All women who’ve reached menopause have less oestrogen available to their bodies than before menopause. But not all women who are menopausal need to have that oestrogen replaced. In fact only about one in four women really needs hormone therapy (HT) for relief of menopausal symptoms.
There is an argument that menopause is a physiological and normal event and should therefore not be treated as an illness, in other words with medication. While this is true, it is also worth considering that women now live for many years beyond the menopause and that these changes in life expectancy are relatively recent.
It has been established that there are risks associated with living for many years with low levels of oestrogen in the body. These risks most importantly affect the bones and the heart.
Most women approaching menopause now start to consider whether or not they should take any sort of therapy to counteract both the symptoms and the potential long-term effects of lack of oestrogen.
Considering the treatment options
There are different types of intervention, depending on the individual symptoms and needs of each woman.
Menopause is not managed according to a formula. Each woman should be evaluated as an individual and will often have selective investigations to establish whether she is:
Healthy with no problems
Healthy, but with significant risk factors for osteoporosis and/or heart disease
Medically compromised, for example has had a heart attack, stroke, breast cancer, diabetes etc.
With your doctor, you should determine your individual health status and risk factors for developing diseases in later years and goals to be achieved in health prevention.
If therapy is needed, there are several options available:
lifestyle modification, such as diet to promote loss of excess weight and to enhance bone health
nonprescription remedies, including bio-equivalent hormones (plant oestrogens), black cohosh, and other herbal remedies. Note that there is unfortunately very little evidence for the efficacy and safety of these drugs.
prescription therapies, including hormone therapy.
Presciption treatment include:
1. Hormone therapy (HT)
HT involves taking low dosages of oestrogen (oestrogen therapy or ET), or low dosages of both oestrogen and progestin (known as combined oestrogen-progestogen therapy or EPT) to relieve short-term symptoms and possibly reduce the risk of long-term diseases associated with menopause.
There are benefits and risks to ET and EPT which may differ for each woman. The decision to use hormones, as well as dosages, routes and duration of use, must be based on your individual risk-factor profile: your personal and family medical history, particularly of certain cancers, heart disease, stroke and osteoporosis. For example, oestrogen-only therapy should not be an option for women who still have a uterus, as it could increase the incidence of endometrial (lining of the womb) cancer.
The hormone testosterone is sometimes prescribed to help when menopause has a negative effect on sex drive, particularly in the case of surgical menopause.
3. Other prescription medicines are also options for certain short-term menopause-related changes: low-dose oral contraceptives, clonidine and belladonna-containing products.
4. Drugs to prevent long-term effects. Some prescription drugs may not help with short-term complaints, but may help prevent long-term effects of lower oestrogen levels.Drugs such as alendronate, risedronate, zolendroic acid, sodium ranelate or raloxifene help to reverse bone loss in osteoporosis; several cholesterol-lowering or antihypertensive drugs can help prevent heart disease by controlling blood pressure and cholesterol.
Reviewed and updated by Dr Alan Alperstein, obestetrician and gynaecologists in Cape Town, in February 2011.
Previously partly reviewed by Dr Mike Davey, President of the South African Menopause Society & Dr Tobie de Villiers, gynaecologist and committee member of both the South African Menopause and International Menopause Societies.