Take Charge of Your Health
An article by Dr. Kirtland Culmer

Menopause And Hormone Replacement
This article is directed toward those ladies who are entering the third phase of their lives, and it invites them to TAKE CHARGE and make decisions over events which were thought to be natural and unchanging during the past century. It is obvious that a portion of the public has accepted the fact that medical steps can be taken to change the natural course of events. The following account of my thoughts will be guided by A Position Paper of the American Council of Science and Health.

Briefly, menopause occurs when essentially all follicles are gone from a womanís ovaries. This eliminates the bodyís most productive estrogen source. When this happens, there is no longer a build-up of the lining of the womb and subsequent sloughing, and therefore the monthly bleeding is eliminated. Generally, when there is lack of bleeding for 6 to 12 months in a woman in her forties and fifties, this is the onset of menopause. It usually occurs between the ages of 47 to 55, but may occur as early as 32 or as late as 60. Women who are excessively thin, those who smoke cigarettes, and those who are mal-nourished for a long period of time experience menopause at an early age.

In the mid-twentieth century, attention was called to the cardiovascular and bone mineral benefits of long term hormone therapy. It was also suggested that it would cause a youthful appearance and attitude. This enthusiasm was dampened by the frequency of the experience of uterine bleeding experienced by women while taking estrogens as replacement. This led to a large number of these women ceasing the therapy. There were also concerns that estrogens might provoke breast, uterine, or other cancers.

The most common events associated with menopause are hot flashes and body sweats. It is interesting that 70% of Americans experience this phenomenon, but only 20% of Japanese women experience them. I believe that Bahamian women are at the lower end of the scale. When I was a child and young adult, I donít remember hearing of many ladies complaining of such symptoms. There probably is a very high cultural and psychological influence. Hot flashes are transient warm feelings that start in the upper body and face and spread downward. They are accompanied by rapid heart beat and profuse sweating. This may last for two minutes. It occurs during waking hours, but may sometimes awaken the lady from her sleep. At the same time, women may experience painful sexual intercourse and vaginal irritation. This results from a decrease in vaginal lubrication, restriction of blood flow, thinning of the covering of the vagina, and loss of elasticity. This could be very frustrating as the sexual interest of these ladies can still be very high. Estrogen in the proper doses can be given systemically to relieve these signs and symptoms, and enhancement can be obtained by the direct vaginal application of estrogen cream.

Cardiovascular disease is the most common cause of death in women in the Bahamas. Postmenopausal coronary heart disease rises in women. It is obvious that estrogens play a great part in delaying the onset of cardiovascular disease. It is therefore suggested that replacing the estrogen in menopause should play a substantial part in reducing the incidence of cardiovascular disease after menopause. Good cholesterol (HDL) is increased under the influence of estrogen, and bad cholesterol (LDL) is decreased. This may also reduce cardiovascular risk.

Osteoporosis is a loss of bone structure and density that leads to weakness of the bones. A rapid loss of density occurs during the 5-10 years immediately following menopause. The risk of these bones becoming fractured increases; especially the wrist, vertebrae and hips. Long-term estrogen administration during and following menopause has been shown to substantially reduce the rate of osteoporotic bone loss and decrease the incidence of both hip and vertebral fractures by about 50%. Bone density testing is available here in Nassau.

Low estrogen levels can produce genitourinary disease. Mention has already been made of the effects on the vagina, and it is speculated that estrogen deficiency changes contribute to urge or stress incontinence. Some studies suggest that estrogens promote nerve cell growth in the brain. Sexual Drive begins to wane during the early perimenopause, and decreases more rapidly some years after menopause. Most healthy 70 year olds engage in sexual intercourse, and a substantial number of postmenopausal women regret the loss of their drive. The estrogen effect on the vaginal mucosa and secretions substantially influences sexual activity, but does not change the intensity of the drive.

Estrogens induce growth of the wall and lining of the Uterus or womb, and this may cause some cancerous degeneration. That is why progesterone is given, in addition to estrogen, in the last 10 to 14 days of the cycle in women whose uteri are intact.

In summary, research findings are not happily conclusive, but seem to suggest that the benefits derived from hormone replacement therapy (HRT) are the reduction of hot flashes and body sweats, cardiovascular disease, osteoporosis, colon cancer, vaginal atrophy and brain deterioration. On the other hand, in long term therapy (exceeding five years), there is a suggestion of a minimal risk of venous thrombosis, and cancer of the uterus and breasts. Those persons with a history of venous thrombosis, chronic liver disease, and a history of breast cancer are advised not to use the treatment. Others must recognize that they should take charge by obtaining as much of the latest information as possible, seeking advice of physicians in the field with knowledge of this subject, and recognizing that decisions must be based on the best information, and the individualís personal requirements.