When estrogen deficiency occurs in the menopause LH levels increase. Later the FSH is raised and remains high for the rest of life. This raised FSH and low estrogen levels appear to cause the characteristic hot flashes. Abrupt deprivation of estrogen causes more symptoms than a slow decline of function.
Estrogen therapy may relieve these symptoms. Prevalence of coronary thrombosis rises sharply in the postmenopausal years. Estrogen-containing pills increase the incidence of venous thrombosis. Estrogen therapy reverses the atrophy of the genital tract. Prophylaxis against cardiovascular disease in the setting of a strong family history of cardiovascular disease may result in indefinite use of HRT.
The same is true for protection against osteoporosis. Before institution of HRT, a complete history and physical examination should be completed Table Pertinent tests include a stool guaiac, a Pap smear, baseline mammogram, a sequential multiple analyzer SMA assay, and fasting cholesterol, triglycerides, and glucose concentrations.
Liver function tests are required in women with a history of liver disease. Pretreatment endometrial biopsies are not necessary for all women. Biopsies should be performed in women with irregular bleeding and in those at increased risk for endometrial carcinoma. Women at increased risk include those with a positive family history for endometrial or breast carcinoma, obesity, alcoholism, hepatic disease, and a long history of amenorrhea or oligomenorrhea during their reproductive years. Some recommend pretreatment biopsies in women who still withdraw to a short course of MPA, although the value of this has not been confirmed.
TABLE History and physical examination Stool guaiac Pap smear Mammogram SMA Fasting cholesterol Triglycerides Glucose Liver function tests with past history of liver disease Endometrial biopsy in high-risk groups.
SMA, sequential multiple analyzer assay. After replacement therapy is initiated, patients should be evaluated in 4 to 6 weeks to adjust the dosage if necessary and to evaluate side effects or complications. If severe headaches, visual changes, chest pain, or symptoms of thrombophlebitis develop, estrogen should be discontinued immediately.
If hypertension develops with the onset of therapy and cannot be controlled, then therapy should be stopped. Blood pressure usually returns to normal in those women. It has been suggested that biopsies be performed in women receiving cyclic progestin only if bleeding occurs before day 11 of progestin therapy, but these data require substantiation. A biopsy should be performed immediately in any woman who develops abnormal bleeding. Women on unopposed estrogen should have an annual endometrial biopsy even in the absence of any bleeding.
Breast and pelvic examination, blood pressure monitoring, and a stool guaiac test should be repeated at least yearly. Periodic mammograms should also be performed, with the frequency dictated by age and the presence of risk factors.
Pap smears should be obtained every 1 to 3 years, depending on history and risk factors. Although the roles of exogenous estrogen and progesterone therapy in cardiovascular disease and breast cancer have not been clearly defined, the use of this hormonal combination has been found to be cost effective and also has been shown to increase life expectancy by 1 month relative to no treatment.
Menopause is a normal and natural event in the female life span. The life expectancy of women already exceeds that of men, and many elderly women enjoy an excellent quality of life without HRT.
All women should be counseled regarding the healthy lifestyle that they themselves can adopt: low-fat, lowcholesterol diet; adequate calcium and vitamin D; exercise; and avoidance of smoking, excessive alcohol, and obesity.
A decision to use or not to use HRT is not irrevocable; it can be changed as new information becomes available. Patient and physician can reassess the current research and future health goals at each annual examination. J Biosoc Sci 4: , Fertil Steril 35, J Clin Invest , J Clin Endocrinol Metab , Vermeulen A: The hormonal activity of the postmenopausal ovary.
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The Management of the Menopause and Postmenopausal Years, p Pyorala T: The effect of synthetic and natural estrogens on glucose tolerance, plasma insulin and lipid metabolism in postmenopausal women.
Furman RH: Are gonadal hormones of significance in the development of ischemic heart disease? Ann N Y Acad Sci , Maturitas 5: 77, Jensen J, Riis B, Strom V et al: Long term effects of percutaneous estrogens and oral progesterone on serum lipoproteins in postmenopausal women. Am J Obstet Gynecol 66, Ann Intern Med — , Hulley S, Grady G, Bush T et al: Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women.
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English D, Schneld A: Endometrial cancer in relation to patterns of menopausal estrogen use. Nyholm HC, Nielsen AI, Norup P: Endometrial cancer in postmenopausal women with and without previous estrogen replacement treatment: Comparison of clinical and histopathological characteristics. Gynecol Oncol , Gambrell DR: The menopause: Benefits and risks of estrogen-progesterone replacement therapy. Maturitas , FSH is sometimes used as a measure of whether a woman is peri or postmenopausal.
Many gynecologists base their decision about whether someone is peri or postmenopausal on the woman's menstrual history and the presence of common menopausal symptoms. The FSH test is not considered diagnostic for the menopause. Sometimes women in the early stages of the menopause transition can actually have high estrogen levels because that month the follicles she has remaining in her ovaries were able to responded to the high levels of FSH and produce more estrogen.
Thus, the menopause can be characterized by very high and very low levels of estrogen. This is for informational purposes only and does not constitute medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.
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