Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: https://www.tandfonline.com/loi/ipgm20
The menopause and thereafter Edward A. Banner To cite this article: Edward A. Banner (1976) The menopause and thereafter, Postgraduate Medicine, 59:6, 174-178, DOI: 10.1080/00325481.1976.11714399 To link to this article: https://doi.org/10.1080/00325481.1976.11714399
Published online: 07 Jul 2016.
Submit your article to this journal
Article views: 1
Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ipgm20
•
1pma annais from the 60th i nterstate postgraduate medical assembly
the menopause and thereafter Edward A. Banner, MD Maya Clinic and Maya Foundation Rochester, Minnesota
The menopause is a fact of life for every woman, and how it affects her depends on her physiologie makeup and on her emotional health. An empathetic physician is a great help ta the patient going through this stage of life. Whether ta offer hormone replacement therapy is a question each physician in general or gynecologie practice must answer.
• Ten years ago a physician 1 published a book who se intriguing title, Feminine Forever, contained a promise. If the book did little else, it created an awareness that female sex hormones differ from those of the male; that at a certain time in life the natural secretion of these hormones decreases; and that the diminishing supply of these substances, which in adequate supply make a woman youthful, sexually attractive, and fertile, causes the doleful symptoms connected with the menopause. This book, and the many other recent popular and scientific publications on the topic of menopause, have aroused many questions that are often asked of the physician. A frrst question is usually ''Are female sex hormones really necessary?'' (In other words, nature's way is often best and lack of these hormones may be beneficiai.) A second question frequently concerns the possible dangers associated with postmenopausal hormone therapy, eg, whether such therapy can cause cancer, high blood pressure, vaginal discharge, breast soreness, excessive weight gain, blood. clots, or a resumption of menstruation. The patient may worry about the possibility of becoming pregnant if she takes hormones after menopause. The questions reflect the increasing verbalization by women of their desire and need to know more about their own physiologie makeup. They also reflect the dilemma of the physician who must decide whether a postmenopausal patient should be given hormone therapy or whether milder treatment or no treatment at ali is indicated. The human female is the only mammal who lives usefully beyond the reproductive years. Today, the average life span of the American Caucasian female is 74 years; at the turn of the century it was 51 years. Since menopause usually occurs between the ages of 44 and 50 years, women now face the possibility of experiencing moderate-to-severe symptoms or sequelae attributable to the menopause for about one third of the ir !ife span. Thus, the question of therapy must be answered by every family physician and gynecologist. What are the facts of the matter? Functlon of Estrogen and General Effects of Deflclency
Estrogen is produced primarily by the avaries and secondarily by the adrenal glands. It has many functions, alone or in
174
POSTGRADUATE MEDICINE • June 1976 • Vol. 59 • No. 6
conjunction with other hormones. It helps to metabolize protein, thus producing strong bones and healthy tissues. It aids in keeping tissues, especially those of the vagina and the bladder, moist, pliable, and resistant to infection. It enhances breast development, assists in maintaining a balanced body chemistry (especially with respect to fats and lipids), and may have a part in the metabolism of cholesterol. At a certain time in !ife, production of estrogen decreases. If the supply reaches certain critical levels, the hormone can no longer fulfill its normal functions, and the symptoms popularly known as the "menopausal syndrome" may develop. These include hot flashes, night sweats, chills, joint pains and bac kache, fatigue, insomnia, and depression. Vasomotor symptoms are most severe in women who previously have had vasomotor instability. Thinning of the mucous membranes, development of dowager's hump (kyphosis), cardiac palpitation, thinning of the hair, and hirsutism may be noted. The bones and the cardiovascular system may also be affected (see sections on Osteoporosis and on Coronary Artery Disease). The severity of symptoms varies from individual to individual. About 50% of women pass through menopause with no symptoms at all, and th us the extent of diminution of estrogen supply has been thought to vary among individuals. A more recent explanation concerns the number of estrogen binding sites within a particular individual. Estrogen deprivation also affects