Dr.
Steven R. Goldstein MD, one of the Best
Obgyns in NYC, comments on an article from the NY Times.
In
it she highlights that if you Google search “menopause and…” you come up with a
whole assortment of very negative symptoms like weight gain, depression, hair
loss, etc. She goes on to state that such a bleak view of menopause is unique
to only modern cultures. She goes into great length about the history of
how menopause was defined in ancient times and has come to be known as a
medical issue only in relatively more modern times. She describes the
importance of women after their reproductive life to the family unit, often
allowing care of younger children as a grandparent so that the parent will be
free to occupy other important roles in the extended as well as nuclear family
unit.
I
could not agree more with such an assessment and hope that all of you realize
that I value women in their post reproductive state and the contributions they
make to their families, to our communities and society in general.
At
the same time, these days many people seem to be obsessed with the concept of
anti-aging. Anti-aging doctors have been giving bio identical hormones and
other non-tested, non-approved substances as patients search for an antidote to
aging. Ponce de Leon left Spain more than 600 years ago in search of the
fountain of youth. People are still looking. The key, in my opinion, is healthy
aging not anti-aging.
My
problem with this excellent article in Sunday’s New York Times is that it does
not acknowledge the very real medical issues that accompany estrogen
deprivation after there is no more ovarian function (the medical definition of
menopause). Other higher order primates live a very short time after they stop
reproducing. My patients will spend more than 40% of their lives in a post reproductive
state. There are very real consequences medically of the lack of estrogen
production that menopause brings. Loss of bone mass occurs quite rapidly, and
osteoporotic fractures are a significant medical issue as the population ages
more and more. A 50-year-old woman who does not already have cancer or heart
disease has a life expectancy of 91. If a woman suffers a hip fracture her
chances of being dead within the next year are 20–30% and she has a 25% chance
of never living independently again. There are also serious changes in the
vagina as a result of a lack of estrogen. A change in the normal bacteria
causes diminished production of lactic acid and thus the pH will change
dramatically, as does the cell count. This leads to dryness and lack of normal
lubrication which, in patients who are sexually active, can result in severe
discomfort. Almost all of you are aware of the symptoms of hot flashes and
night sweats, the most common of the menopausal transition. Fortunately, for
the majority of women, these will ameliorate by 4–5 years, although some women
will have these indefinitely. In addition, lack of estrogen can result in joint
pains. After the Women’s Health Initiative published its findings in 2002
showing that estrogen plus progesterone therapy caused an increase in breast
cancer and heart disease, 50% of women stopped their hormones immediately but
25% went back on. The most common reason for resuming was hot flashes and night
sweats as you would think. The second most common reason was joint pains.
Furthermore, menopause, with its lack of estrogen, on average causes an
increase of 15 -20% in total cholesterol and LDL cholesterol (the bad
cholesterol). In addition, estrogen helps promote lean body mass and after
menopause women tend to accumulate more fat centrally (that old “midriff
bulge”).
I
am not trying to medicalize menopause. However, we cannot ignore the effects of
estrogen deprivation on a variety of organ systems especially as women are
living longer and longer. There are new approaches to replacing estrogen
without the use of progesterone. As evidenced by the Women’s Health Initiative,
it is the addition of progesterone in order to protect the uterus that seems to
be the culprit in causing most of the negative findings. These new approaches
are, in my opinion, much safer than what we’ve done for the past half century.
They involve combining the estrogen Premarin with a different category of drug
than progesterone. That category is SERM (selective estrogen receptor
modulator). There are a number of SERMs already on the market for breast cancer
prevention and prevention and treatment of osteoporosis.
In
summary, yes menopause can and should be a time of healthy aging and continued
productivity and personal satisfaction indefinitely. The pros and cons of
replacing estrogen need to be individualized and discussed on a case by case
basis.
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