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When
to Switch from oral contraceptives (Ocs) to hormone replacement
therapy (HRT)?
Question:
As OCs are becoming more popular
for control of irregular menstrual periods and for contraceptive
purposes in perimenopausal women, the following question becomes
more relevant to more people: when should a woman switch from
oral contraceptives to HRT?
Answer: A woman who takes an oral contraceptive
typically takes two hormones, some type of progestogen (to act
as the contraceptive) and some type of estrogen (to reduce side
effects of progestogen). A woman who needs hormone replacement
therapy for menopause-related complaints typically takes some
type of estrogen and, if she still has a uterus, some type of
progestogen to protect the uterus. However, these two women
take different doses of these hormones. OCs contain far more
hormone than the doses found in hormone replacement therapy
for the menopause. The increased amount is needed to protect
against an unwanted pregnancy. Women should not continue to
take higher doses of hormones than those needed. If women are
no longer partnered with men, they can switch to lower doses
without concern.
Other women still partnered with men should be tested to see
if they have reached menopause. Women not taking oral contraceptives
will have an idea that they have reached menopause because their
periods stop (menopause is confirmed after 12 consecutive months
without periods). However, those taking oral contraceptives
will continue to have periods. To confirm menopause in these
women, it has been suggested that a blood test for follicle-stimulating
hormone (FSH) be measured at the end of the pill-free week.
FSH should increase in menopausal women, as the pituitary secretes
more and more of this hormone in its failed efforts to stimulate
the ovary to release an egg. Very little data are available
to support this recommendation.
One small study measured hormone levels in four different age
groups at the beginning and end of the pill-free week. Neither
estrogen nor FSH alone accurately identified all menopausal
women. Some women known to be menopausal did not have the expected
rise in FSH. The authors recommended stopping the oral contraceptive
for one to two weeks, then measuring both FSH and estradiol
at that time improving the accuracy. More research is needed.
Relationship between
Menopause, Menopausal Blues and Depression
Question: I'm confused. Recently I heard that
menopause was not linked to depression, yet many women during
perimenopause appear depressed and moody. Please explain.
Answer: Some of the confusion stems from the fact that
the term "depression" may apply to a symptom (feeling down),
a mood (the predominant feeling over a period of time), or a
syndrome. The syndrome of depression is usually called major
depressive syndrome (or illness) and is a very sad mood continuous
for more than two weeks, accompanied by some of the following
symptoms: change in sleep, eating, concentration and memory,
suicidal thoughts, a lack of pleasure, increased fatigue and
-- at times -- feelings of worthlessness and guilt. If instead
of feelings being down, sometimes there are cycles during which
the individual may feel elation and grandiosity rather than
feel very depressed. This is often the case in bipolar or manic
depressive disorder. To answer your question, there is no link
between menopause and depression syndrome.
Question:
Do women experience depression more
than men? and are menopausal women likely to get depressive
disorders?
Answer: Yes, women experience depressive disorders about
twice as frequently as men from the onset of adolescence until
the mid-50s. This occurs in almost all cultures. It may be that
women have better recall than men. More likely it is due to
genetic factors, hormonal cycles, and psychological issues which
make women more vulnerable to stressors such as victimization
and abuse in childhood. Women may experience depressive symptoms
during the time they are going through menopause, when ovarian
hormones are declining, and there may be stressors associated
with midlife. Women in these years may experience more irritability,
headaches, and emotional liability but not a depressive disorder
unless they have had past episodes of depressive disorders or
a strong family history of depression. The best way for a woman
to understand this aspect of the perimenopause is to keep a
record of menstruations -- to monitor the intervals between
bleeds as well as the rate and the quality of bleeds. Many ways
of recording are discussed in the scientific literature. Women
experience most depressive disorders in young adulthood when
they are having young children or may have premenstrual syndrome
(PMS).
Question:
My mother was depressed
and irritable when she was going through "the change". Does
this mean that will happen to me?
Answer: Not necessarily. Your expectations that you will
feel that way, however, will increase the likelihood that it
might happen. But with diet, exercise, support groups, and friends
who can share information and emotional support, you may feel
much better.
Abnormal Uterine Bleeding
in Perimenopausal Women
Question: In perimenopausal women, when is the
bleeding pattern of menstrual periods abnormal and cause for
concern and when is it normal but "irregular" or different from
previous episodes of uterine bleeding?
Answer: Contrary to what some might believe, a change
in the bleeding pattern as women approach menopause is not unusual.
Most of the time, the changes are normal and these changes are
nothing to fear. However, many days of menstrual bleeding, whether
heavy or light, with a short period of time between bleeds is
not normal.
Several factors need to be understood related to the change
in bleeding. First, more perimenopausal women experience a change
in their pattern of bleeding. Yes, there are a few women who
"just stop" -- never to bleed again. These women are the exception
rather than the rule. Second, the change in pattern usually
means a lengthening of the interval between menstrual bleeds,
and a change in the quality of the bleeding. Whereas previously
a woman may say, "I am as regular as a clock", when she is in
the menopause transition (perimenopause), periods become more
unpredictable. This kind of change in the menstrual pattern
is normal. Sound advice here is to always be prepared as a menstrual
bleed can come at any time, and usually at a time when it is
most annoying.