the supply of other hormones. Estrogenic inhibition of gonadotropin production in the pituitary disappears, with a consequent increase in supply of these pituitary hormones. Vasomotor instability may be due to Jack of estrogen or to increased levels of folliclestimulating hormone (FSH), orto bath. The supply of thyroid and of adrenocortical hormones decreases moderately. Surprisingly, however, estrogen may be found in the urine of women who have undergone oophorectomy or even oophorectomy and adrenalectomy, suggesting an extraglandular source for this hormone. The thyroid gland bec ornes smaller, and there is often a commensurate decrease in the basal metabolic rate. Hyperparathyroidism is seen much more commonly during and after
Vol. 59 • No. 6 • June 1976 • POSTGAADUATE MEDICINE
the menopause than during the years preceding this period. The incidence of diabetes rises. Elasticity of the skin and connective tissue gradually declines and degenerative changes occur; hyperkeratotic areas of the skin are not uncommon. Osteoporosis
Skeletal changes are among the most important pathophysiologic effects of the menopause. The incidence of osteoporosis in postmenopausal women is approximately 25%. Osteoporosis results from a normal or decreased rate of bane formation and an increased rate ofbone resorption. The net result is diminution of bane mass, increased bane porqsity, and bane fragility. This leads to fractures, mostly of the vertebral bodies but also of the upper femur, humerus, distal portion of the forearm, and ribs. Osteoporosis precedes 80% of all hip fractures, and this event is 2 Y.z times more common in women than in men. Hip fracture is an a minous complication of the menopause, for one sixth of all patients with this type of injury die within three months of sustaining it. Symptomatic spinal osteoporosis is four times more cornmon in women than in men. Orthopedists have called attention to an ''osteoporosis-prone population,'' which ineludes petite women, particularly those of north European descent, who have a small adult bane mass. Black women orthose who are tall or obese have above-average peak bane mass and are therefore less likely to sustain osteoporotic fractures. Diagnosis-The spinal x-ray film is the most important diagnostic aid for the detection of osteoporosis. It may show wedgeshaped compressions of the vertebrae, increased vertical striations, increased radiolucency of the vertebrae, and accentuation of size of the end plates. At an advanced stage of the condition, fractures may be seen. If an x-ray film shows cortical erosion, bane biopsy is necessary to rule out malignant disease. Other osteoporotic findings on x-ray examination necessitate further investigation to rule out not only malignant disease but also Cushing's disease, b~liary cirrhosis, and intestinal malabsorption. Osteoporosis is also a consequence of prolonged immobilization. Laboratory tests are of little help in diagnosing osteoporosis. Serum calcium and al-
175
Edward A. Banner Dr. Banner is in the department of obstetrics and gynecology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, and is professer of obstetrics and gynecology, Mayo Medical School.
kaline phosphatase levels are within normal limits. The level ofparathyroid hormone may be slightly depressed. U sually, the only persistent chemical abnormality is arise in serum phosphate concentration. Such an increase, however, occurs with any condition causing increased bane catabolism, such as ~cro megaly, thyrotoxicosis, metastatic breast cancer, Cushing's disease, and multiple myeloma. Bane densitometry using isotopes has been suggested as a useful diagnostic procedure.Results obtained at the Maya Clinic using this procedure have been inconclusive. Thus, there is no single diagnostic test for postmenopausal osteoporosis. The clinical findings and results of x-ray films must be considered together. Height as an indicator-The patient's height is one of the most sensitive indicators of the progression of osteoporosis, even more sensitive than symptoms. Recent studies have shawn that postmenopausal women may lose from 2 to 15 cm (1 to 6 in) in height. A measurement of the patient's height should thus be recorded at each annual physical examination. The extent of height loss can also be estimated by noting the difference between arm span and present height: these measurements usually agree within about 3 cm (Ph in). However, in sorne women, eg, black women, those with Marfan's syndrome, orthose who were castrated while young and in whom epiphyseal fusion was delayed, arm span may exceed height without the presence of osteoporosis. Coronary Artery Dlsease
Published studies disagree concerning the effect of the menopause on the female cardiovascular system. The increase in incidence of coronary artery disease and in related mor-
