Increasing life expectancy has caused women to spend one-third of their lives after menopause. This situation has drawn attention to the physical and psychological changes of menopause and the postmenopausal period, making this an important health issue. Important observational studies had described the use of hormone medications in women during this period as highly beneficial.
The publication called WHI (Women’s Health Initiative), published in 2002, created a major impact not only in the medical community regarding this subject, but perhaps even more surprisingly, it had already appeared in the media earlier as “breaking news.” As a result of this study conducted on more than 16 thousand (161,808) postmenopausal women in the United States, hormone therapy was practically “EXCOMMUNICATED.” Physicians who had been dealing with this issue for many years were astonished by the results and examined the findings closely. First of all, the most criticized issue was age. Indeed, the average age of the women in the study group was between 50–79 (average 64). 12% of the cases had been in the postmenopausal period for more than 20 years. From this perspective, the idea of giving hormone medication to a 73-year-old woman who had no complaints and had been menopausal for 22 years became the main target of criticism. Moreover, the fact that among the women in this supposedly randomly selected study group, a symptomatic group had been separated and that some of the remaining women had diseases related to cardiovascular health, such as high blood pressure, caused this study to receive serious criticism after its publication in 2002, especially in the last 5 years. Prof. Robert Langer, who was part of the team conducting this study, made the following statement at the 2016 International Menopause Society (IMS) meeting held in Prague: “The process of conducting a clinical study is very complicated. Human metabolism and physiology – its functioning – are complex and full of surprises. In the end, we are never as smart as we were at the beginning.” His speech almost meant that we accept there were mistakes in this study. So then, where does “menopause” stand today, what awaits us during menopause, and what is the current status of hormone therapy? I will present the answers to these questions below in a question-and-answer format as “Menopause; Start Over.” This subject has also been worked on extensively by the board of directors of the Turkish Menopause and Osteoporosis Society, of which I am a member, and a report has been prepared. In light of this report and current international data, let me begin with the questions and answers:
What is menopause?
Menopause, in its true meaning, is the name given to the “last menstrual bleeding” due to the end of ovarian function. As understood, the diagnosis can only be made retrospectively.
What kind of complaints occur during the menopausal process?
The period starting before menopause and continuing until old age (senility), namely the climacteric period, is the time when complaints are most commonly seen. In fact, during this period, especially perimenopause, hot flashes occur in 75% of cases (vasomotor symptoms). In 30% of women, these hot flashes are moderate to severe and significantly reduce quality of life. Hot flashes cause insomnia at night, which affects the following day(s), bringing along problems such as fatigue, loss of concentration, decreased work efficiency, and depressive mood. Joint and muscle pain may also occur.
As time passes after menopause, problems such as vaginal dryness, burning, and pain during intercourse (GSM = genitourinary syndrome of menopause) also begin to appear.
In fact, all these complaints are like the tip of the iceberg; with the decrease of hormones, heart and bone health, above all else, begin to be negatively affected.
Does weight gain occur during menopause?
We all know that weight gain occurs from middle age onward, which is approximately 0.5 kg per year. However, this weight gain seen in middle age cannot be attributed solely to menopause. Nevertheless, it has been shown that during menopause there is an increase in total body fat and a change in fat distribution. Especially in women, fat accumulation around the waist area increases. This is a negative sign in terms of health, and both careful nutrition and exercise should be used to prevent fat accumulation, especially around the waist. Studies have shown that especially in women receiving estrogen treatment, this negative fat distribution tends to improve and the risk of diabetes mellitus (Type II diabetes) decreases.
Am I in menopause?
In women who no longer menstruate, the menopausal process is diagnosed through physician examination and the tests requested by the doctor. It is best to leave the interpretation of the FSH test, which is among these tests, to the physician. As textbook knowledge, FSH values of 40 IU/L and above, measured at least twice at different times, indicate that the ovaries are no longer functioning; however, FSH alone does not establish a menopause diagnosis.
What is Early Menopause?
If menopause is diagnosed before the age of 40, this is called early menopause.
What causes Early Menopause?
In the vast majority of cases, no specific cause can be found. Sometimes genetic disorders (monosomy X, FMR1 etc.), congenital enzyme deficiencies, or certain immune system problems may be the cause.
Is it possible to delay menopause?