Once the bleeding starts, it may often than not be characterized
by a bleed that is heavier than during reproductive years and
clots may be passed with blood. Even this qualitative change
in bleeding is normal if it occurs over the short term. During
regularly menstruating years, most menstrual blood is resorbed
-- which means it never leaves the uterus. What does issue forth
through the vagina amounts to only about 2 ounces. A woman who
reports heavier bleeding with clots may exceed this amount a
little. However, a woman who is bleeding very heavily may exceed
these 2 ounces 5 to 10 times, may find herself using 8 to 10
super napkins and tampons every day, and may change menstrual
products every hour. If this kind of heavy bleeding persists
over the long term or if there is a short interval of no bleeding
in between heavy bleeds, this is abnormal and should be a signal
that something is not right. Heavy bleeding does not necessarily
mean disease. What it means is that for some reason or other,
more blood leaves the uterus than is resorbed.
A good rule of thumb to follow is that if bleeding is continuous
for more than two weeks, see a care provider. If bleeding is
heavy and the interval between bleeds is two weeks or less,
see a care provider. Heavy and/or prolonged uterine bleeding
can result in anemia which in and of itself can lead to symptoms
of fatigue and heart problems; taking an iron supplement may
be called for.
Colon Cancer Risk
Question:
I'm worried about colon
cancer, as it's in my family. What can I do to prevent it?
Answer: Talk to your doctor about screening tests, such
as a home test for blood in your stool, and a procedure called
flexible sigmoidoscopy. In addition, there are many things you
can do for yourself. Women who take estrogen therapy have been
found to have a 20-35% lower risk of colon cancer, which persists
while they take estrogen but not after they stop. Long-term
use of multivitamins containing folate (folic acid) has been
associated with a 75% decrease in risk of colon cancer after
15 years of use. Vitamins A, C, and E, as well as calcium have
also been associated with lower risks of colon cancer. Other
helpful strategies include not smoking, and eating a diet high
in fiber (whole grains, fruits, and vegetables) and low in red
meat, and getting regular physical exercise.
Breast Cancer Risk
Question:
I'm worried about breast
cancer. I'd like to know if HRT or ERT increase my risk of breast
cancer?
Answer: Some scientific studies have suggested a slightly
increased incidence of breast cancer among women taking estrogens
for prolonged periods; however, the majority of studies have
found no additional risk. Some studies have suggested a possible
increased incidence of breast cancer in those women taking estrogen
for prolonged periods of time respectively if higher doses are
used. Regular breast examinations by a health care professional
and self-examination are recommended for women receiving estrogen
therapy, as they are for all women. In 2005 researchers will
complete the 10-year government-sponsored Women's Health Initiative
(WHI) on 27,500 women divided into two groups--one group takes
HRT or ERT while the other group takes a placebo. This study
should provide clearer information about potential risks. Women
should discuss their individual concerns and personal health
profiles with their physician or other health care provider.
Hot flushes
Question:
How can I cope with
hot flushes?
Answer:
Taking estrogen is the most effective treatment
for relieving the symptoms of menopause, including hot flashes
and night sweats. If you cannot take estrogen for a medical
reason, a drug called clonidine, a medication for high blood
pressure, may help reduce your hot flashes. But clonidine may
produce side effects such as dizziness and fatigue. A mild,
combined sedative preparation of belladonna, ergotamine, and
phenobarbital is also sometimes used to treat symptoms of menopause--including
hot flashes, sweating, restlessness, and insomnia. This combination
of medications is effective in about half of the women who take
it.
Self image
Question:
How do my body's hormone
levels influence hair growth?
Answer:
A change in the balance between your body's production
of female hormones and male hormones (androgens) may affect
your pattern of hair growth. A relative increase in the level
of male hormones in your body after menopause and decrease in
estrogen may cause some of the normally fine, light hairs that
cover your face and body to darken and thicken. Taking estrogen
in hormone replacement therapy can help reduce this excessive
hair growth. You can remove the hairs by plucking them or using
hair-removal creams. You may want to consider electrolysis,
a procedure to remove hair permanently. As they go through menopause,
some women notice that their hair begins to thin, especially
on their scalp and in their pubic area. Taking estrogen in hormone
replacement therapy can also help reduce hair thinning.
Question:
Can taking estrogen
help prevent wrinkles?
Answer:
Although most skin aging is caused by the damaging
effects of exposure to the sun, your body's decreasing estrogen
production during menopause can make your skin thinner and less
elastic. This thinning and loss of elasticity can cause wrinkling
and sagging. Your body is also producing less collagen, one
of the main supporting proteins of the skin. Collagen cannot
be restored through lotions or creams, and injections of collagen
have only temporary effects. Taking estrogen in hormone replacement
therapy helps maintain collagen levels and skin thickness. As
you age, your skin becomes more delicate, making it more susceptible
to damage from the sun. It is more important than ever to shield
your skin from exposure to the sun by using a sunscreen with
a sun protection factor (SPF) of at least 15, wearing protective
clothing, and staying out of the sun when its rays are the strongest
(between 10:00 am and 3:00 pm).
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