176
tality that begins for American women about the middle of the fifth decade of life, and the corresponding decrease in the male-to-female ratio for these events, is a statistical commonplace. Of interest is the fact that the sex difference is much smaller or is negligible in populations lacking the affluence and high standard of living enjoyed in the United States. For example, in 1965 the male-tofemale ratio for death from coronary artery disease for persans aged 45 to 54 years was 5:1 in the United States, 2:1 in Ital y, and only slightly greater than 1:1 in Japan. In the United States, the ratio is much lower among blacks than among whites. After considering data from various countries, it appears that for women in most societies mortality from coronary artery disease increases with age and that this increase is independent of the menopause. The lowest mortality rate is found in affluent Caucasian women. Atrophy
With menopause, atrophie changes occur in the genital tract and the breasts. These mainly involve the epithelium of the vagina and of the distal portion of the urethra. Atrophy of the bladder sphincter may eventually develop. The labial subcutaneous fat is gradually lost, and labial atrophy can lead to ulceration. Drying and shrinking of the vulva leads to the dermatologie condition known as kraurosis vulvae. Loss of tissue elasticity may cause gaping of the introitus and prolapse of the cervix and uterus, and may result in cystocele or rectocele. The breasts sag and diminish in size. Determination of Estrogen Deflciency
Of interest is the recent finding of no significant difference in plasma concentrations of estrogen in women with menopausal symptoms and in women without such symptoms. Further, an exact correlation between symptoms and maturation index as determined from a vaginal smear has not been found. This index, of course, is affected by drugs, such as digitalis, and by various disorders, eg, carcinoma of the cervix or vagina, diabetes, and pernicious anemia. A finding of a positive correlation in maturation index, plasma estrogen concentration, and symptoms may be valid only in cases of ex-
POSTGRADUATE MEDICINE • June 1976 • Vol. 59 • No. 6
treme estrogen deprivation, when tissue atrophy is substantial and the effects of law estrogen supply are evident. Although pyknosis detected on vaginal smear may have sorne significance in determining estrogen Jack, few gynecologists use the carnification index alone as a measure of such Jack. Sorne believe that the fern test, which is merely the appearance of dried mucus on a slide, best shows the presence or absence of adequate levels of estrogen. Ifurinary estrogen value is found to be law, the leve! of pituitary gonadotropins is expected to be elevated. Possible Adverse Effects of Estrogen Administration
In sorne women, the endometrium is particularly susceptible to estrogen stimulation; prolonged stimulation has been positively correlated with endometrial hyperplasia and, to a lesser extent, with carcinoma of the endometrium. The prolonged presence of excess estrogen also gives rise to ovarian granulosa or theca cell tumors, ovarian stroma! hyperplasia, polycystic avaries, and prolonged anovulation. The occurrence of vaginal carcinoma in women whose mothers received diethylstilbestrol during pregnancy has become a matter of concern, and use of estrogen during pregnancy has been discontinued. Carcinoma of the breast has been reported in men treated with estrogen for prostatic carcinoma, in transsexual men given estrogen, and in Bantu men with gynecomastia. Since the incidence of breast cancer in men is law, these data suggest a possible estrogen effect. Breast cancer is apparently more common in women who have not borne children and in those who delay childbearing than it is in other women; it is Jess common in women who have had an early artificial menopause. However, to date there is no evidence that a woman who takes oral contraceptives orother hormones has an increased risk of breast cancer. Healthy women taking estrogen orally are at increased risk for vascular accidents; the risk of thromboembolic disease is estimated to be four to eighttimes that of women who do not take estrogen. Studies designed to demonstrate a prophylactic value of estrogen for coronary artery disease and stroke in women
Vol. 59 o No. 6 o June 1976 o POSTGRADUATE MEDICINE
have not yielded clear-cut answers. Men treated for carcinoma of the prostate with 5 mg of diethylstilbestrol per day have had an increased incidence of myocardial infarction, thromboembolic disease, and stroke. Management of the Postmenopausal Woman
