Menopause: Long-Term Health Risks, Replacing Estrogen

by Food and Drug Administration (FDA)

(Page 2 of 3)

Long-Term Health Risks

Since women today live an average of 35 years longer than they did 150 years ago, scientists have only recently come to understand the long-term outcomes of living without the protective effects of estrogen. Ongoing studies have confirmed these effects, and women should be aware of them in order to avoid serious health risks.

Cardiovascular disease is the leading killer of American women. Before menopause, estrogen appears to help women maintain a healthy balance between LDL (bad) and HDL (good) cholesterol, making them six times less likely to experience a heart attack than men age 50 and younger, according to Jovanovic. Once estrogen is no longer present, LDL levels rise, and atherosclerosis (narrowing of the arteries) occurs. After menopause, a woman's risk for heart disease is about the same as a man's.

Estrogen also protects a woman against osteoporosis, the bone disease that affects 50 percent of American women over 60. In osteoporosis, bones become brittle and are easily fractured. It is the cause of the distinctive hump noticed in some elderly women and of dangerous hip fractures-the twelfth leading cause of death in the United States.

A 1996 study, reported in the medical journal The Lancet suggests estrogen protects against Alzheimer's disease, as well. The study showed that patients with Alzheimer's were significantly less likely to have taken estrogen following menopause (7 percent versus 18 percent). Additionally, the study found that four of seven Alzheimer's patients taking daily estrogen improved on mental test scores.

"It's predicted that the number of Americans with Alzheimer's will double in the next 30 years — affecting up to 14 million people. It's a major health issue for women, and the fact that estrogen may help prevent the disease is an important finding," says Richter.

Other health risks associated with the loss of estrogen include increased risk for ovarian and colon cancer, periodontal (gum) disease and tooth loss, and cataract formation.

When menopause symptoms begin, a woman should see her doctor to rule out pregnancy or serious health problems such as uterine cancer. A blood test to assess estrogen status also should be performed.

The most reliable test measures the level of follicle stimulating hormone (FSH), a hormone that is secreted by the pituitary gland to stimulate estrogen production. Levels of 30 to 40 milli International Units per milliliter (MIU/mL) or above means a woman has reached menopause. A level in the teens or 20s means there is still partial ovarian function.

If the ovaries are still functioning, many physicians prescribe low-dose contraceptive pills, which regulate periods and alleviate other symptoms. Because contraceptives can mask menopausal changes, a yearly FSH test should be performed beginning at age 50 to assess ovary status.

"Once a woman reaches menopause [and ovaries no longer function], we discontinue the contraceptives and consider other options," Richter says.

Replacing Estrogen

Estrogen replacement therapy (ERT) is an effective treatment for menopausal symptoms and has been approved for this use since the 1940s. During the 1980s, ERT also received approval by the Food and Drug Administration for preventing osteoporosis. When taken for many years, ERT reduces the risk of wrist, hip and spine fractures by 50 to 75 percent.

Its health benefits don't stop there. Numerous studies suggest possible effectiveness in prevention of heart disease, Alzheimer's, and other menopause-related conditions. In fact, a study published in the Feb. 1999, issue of The Lancet cited research revealing that postmenopausal women who use ERT have a 30 to 50 percent lower death rate than those who do not.

Currently ERT is available in pill and transdermal (skin) patch form. Different regimens and dosages are available. Health status and personal choice determine which is best. Because estrogen causes the buildup of endometrial tissue, and may increase the risk of cancer, a woman who still has her uterus must also take a progestin, which causes the excess tissue to shed.

Progestins can be taken either cyclically or continuously. In the cyclical regimen, estrogen is taken daily and progesterone is added for 12 to 14 days of each month. Several days after progesterone is stopped, a woman will usually experience a short period. Monthly bleeding can be lessened by taking a low dose of progestin with estrogen every day.

ERT may increase the risk for uterine cancer, blood clots, or gallbladder disease. Many studies have evaluated the possibility of increased breast cancer risk, but results are conflicting. Women taking ERT should perform monthly breast self-exams, says Richter, and have yearly mammograms after age 50.

Side effects associated with ERT include weight gain, bloating, breast tenderness, and nausea.

The hormones available for ERT are derived from two sources. Premarin (conjugated estrogens), the oldest and still the most widely prescribed estrogen, is derived from pregnant horse urine. It is approved for both symptom relief and prevention of osteoporosis.

Other ERTs are plant-derived, and several are available in both pill and patch form. One of the newest to receive FDA approval is Cenestin (synthetic conjugated estrogens, A), which is synthesized from soy and yam extracts. "Cenestin is approved for the relief of vasomotor symptoms such as hot flashes," says Lisa Rarick, M.D., director of FDA's division of reproductive and urologic drug products. "There have been no trials on osteoporosis prevention yet."

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