No. Unfortunately, there is no medication or method to delay menopause. However, we should remember this information here: “Women who smoke experience menopause earlier.” Therefore, quitting smoking would at least remove this negative factor.
It is not possible to delay menopause, but regular menstrual bleeding can be achieved with medications in women during this process. This does not mean that menopause has been delayed.
I had bleeding after menopause, what should I do?
The vast majority of postmenopausal bleeding is due to hormonal and benign causes. However, in about 10–15% of postmenopausal bleeding cases, uterine cancer is detected. Therefore, it is necessary to consult a physician immediately in cases of postmenopausal bleeding.
I have urinary incontinence after menopause, what should I do?
Since the lower urinary tract also depends on the hormone called “estrogen,” changes occur in these areas after menopause as well. Simply put, there are basically two types of urinary incontinence: leakage with increased abdominal pressure such as coughing, sneezing, laughing (stress urinary incontinence), and the type associated with sudden urgency to urinate (overactive bladder). It would be appropriate to consult your physician regarding treatment. Because whether you need surgery or medication is determined by examination and some tests. In this sense, menopause treatment itself is not recommended.
What is the riskiest disease after menopause?
Considering frequency, in general for women (and men as well), the leading cause of death is “heart disease”. Especially after menopause, with the decrease of the hormone called estrogen, heart protection decreases and the risk of heart disease increases.
Which vitamins should I use after menopause?
For people who eat regularly, carrying around a bag of vitamins (!) is not necessary; however, it would be appropriate to use the vitamins recommended by the physician. It should be emphasized that Vitamin D is important in this regard: the daily Vitamin D requirement for postmenopausal women is determined as 800–1000 IU. Since this amount of Vitamin D cannot be obtained through food, Vitamin D should be used as recommended by the physician.
The use of calcium supplements, however, is not recommended recently—unless specifically prescribed by the doctor—because of conflicting results, especially regarding risks such as heart attack.
What about breast cancer, which all women fear? Does medication use cause breast cancer?
Breast cancer (excluding skin cancer) is among the cancers with the highest lifetime risk for women. The lifetime probability is 1 in 8–10 women. In general, the risk of breast cancer increases with age.
Do menopause medications cause blood clotting?
In menopausal hormone treatments, the most notable concern is the increased risk of blood clotting; however, with individually selected medications, this risk is minimized.
Should I use medication after menopause? I am very confused.
If 1) there are complaints, especially hot flashes, AND 2) there is no condition preventing use, menopause medications may be used under physician recommendation in women under 60 years old (or with menopause duration less than 6 years). For menopausal complaints such as hot flashes and insomnia, these medications are the most effective treatment. They can be used safely.
I want to use medication, but which medication and for how long should I use it?
Everyone is different from one another because of personal characteristics, severity of complaints, and expectations from treatment. Therefore, choosing the right medication for you depends on examinations and test results. You can comfortably use the medications prescribed to you for 5 years under supervision. Longer-term use may also be possible depending on your physician’s general evaluation and consultation with you.
I was diagnosed with breast cancer, but I have very severe hot flashes and vaginal complaints. What can I do?
In this case, there are also proven effective alternative treatments that you can use. These may include different non-hormonal pills or vaginal lubricants and creams.
I almost avoid sexual intercourse after menopause, what can I do?
After menopause, due to the decrease in the “estrogen” hormone, significant thinning occurs in the vaginal lining. This causes severe burning and pain during intercourse and is one of the most important reasons for avoiding sexual intercourse in the postmenopausal period. In addition, a decrease in sexual desire (libido) is also seen due to hormonal reasons. In this case, it would first be appropriate to thicken the vaginal tissue sufficiently with creams or suppositories, and then increase libido. Soon, supportive medications especially aimed at increasing sexual desire will also be available on the shelves in our country.
Which herbs sold by herbalists are good for menopause?
NEVER. Although plants are generally present in many modern medical drugs today, with herbs bought from herbal shops, it is uncertain how much active substance they contain, how much should be used, and how often they should be taken—it is almost “by guesswork.” Therefore, instead of such herbs, it is more appropriate to use supportive products sold in pharmacies after consulting a physician.
In short, for a healthy menopause and postmenopausal period, please have annual check-ups with your gynecologist and consult them. Spend this significant period of a woman’s life in a healthy way.
Wishing you days full of health and happiness…
Prof. Dr. Ümit İnceboz / Obstetrics and Gynecology Specialist / İRENBE