Preventive measures-Preventive health care is the key to maintaining physical and emotional health after menopause. Such care, of course, begins with an annual physical examination that includes measurements of height, weight, and blood pressure and special attention to the breasts and reproductive organs. Routine laboratory investigation ineludes making of a hemogram; determination of serum levels of lipids, urea nitrogen, and thyroxine; urinalysis; performance of a Pap test; electrocardiography; and a chest x-ray examination. Mammography, xeroradiography, or thermography should also be done routinely. A Schiller test and colposcopy are performed if indicated. It is important that the patient understand the meaning of the menopause and of the aging process. Emotional support given her by an empathie physician is extremely helpful. The physician should institute measures to prevent the predictable sequelae to the menopause, eg, a diet to maintain normal height and weight ratio, one that is rich in protein and law in cholesterol; elimination of cigarette smoking; and a physical activity program to maintain proper body tone. Drug therapy-Before administering any drug to a patient, particularly estrogen, the physician must search for certain relative contraindications to use of the drug, such as the presence of moderately severe hypertension or a history of breast carcinoma, congestive heart failure, or renal or liver disease. A history of recent thromboembolic phenomena or abnormal liver function should provoke extreme caution in regard to estrogen therapy. Mild menopausal symptoms may be controlled quite adequately with small doses of a sedative, such as phenobarbital, or with mild tranquilizers. If estrogen is to be prescribed, the smallest orally effective dose should be given initially, increasing by moderate amounts until optimal results are achieved. (ln the normal premenopausal woman, estrogen secretion amounts to Jess than the equivalent ofO.l mg of diethylstilbestrol per day.)..,.
177
1t ls important that the patient understand the meaning of the menopause and of the aging process.
Occasionally, estrogen and androgen have been used together wlth some success in the treatment of perimenopausal vasomotor instability.
Sorne investigators believe that large doses of estrogen alter the cholesterol-phospholipid ratio. However, the administration of estrogen ta postmenopausal women does not reestablish a premenopausallipid protein pattern. Estrogen applied locally may suffice for vulvovaginal or urinary disorders that are secondary ta ovarian deficiency. Parenteral administration of estrogen is rarely required. Oral contraception should not be prescribed. Occasionally, I have prescribed an amphetamine when depression was evident. Rarely, I have resorted ta use of androgen. Androgen may be indicated in cases of fibrosis, endometriosis, or cachexia. Given buc ally, it increases libido and has less tendency ta cause mastalgia and uterine bleeding than has estrogen. The patient should, however, be informed regarding possible side effects ofhirsutism and deepening of the voice. Administration of estrogen tends ta depress the rate of bane resorption and may lead ta reduced urinary excretion of calcium and a positive calcium-phosphorus balance. If postmenopausal osteoporosis is a principal concern, a therapeutic dose of estrogen may be given along with a high-calcium diet supplemented with calcium tablets, such as calcium carbonate, 600 mg three times a day. A multiple vitamin tablet may be added ta this regimen. In many patients, estrogen relieves osteoporotic pain and reduces the chance of fracture. Recently, interest in the use offluoride for postmenopausal osteoporosis has been increasing. Administration of sodium fluoride in doses of 40 ta 60 mg per day has been suggested. As yet, however, this method of treatment is in an experimental stage and has been approved by the FDA only for investigational use. In 10% ta 20% ofthose patients in whom this therapy has been tested, joint symptoms and stiffness similar ta arthritis have developed. In sorne patients, gastric and duodenal ulcers have appeared. When fluoride therapy has been given for five years or more, fluorosis has developed, with calcification of the ligaments and connective tissue. Occasionally, estrogen and androgen have been used together with sorne success in the treatment of vasa mo tor instability. When a patient with osteoporosis has been unable ta
178
tolerate estrogen therapy, the use of a synthetic anabolic hormone such as oxandrolone (Anavar, 2.5 mg) has been suggested. Oxandrolone, a spinoff from testosterone, has few masculinizing properties. Basic ally, the controversy about use of estrogen after menopause is a matter of philosophy. The dispute concerns whether the menopause constitutes a physiologie stage in a woman's life or whether it is a quasipathologie state of endocrine imbalance. No laboratory test can accurately measure the magnitude of systemic change occasioned by the menopause or indicate exactly what therapy is needed. U nfortunately, menopause-related disorders do not begin just when menses stop but may antedate this event by various intervals. Summary
Menopause usually occurs in the flfth decade of a woman's life. Although about 50% of women do not seem to be adversely affected, others face many years of experiencing the symptoms and sequelae attributable ta menopause. Symptoms include hot f!ashes, night sweats, chills, insomnia, and fatigue. Osteoporosis is one of the most important pathophysiologic changes. The cardiovascular system may be affected. Whether ta offer estrogen replacement therapy ta symptomatic postmenopausal women is a debated question. Estrogen administration tends ta depress the rate of bane resorption and relieve osteoporotic pain, and its local application may suffice for vulvovaginal or urinary disorders secondary ta ovarian deficiency. However, there is sorne question conceming the role of estrogen replacement therapy in carcinoma of the endometrium, and women who take estrogen orally are at increased risk for vascular accidents and thromboembolic disease. Each physician therefore must make a personal decision concerning estrogen replacement therapy after weighing the available evidence and relating it to the needs of the individual patient. • Address reprint requests to Edward A Banner, MD, Department ofObstetrics and Gynecology, Mayo Clinic, Rochester, MN 55901.
References 1. Wilson RA: Feminine Forever. New York, M Evans &
Co, Inc, 1966
POSTGAADUATE IIEDICIIIE
o June 1976 o Vol. 59 o No. 6
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: https://www.tandfonline.com/loi/ipgm20
The menopause and thereafter Edward A. Banner To cite this article: Edward A. Banner (1976) The menopause and thereafter, Postgraduate Medicine, 59:6, 174-178, DOI: 10.1080/00325481.1976.11714399 To link to this article: https://doi.org/10.1080/00325481.1976.11714399
Published online: 07 Jul 2016.
Submit your article to this journal
Article views: 1
Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ipgm20
•
1pma annais from the 60th i nterstate postgraduate medical assembly
the menopause and thereafter Edward A. Banner, MD Maya Clinic and Maya Foundation Rochester, Minnesota
The menopause is a fact of life for every woman, and how it affects her depends on her physiologie makeup and on her emotional health. An empathetic physician is a great help ta the patient going through this stage of life. Whether ta offer hormone replacement therapy is a question each physician in general or gynecologie practice must answer.
• Ten years ago a physician 1 published a book who se intriguing title, Feminine Forever, contained a promise. If the book did little else, it created an awareness that female sex hormones differ from those of the male; that at a certain time in life the natural secretion of these hormones decreases; and that the diminishing supply of these substances, which in adequate supply make a woman youthful, sexually attractive, and fertile, causes the doleful symptoms connected with the menopause. This book, and the many other recent popular and scientific publications on the topic of menopause, have aroused many questions that are often asked of the physician. A frrst question is usually ''Are female sex hormones really necessary?'' (In other words, nature's way is often best and lack of these hormones may be beneficiai.) A second question frequently concerns the possible dangers associated with postmenopausal hormone therapy, eg, whether such therapy can cause cancer, high blood pressure, vaginal discharge, breast soreness, excessive weight gain, blood. clots, or a resumption of menstruation. The patient may worry about the possibility of becoming pregnant if she takes hormones after menopause. The questions reflect the increasing verbalization by women of their desire and need to know more about their own physiologie makeup. They also reflect the dilemma of the physician who must decide whether a postmenopausal patient should be given hormone therapy or whether milder treatment or no treatment at ali is indicated. The human female is the only mammal who lives usefully beyond the reproductive years. Today, the average life span of the American Caucasian female is 74 years; at the turn of the century it was 51 years. Since menopause usually occurs between the ages of 44 and 50 years, women now face the possibility of experiencing moderate-to-severe symptoms or sequelae attributable to the menopause for about one third of the ir !ife span. Thus, the question of therapy must be answered by every family physician and gynecologist. What are the facts of the matter? Functlon of Estrogen and General Effects of Deflclency
Estrogen is produced primarily by the avaries and secondarily by the adrenal glands. It has many functions, alone or in
174
POSTGRADUATE MEDICINE • June 1976 • Vol. 59 • No. 6
conjunction with other hormones. It helps to metabolize protein, thus producing strong bones and healthy tissues. It aids in keeping tissues, especially those of the vagina and the bladder, moist, pliable, and resistant to infection. It enhances breast development, assists in maintaining a balanced body chemistry (especially with respect to fats and lipids), and may have a part in the metabolism of cholesterol. At a certain time in !ife, production of estrogen decreases. If the supply reaches certain critical levels, the hormone can no longer fulfill its normal functions, and the symptoms popularly known as the "menopausal syndrome" may develop. These include hot flashes, night sweats, chills, joint pains and bac kache, fatigue, insomnia, and depression. Vasomotor symptoms are most severe in women who previously have had vasomotor instability. Thinning of the mucous membranes, development of dowager's hump (kyphosis), cardiac palpitation, thinning of the hair, and hirsutism may be noted. The bones and the cardiovascular system may also be affected (see sections on Osteoporosis and on Coronary Artery Disease). The severity of symptoms varies from individual to individual. About 50% of women pass through menopause with no symptoms at all, and th us the extent of diminution of estrogen supply has been thought to vary among individuals. A more recent explanation concerns the number of estrogen binding sites within a particular individual. Estrogen deprivation also affects the supply of other hormones. Estrogenic inhibition of gonadotropin production in the pituitary disappears, with a consequent increase in supply of these pituitary hormones. Vasomotor instability may be due to Jack of estrogen or to increased levels of folliclestimulating hormone (FSH), orto bath. The supply of thyroid and of adrenocortical hormones decreases moderately. Surprisingly, however, estrogen may be found in the urine of women who have undergone oophorectomy or even oophorectomy and adrenalectomy, suggesting an extraglandular source for this hormone. The thyroid gland bec ornes smaller, and there is often a commensurate decrease in the basal metabolic rate. Hyperparathyroidism is seen much more commonly during and after
Vol. 59 • No. 6 • June 1976 • POSTGAADUATE MEDICINE
the menopause than during the years preceding this period. The incidence of diabetes rises. Elasticity of the skin and connective tissue gradually declines and degenerative changes occur; hyperkeratotic areas of the skin are not uncommon. Osteoporosis
Skeletal changes are among the most important pathophysiologic effects of the menopause. The incidence of osteoporosis in postmenopausal women is approximately 25%. Osteoporosis results from a normal or decreased rate of bane formation and an increased rate ofbone resorption. The net result is diminution of bane mass, increased bane porqsity, and bane fragility. This leads to fractures, mostly of the vertebral bodies but also of the upper femur, humerus, distal portion of the forearm, and ribs. Osteoporosis precedes 80% of all hip fractures, and this event is 2 Y.z times more common in women than in men. Hip fracture is an a minous complication of the menopause, for one sixth of all patients with this type of injury die within three months of sustaining it. Symptomatic spinal osteoporosis is four times more cornmon in women than in men. Orthopedists have called attention to an ''osteoporosis-prone population,'' which ineludes petite women, particularly those of north European descent, who have a small adult bane mass. Black women orthose who are tall or obese have above-average peak bane mass and are therefore less likely to sustain osteoporotic fractures. Diagnosis-The spinal x-ray film is the most important diagnostic aid for the detection of osteoporosis. It may show wedgeshaped compressions of the vertebrae, increased vertical striations, increased radiolucency of the vertebrae, and accentuation of size of the end plates. At an advanced stage of the condition, fractures may be seen. If an x-ray film shows cortical erosion, bane biopsy is necessary to rule out malignant disease. Other osteoporotic findings on x-ray examination necessitate further investigation to rule out not only malignant disease but also Cushing's disease, b~liary cirrhosis, and intestinal malabsorption. Osteoporosis is also a consequence of prolonged immobilization. Laboratory tests are of little help in diagnosing osteoporosis. Serum calcium and al-
175
Edward A. Banner Dr. Banner is in the department of obstetrics and gynecology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, and is professer of obstetrics and gynecology, Mayo Medical School.
