. The lost hormones are estrogen, progesterone, and testosterone all of which play a central role in the lives of all mammals and actually define what and who we are in the world in every respect. This is why deficiency of these hormones has such a major impact on women.
The loss of these important regulatory hormones negatively permeates all aspects of a women’s life including her physical, psychological, interpersonal health, and athletic fitness.
The best-known consequences of menopause are those associated with loss of estrogen and progesterone and include hot flushes and vaginal atrophy. Some women pass through menopause with no significant outward symptoms such as hot flushes or night sweats while others are tormented by these vasomotor events that can persist for up to 8 years in some. Vaginal atrophy can be of mild, moderate, or severe concern depending upon how much pain and emotional stress it causes. Traditional hormone replacement therapy (HRT) using oral estrogen and progesterone and/or vaginal estrogen addressed these issues adequately for most women but HRT has fallen out of favor over concerns about breast cancer and heart disease risk, which is overestimated by most women and physicians too.
What is the Risk of Traditional Hormone Replacement Therapy?
Heart Attack: 0.0008 events per year of use = 8/10,000
This is estimated to be about the same risk for breast cancer
as having 1 glass of wine with dinner each evening
The risk of breast cancer and cardiovascular disease with use of traditional HRT was best evaluated in the Women’s Health Initiative study. This major study was conducted in the 1990s and sponsored by the National Institutes of Health. It used PremPro as the HRT, which included Premarin a group of estrogen metabolites extracted from pregnant mare urine and Proveria, synthetic progesterone that has a prolonged effect, compared with natural bioidentical progesterone.
Proveria was shown in prior studies to increase mammographic density, which heightens the risk for breast cancer. There were 16,000 women in the study that lasted 5 years. The chance of breast cancer occurring in the study was about the same as a woman experiences from drinking 1 glass of wine with dinner. The actual number for breast cancer or heart attack seen in this study was 8/10,000 each year of therapy which is an itty-bitty number = 0.0008. There were no deaths due to HRT in this study as a result of breast cancer, heart attack, or stroke.
Data from that study was first published with great fanfare in 2002 because it proved for the first time that use of HRT did cause breast cancer and heart attacks. This was big news because up to that point all the data had shown HRT was associated with a reduced risk of heart disease. The investigators and most medical experts believed estrogen prevented heart disease and that is what the study was designed to demonstrate. When it proved definitively the exact opposite it caused an earthquake in the medical world and changed the practice of medicine profoundly. In retrospect even though we had the correct information on the degree of risk, 8 events in 10,000 patient years our interpretation of it was flawed as is clear in hindsight, as is often the case. We all “drank the Kool-Aid ” including me!
A very successful strategy employed by gynecologists and internists was to use HRT to prevent osteoporosis in women at risk. This was prior to the publication of the Women’s Health Initiative study results. With the introduction of DXA bone densitometry in the late 1980s, we were able to accurately identify which women were at highest risk and focus our preventive efforts on them. However when the Women’s Health Initiative study data became public in 2002 showing a tiny increase in risk for breast cancer and cardiovascular disease this practice was regrettably advised against. The rationale for this was since other therapy like Fosamax was available for prevention there was no need for use of HRT especially given HRT’s risks, however small.
While well meant, that advice lost value later in 2007 when concerns over long-term use of Fosamax and similar drugs became widely recognized. Women who had stopped HRT and had begun Fosamax now stopped Fosamax too! As a consequence in 2018, we have seen an increase in hip fracture rates among white women after seeing a decline in the 2000-2010 period. The rates are higher now than ever recorded.
The Third Ovarian Hormone
While most of the research into the loss of hormones at menopause has focused on estrogen and progesterone, the importance of the loss of the third ovarian hormone to a woman’s health is now becoming apparent. Testosterone is essential for the proper replacement of the body’s somatic tissues and when it is deficient these tissues, which wear out and have to be replaced by adult stem cells every 7 years, are replaced by fat. The somatic tissues include blood vessels, the heart, muscle, bone, cartilage, fat, and fiber, and make up about 87% of the body tissues.
Unless testosterone is present in the nucleus of the adult stem cell meant to replace the worn out somatic cell, it defaults to fat. We can measure this using a software application on our DXA bone density machine called Body Composition Analysis and it clearly shows this occurring in almost every woman during menopause. This occurs even to women who follow a healthy diet and exercise regularly because it is due to the loss of testosterone. While the causes of health are nutrition and exercise the condition that activates these causes in both women and men is testosterone. Without it the causes are ineffective.
Body Composition Changes
The Body Mass Index (BMI) is commonly used to classify people’s weight to height as appropriate or not. When the weight is too high the person is classified as overweight or obese and when too low for their height they are considered underweight. The normal range for BMI is between 19-25. With Body Composition Analysis (BCA) we directly and accurately measure the body fat, muscle mass, and bone mass and are able to quantify how much of each in pounds are in the body, where it is, and their relative percentages. Using BCA the normal body fat percentage is between 20% and 25%.
We measure BCA in all women between age 50 and 60 having bone density tests at our Women’s Health Center and it is a common finding that many have a BMI in the normal range with a body fat % in the obese range. This is important because this occult obesity has a very harmful effect on a woman’s metabolic health. It causes her blood cholesterol, blood pressure, blood sugar, and inflammatory markers to all rise ultimately leading to diabetes, cardiovascular disease, cancer, and arthritis. These medical conditions are the cause of the 10 most common chronic diseases responsible for most instances of death and disability and >75% of the healthcare costs for adults after age 50.
The internal increase in body fat burden may not be visible on the scale. But it is seen by a change in the woman’s figure as she loses muscle and gains fat. The change usually occurs around the middle of the body and in the breasts, thus affecting her dress size. The loss of muscle mass results in loss of strength and energy too. These changes occur gradually over many years beginning with the onset of menopause in the early forties but do not cease with the loss of menses at the onset of the postmenopause. On the contrary, they accelerate at that point because the ovary has completely stopped the production of testosterone.
Fortunately, women have an alternative source of testosterone which is DHEA made in the adrenal gland. It is converted inside the somatic stem cells into testosterone, which permits them to become functional tissues like muscle, bone, blood vessels, and cartilage but the average amount of DHEA produced by the adrenal is only about 35% of the peak production of testosterone seen in women at age 30 years. What’s more adrenal gland function declines by about 1.5% annually through the remaining years of life so even this source of testosterone is waning.
Hormone Loss With Menopause
Much is known about the psychological impact of menopause but little is done about it even when it is possible to address the problem definitively. There are estrogen, progesterone, testosterone, and DHEA receptors in every corner of the brain. Every brain cell has receptors for these key hormones because they regulate the DNA of these cells having a multitude of effects. Deficiency of these hormones has a major adverse impact on the emotions and ability to solve problems in women and represents one of the worse consequences of menopause. These hormones are fundamental to our thought process and emotional stability and their loss or deficiency is devastating.
Menopause occurs over many years. Since it is not fatal to lose these hormones and the mental impact is internal, women learn to adjust. But the cost is terribly high. It is in the nature of humankind to adapt to unpleasant circumstances and survive. This is one of the reasons our species has thrived but this particular adaptation comes with a heavy price one that it is unnecessary for most women to pay. These hormones can be supplemented in their natural form in a balanced manner that provides women with their benefits at low risk of harm.
Progesterone opposes some of the negative effects of estrogen including sodium retention that causes swelling. Its use is known to be effective in controlling vasomotor symptoms including hot flushes and night sweats. Progesterone use reduces anxiety and is associated with improved sleep efficiency meaning obtaining a deeper more restful sleep. This may explain why it has a positive effect on anxiety and depression.
DHEA improves memory, control over emotions, and reduces emotional reactivity and negative emotions. It reduces anxiety and depressive symptoms. Studies show the use of DHEA is an effective treatment for major depression and PTSD. It helps women think more clearly and this makes it easier to make decisions.
Testosterone is essential for adult stem cells to transform into functional somatic tissues including bone, muscle, and cartilage. When absent these stem cells are forced to differentiate into fat cells, their default setting. Testosterone increases self-esteem and a sense of self-worth. It increases the ability to think decisively and make choices between several options. Testosterone promotes the ability to take action rather than procrastinate in doubt. Testosterone itself is not the cause of aggressive behavior often attributed to this hormone rather that adverse effect is due to one of its metabolites dihydrotestosterone (DHT). DHT is also the cause of hair loss, acne, oily skin, and unwanted hair growth in women and its production from testosterone can be blocked by inhibiting the enzyme responsible for this transformation.
Estrogen is essential for female sexual characteristics and form. In the fetus, it creates the female form that blossoms with its rise at menarche and in the adult it maintains its glory. Estrogen has a deterministic effect on every aspect of a woman including her behavior, voice, thinking, expressions, hair, skin, facial features, breasts, hands, feet, arms, abdomen, legs, buttock, and of course vagina. When lost these tissues atrophy and feminity wanes. Judicious supplementation of this essential hormone results in the rejuvenation of these tissues restoring their healthy feminine properties. When used vaginally estrogen improves the health and function of the vaginal tissues, increasing lubrication, eliminating discomfort with intercourse in postmenopausal women.
We have developed products containing bioidentical hormones in a balanced formula designed for use in postmenopausal women as a supplement. The two products are compounded in our laboratory and are called EOS and Aurora. They both contain bioidentical estradiol, progesterone, testosterone, and DHEA and are designed for topical use specifically intravaginal administration on a nightly basis. These are systemic therapies formulated to specifically address all the issues discussed above and many others. The products are not for sale but are provided to our patients who subscribe to our Femegen Health and Wellness Program. For more information contact Kim Teasley at 404.547.2373 or at KimT@ARCenter.net.