Climacteric Symptoms & Hormone Therapy

Hyoung Moo Park

doi:10.5124/jkma.2006.49.1.11

Journal List > J Korean Med Assoc > v.49(1) > 1080600

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Park: Climacteric Symptoms & Hormone Therapy

Special Issue

Perspectives for Managing Menopause

Journal of the Korean Medical Association

Journal of the Korean Medical Association 2006; 49(1): 11-29.

Published online: 31 January 2006

DOI: https://doi.org/10.5124/jkma.2006.49.1.11

Climacteric Symptoms & Hormone Therapy

Hyoung Moo Park, M.D.

Department Of Obstetrics and Gynecology, Chung-Ang University College of Medicine & Hospital, Korea. hmpark@hananet.net

Abstract

After menopause, estrogen deficiency from the loss of ovarian function results in various symptoms and metabolic changes, which lead to an increased risk of chronic diseases. Troublesome menopausal symptoms, vasomotor and/or psychological, are the first to develop, and various kinds of disorders related to estrogen deficiency such as genitourinary atrophy, involutional osteoporosis, cardiovascular, and Alzheimer's diseases follow. Among these, two major long-term consequences of ovarian failure are osteoporosis and cardiovascular disease, which are also the major causes of morbidity, mortality and financial costs. Hormone therapy by using estrogen with or without progesterone, is most consistently effective for the treatment of acute and some intermediate menopause-related symptoms such as vasomotor symptoms and vaginal dryness, and therefore has been recommended as the first-line measure to prevent and treat the acute symptoms of estrogen deficiency. It also has been reported that hormone therapy reduces the risks of some long-term sequelaes, suggesting both therapeutic and preventive roles in postmenopausal women. However, it is clear that hormone therapy is not a panacea and is not suitable for all postmenopausal women because of side effects and some concerns about cancer risks. The rate of long-term compliance is also low at present. Recent RCTs showed that hormone therapy does not seem to be effective in improving cognition and preventing CHD and dementia. However, there is a growing consensus that the early initiation of hormone therapy provides protection from CVS and CNS, the two most important areas, whereas RCTs have disagreed with observational data. This means that in young women at early menopause, "a window of therapeutic opportunity" exists for hormone therapy, since treatment during this period may provide cardio- and neuroprotection. More studies are urgently needed on this controversy. Current recommendations suggest treatment with the lowest effective dose for the shortest period of time and individualized treatment based on patient's risk and benefit ratio.

Keywords: Menopause, Symptom, Sormone, Benefit, Risk, Early initiation

Figures and Tables

Table 1

Short- & long-term consequences of menopause

Table 2

Incidence of climacteric symptoms in Korean women

Table 3

Clinical manifestation of hot flush

Table 4

Management of hot flushes

Table 5

Risk of cognitive impairment & dementia in WHI memory study

Table 6

Risk of invasive breast cancer in WHI

References

3. Whitehead M, Godfree AV. Hormone replacement therapy. Your Questions Answered. 1992. London: Churchill Livingstone;13–23.

4. Utian WH, Shoupe D, Bachmann G, Punkerton JV, Pickar JH. Relief of vasomotor symptoms and vaginal atrophy with lower doses of conjugated equine estrogens and medroxyprogesterone acetate. Fertil Steril. 2001. 75:1065–1079.

5. Crandall C. Low-dose estrogen therapy for menopausal women: A review of efficacy and safety. J Womens Health (Larchmt). 2003. 12:723–747.

6. Ettinger B, Pressman A, VanGessel A. Low-dosage esterified estrogen opposed by progestin at 6-month intervals. Obstet Gynecol. 2001. 98:205–211.

7. Barnabei VM, Cochrane BB, Aragaki AK, Nygaard I, Williams S, McGovern PG, et al. Menopausal symptoms and treatment related effects of estrogen and progestin in the Women's Health Initiative. Obstet Gynecol. 2005. 105:1063–1073.

8. Management of menopause symptoms focus of NIH conference statement. National Institutes of Health state-of-the-science conference statement. http://consensus.nih.gov/ta/025/025MenopauseINTROpostconf.htm.

9. Ockene JK, Barad DH, Cochrane BB. Recurrent vasomotor symptoms common for EPT users in WHI after study was discontinued. JAMA. 2005. 294:183–193.

10. Pandya KJ, Morrow GR, Roscoe JA. Gabapentin for hot flashes in 420 women with breast cancer: a randomised double-blind placebo-controlled trial. Lancet. 2005. 366:818–824.

11. Avis NE, Brambilla D, Mckinlay SM, Vass K. A longitudinal analysis of the association between menopause and depression. Results from the Massachusetts Women's Health Study. Ann Epidemiol. 1994. 4:214–220.

12. Kessler RC, McGonagle KA, Swartz M, Blazer DG, Nelson CB. Sex and depression in the National Comorbidity Survey I : lifetime prevalence, choronicity and recurrence. J Affect Disord. 1993. 29:85–96.

13. Busch CM, Zonderman AB, Costa PT Jr. Menopausal transition and psychological distress in a nationally representative sample: is menopause associated with psychological distress? J Aging Health. 1994. 6:209–228.

14. 2002 Sleep in America Poll. 1998. Washington, DC: National Sleep foundation;Accessible at http://www.sleepfoundation.org/2002poll.html.

15. Cardozo L, Bachmann G, McClish D, Fonda D, Birgerson L. Meta-analysis of estrogen therapy in the management of urogenital atrophy in postmenopausal women: second report of the Hormones and Urogenital therapy committee. Obstet Gynecol. 1998. 92:722–727.

16. Johnson SR, Ettinger B, Macer JL, Ensrud KE, Quan J, Grady D. Uterine and vaginal effects of unopposed Ultralow-dose transdermal estradiol. Obstet Gynecol. 2005. 105:779–787.

17. Fantl JA, Bump RC, Robinson D, McClish DK, Wyman JF. Efficacy of estrogen supplementation in the treatment of urinary incontinence. The continence program for women research group. Obstet Gynecol. 1996. 88:745–749.

18. Jackson S, Shepherd A, Brookes S, Abrams P. The effect of estrogen supplementation in the treatment of urinary incontinence. ; a double-blind placebo-controlled trial. Br J Obstet Gynaecol. 1999. 106:711–718.

19. Grodstein F, Lifford K, Resnick NM, Curhan GC. Postmenopausal hormone therapy and risk of developing urinary incontinence. Obstet Gynecol. 2004. 103:254–260.

20. Stenmauer JE, Waetgen LE, Vittinghoff E, Subak LL, Hulley SB, Grady D. Postmenopausal Hormone therapy. Dose it cause incontinence? Obstet Gynecol. 2005. 106:940–945.

21. Hendrix SL, Cochrane BB, Nygaard IE, Handa VL, Barnabei VM, Iglesia C, et al. Effects of estrogen with and without progestin on urinary incontinence. JAMA. 2005. 293:935–948.

22. Waetjen LE, Brown JS, Vittinghoff E, Ensrud KE, Pinkerton J, Wallace R, et al. The effect on Ultralow-dose transdermal estradiol on urinary incontinence in postmenopausal women. Obstet Gynecol. 2005. 106:946–952.

23. Hulley S, Grady D, Bush T. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. JAMA. 1998. 280:605–613.

24. Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002. 288:321–333.

25. Manson JE, Hsia J, Johnson KC. Estrogen plus progestin and the risk of coronary heart disease. N Engl J Med. 2003. 349:523–534.

26. Women's Health Initiative Steering Committee. Effects of conjugated equine estrogen in postmenopausal women with hystetectomy: the Women's Health Initiative randomized controlled trial. JAMA. 2004. 291:1701–1712.

27. Clarkson TB, Anthony MS, Klein KP. Hormone replacement therapy and coronary artery ahterosclerosis: the monkey model. Br J Obstet Gynaecol. 1996. 103:Suppl 13. 53–57.

28. Clarkson TB, Anthony MS, Morgan TM. Inhibition of postmenopausal atherosclerosis progression : a comparison of the effects of conjugated equine estrogens and soy phytoestrogens. J Clin Endocrinol Metab. 2001. 86:41–47.

29. Admans MR, Kaplan JR, Manuck SB. Inhibition of coronary artery atherosclerosis by 17-beta estradiol in ovariectomized monkeys. Lack of an effect of added progesterone. Arteriosclerosis. 1990. 10:1051–1057.

30. DeKleijin MJJ, Bots ML, Bak AA. Hormone replacement therapy in perimenopausal women and 2-year change of carotid intima-media thickness. Maturitas. 1999. 32:195–204.

31. Hodis HN, Mack WJ, Lobo RA. Estrogen in the prevention of atherosclerosis : a randomized double-blind, placebo-controlled trial. Ann Int Med. 2001. 135:939–953.

32. Akhrass F, Evnas AT, Wang Y. Hormone replacement therapy is associated with less coronary atherosclerosis in postmenopausal women. J Clin Endocrinol Metab. 2003. 88:5611–5614.

33. Harman SM, Brinton EA, Cedars M, Lobo R, Manson JE, Merriam GR. KEEPS: The Kronos early estrogen prevention study. Climacteric. 2005. 8:3–12.

34. Rapp SR, Espeland MA, Shumaker SA, Henderson VW, Brunner RL, Manson JE, et al. the WHIMS Investigators. Effect of estrogen plus progestin on global cognitive function in postmenopausal women: the Women's Health Initiative Memory Study: a randomized controlled trial. JAMA. 2003. 289:2663–2672.

35. Shumaker SA, Legault C, Rapp SR, Thal L, Wallace RB, Ochene JK, et al. the WHIMS Investigators. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women: the Women's Health Initiative Memory Study: a randomized controlled trial. JAMA. 2003. 289:2651–2662.

36. Espeland MA, Rapp SR, Shumaker SA, Brunner R, Manson JE, Sherwin BB. Conjugated equine estrogens and global cognitive function in postmenopausal women. Womens health initiative memory study. JAMA. 2004. 291:2959–2968.

37. Shumaker SA, Legault C, Kuller L, Rapp SR, Thal L, Lane DS, et al. the Women's Health Initiative Memory Study Investigators. Conjugated equine estrogens and incidence of probable dementia and mild cognitive impairment in postmenopausal women: Women's Health Initiative Memory Study. JAMA. 2004. 291:2947–2958.

38. Zandi PP, Carlson MC, Plassman BL, Welsh-Bohmer KA, Mayer LS, Steffens DC. Hormone replacement therapy and incidence of Alzheimer disease in older women. The Cache County Study. JAMA. 2002. 288:2123–2129.

39. Bagger YZ, Tanko LB, Alexandersen P, Qin G, Christiansen C. the PERF Study Group. Early postmenopausal hormone therapy may prevent cognitive impairment later in life. Menopause. 2005. 12:12–17.

40. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and hormone replacement therapy : collaborative reanalysis of data from 51 epidemiological studies of 52,705 women with breast cancer and 108,411 women without breast cancer. Lancet. 1997. 350:1047–1059.

41. Viscoli CM, Brass LM, Kernan WN, Sarrel PM, Suissa S, Horwitz RI. A clinical trial of estrogen replacement therapy after ischemic stroke. N Engl J Med. 2001. 345:1243–1249.

42. Beral V, Reeves G, Banks E. Current evidence about the effect of hormone replacement therapy on the incidence of major conditions in postmenopausal women. BJOG. 2005. 112:692–695.

43. Chlebowski RT, Hendrix SL, Langer RD, Stefanick ML, Lane GD, Rodabough RJ, et al. Influence of estrogen plus progestin on breast cancer and mammography in healthy postmenopausal women : the Womens Health Initiative Randomized Trial. JAMA. 2003. 289:3243–3253.

44. Hulley S, Furberg C, Barrett-connor E, Cauley J, Grady D, Haskell W, et al. Noncardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and estrogen/progestin replacement study follow-up (HERS II). JAMA. 2002. 288:58–66.

45. de Lignieres B, de Vathaire F, Fournier S, Urbinelli R, Allaert F, Le MG. Combined hormone replacement therapy and risk of breast cancer in a French cohort study of 3175 women. Climacteric. 2002. 5:332–340.

46. Fournier A, Berrino F, Riboli E, Avenel V, Clavel-Chapelon F. Breast cancer risk in relation to different types of hormone replacement therapy in the E3N-EPIC cohort. Int J Cancer. 2005. 114:448–454.

47. Von Schoultz E, Rutqvist LE. Menopausal hormone therapy after breast cancer: the Stockholm randomized Trail. J Natl Cancer Inst. 2005. 97:533–535.

48. Holmberg L, Anderson G. HABITS (hormonal replacement therapy after breast cancer- is it safe?) a randomized comparison stopped. Lancet. 2004. 363:453–455.

TOOLS

Similar articles