kaline phosphatase levels are within normal limits. The level ofparathyroid hormone may be slightly depressed. U sually, the only persistent chemical abnormality is arise in serum phosphate concentration. Such an increase, however, occurs with any condition causing increased bane catabolism, such as ~cro megaly, thyrotoxicosis, metastatic breast cancer, Cushing's disease, and multiple myeloma. Bane densitometry using isotopes has been suggested as a useful diagnostic procedure.Results obtained at the Maya Clinic using this procedure have been inconclusive. Thus, there is no single diagnostic test for postmenopausal osteoporosis. The clinical findings and results of x-ray films must be considered together. Height as an indicator-The patient's height is one of the most sensitive indicators of the progression of osteoporosis, even more sensitive than symptoms. Recent studies have shawn that postmenopausal women may lose from 2 to 15 cm (1 to 6 in) in height. A measurement of the patient's height should thus be recorded at each annual physical examination. The extent of height loss can also be estimated by noting the difference between arm span and present height: these measurements usually agree within about 3 cm (Ph in). However, in sorne women, eg, black women, those with Marfan's syndrome, orthose who were castrated while young and in whom epiphyseal fusion was delayed, arm span may exceed height without the presence of osteoporosis. Coronary Artery Dlsease
Published studies disagree concerning the effect of the menopause on the female cardiovascular system. The increase in incidence of coronary artery disease and in related mor-
176
tality that begins for American women about the middle of the fifth decade of life, and the corresponding decrease in the male-to-female ratio for these events, is a statistical commonplace. Of interest is the fact that the sex difference is much smaller or is negligible in populations lacking the affluence and high standard of living enjoyed in the United States. For example, in 1965 the male-tofemale ratio for death from coronary artery disease for persans aged 45 to 54 years was 5:1 in the United States, 2:1 in Ital y, and only slightly greater than 1:1 in Japan. In the United States, the ratio is much lower among blacks than among whites. After considering data from various countries, it appears that for women in most societies mortality from coronary artery disease increases with age and that this increase is independent of the menopause. The lowest mortality rate is found in affluent Caucasian women. Atrophy
With menopause, atrophie changes occur in the genital tract and the breasts. These mainly involve the epithelium of the vagina and of the distal portion of the urethra. Atrophy of the bladder sphincter may eventually develop. The labial subcutaneous fat is gradually lost, and labial atrophy can lead to ulceration. Drying and shrinking of the vulva leads to the dermatologie condition known as kraurosis vulvae. Loss of tissue elasticity may cause gaping of the introitus and prolapse of the cervix and uterus, and may result in cystocele or rectocele. The breasts sag and diminish in size. Determination of Estrogen Deflciency
Of interest is the recent finding of no significant difference in plasma concentrations of estrogen in women with menopausal symptoms and in women without such symptoms. Further, an exact correlation between symptoms and maturation index as determined from a vaginal smear has not been found. This index, of course, is affected by drugs, such as digitalis, and by various disorders, eg, carcinoma of the cervix or vagina, diabetes, and pernicious anemia. A finding of a positive correlation in maturation index, plasma estrogen concentration, and symptoms may be valid only in cases of ex-
POSTGRADUATE MEDICINE • June 1976 • Vol. 59 • No. 6
treme estrogen deprivation, when tissue atrophy is substantial and the effects of law estrogen supply are evident. Although pyknosis detected on vaginal smear may have sorne significance in determining estrogen Jack, few gynecologists use the carnification index alone as a measure of such Jack. Sorne believe that the fern test, which is merely the appearance of dried mucus on a slide, best shows the presence or absence of adequate levels of estrogen. Ifurinary estrogen value is found to be law, the leve! of pituitary gonadotropins is expected to be elevated. Possible Adverse Effects of Estrogen Administration
In sorne women, the endometrium is particularly susceptible to estrogen stimulation; prolonged stimulation has been positively correlated with endometrial hyperplasia and, to a lesser extent, with carcinoma of the endometrium. The prolonged presence of excess estrogen also gives rise to ovarian granulosa or theca cell tumors, ovarian stroma! hyperplasia, polycystic avaries, and prolonged anovulation. The occurrence of vaginal carcinoma in women whose mothers received diethylstilbestrol during pregnancy has become a matter of concern, and use of estrogen during pregnancy has been discontinued. Carcinoma of the breast has been reported in men treated with estrogen for prostatic carcinoma, in transsexual men given estrogen, and in Bantu men with gynecomastia. Since the incidence of breast cancer in men is law, these data suggest a possible estrogen effect. Breast cancer is apparently more common in women who have not borne children and in those who delay childbearing than it is in other women; it is Jess common in women who have had an early artificial menopause. However, to date there is no evidence that a woman who takes oral contraceptives orother hormones has an increased risk of breast cancer. Healthy women taking estrogen orally are at increased risk for vascular accidents; the risk of thromboembolic disease is estimated to be four to eighttimes that of women who do not take estrogen. Studies designed to demonstrate a prophylactic value of estrogen for coronary artery disease and stroke in women
Vol. 59 o No. 6 o June 1976 o POSTGRADUATE MEDICINE
have not yielded clear-cut answers. Men treated for carcinoma of the prostate with 5 mg of diethylstilbestrol per day have had an increased incidence of myocardial infarction, thromboembolic disease, and stroke. Management of the Postmenopausal Woman
Preventive measures-Preventive health care is the key to maintaining physical and emotional health after menopause. Such care, of course, begins with an annual physical examination that includes measurements of height, weight, and blood pressure and special attention to the breasts and reproductive organs. Routine laboratory investigation ineludes making of a hemogram; determination of serum levels of lipids, urea nitrogen, and thyroxine; urinalysis; performance of a Pap test; electrocardiography; and a chest x-ray examination. Mammography, xeroradiography, or thermography should also be done routinely. A Schiller test and colposcopy are performed if indicated. It is important that the patient understand the meaning of the menopause and of the aging process. Emotional support given her by an empathie physician is extremely helpful. The physician should institute measures to prevent the predictable sequelae to the menopause, eg, a diet to maintain normal height and weight ratio, one that is rich in protein and law in cholesterol; elimination of cigarette smoking; and a physical activity program to maintain proper body tone. Drug therapy-Before administering any drug to a patient, particularly estrogen, the physician must search for certain relative contraindications to use of the drug, such as the presence of moderately severe hypertension or a history of breast carcinoma, congestive heart failure, or renal or liver disease. A history of recent thromboembolic phenomena or abnormal liver function should provoke extreme caution in regard to estrogen therapy. Mild menopausal symptoms may be controlled quite adequately with small doses of a sedative, such as phenobarbital, or with mild tranquilizers. If estrogen is to be prescribed, the smallest orally effective dose should be given initially, increasing by moderate amounts until optimal results are achieved. (ln the normal premenopausal woman, estrogen secretion amounts to Jess than the equivalent ofO.l mg of diethylstilbestrol per day.)..,.
177
1t ls important that the patient understand the meaning of the menopause and of the aging process.
Occasionally, estrogen and androgen have been used together wlth some success in the treatment of perimenopausal vasomotor instability.
Sorne investigators believe that large doses of estrogen alter the cholesterol-phospholipid ratio. However, the administration of estrogen ta postmenopausal women does not reestablish a premenopausallipid protein pattern. