Terminology
THE MENOPAUSE
Terminology
The menopause or change of life is essentially that time of life when women go from their fertile years of regular menstruation to the era of absent periods free from the risk of pregnancy.
The different elements of this time zone have a confusing terminology. To the doctor, the menopause is actually the time of the cessation of periods, and the first 6 months afterwards. This is a time where hormonal patterns and bleeding and the need for contraception are uncertain.
To the patient the menopause generally indicates a variable time of life from when the periods become irregular and often heavier, until the time when they actually cease and beyond. This is medically known as the climacteric. Some people have a very long history of these symptoms, and so not all irregular and heavy periods of course are associated with the beginnings of the onset of the change of life.
The variable time either side of the menopause is the peri-menopause, and this is a time of heightened symptoms.
The post menopausal period is essentially the time after the cessation of periods when menopausal symptoms occur, and in some patients this can represent the rest of their life. For many people the symptoms will either not be a problem at all, or will settle down over the first 6 months to 2 years.
Safety
Safety of HRT
When people first started treating the disabling features of the menopause with oestrogen (Ethinyl Estradiol - the pill oestrogen), the results were miraculous. It reversed menopause! This was soon (wrongly) equated with reversing ageing! Needless to say it was used in higher and higher doses (mainly in the USA) without a thought to protection of the uterus. The end result - "Oops, it causes cancer - stop using it".
"But we need it" was the outcry! Fortunately, when given in cycles with a 1 week break every month, it was safe. Unfortunately, many would start flushing in their week off and compliance was bad. Progesterone was natures answer, and artificial progesterone agents were found to be protective. "Natural" oestrogens came on the scene in the form of Conjugated Equine Estrogens (soluble horse oestrogen mixture). These were metabolised by the same pathways as human oestrogens, and indeed much of it was identical to the human stuff. At last it was safe!
Ways were found to make human oestrogens absorbable (and patentable), and many choices came on the market. New (and patentable) delivery systems for the hormones were developed. It was realised that women had more osteoporosis than men, and much of this was because of rapid calcium loss when they ran out of oestrogen. Women were also less likely than men to have heart attacks and strokes, until they ran out of oestrogen. A new market developed - illness prevention!
"Oops! It may cause breast cancer and, paradoxically, seems to make heart attacks worse!". Many types of study were undertaken to sort this out. They are inherently hard to do as the risks are obviously low, and good studies required large numbers of representative women, and a lot of time. Unfortunately, although many studies have been done, they are all criticised for being too small, too short, too unrepresentative, or for being stopped too soon to achieve good statistical proof of the risks. (See links).
So where does that leave us? We know that HRT has risks, to breast and to clogged arteries. The risks are low, in the same order of magnitude as driving a car. There may be as yet unrecognised risks but these cannot be large. We know that the benefits of HRT are predominately Quality of Life issues, but in some people these can be disastrous. Given the choice and the knowledge, most women with significant quality of life problems will choose to take a slight risk to their duration of life in order to enjoy good quality of life. It is a decision each person makes for themselves.
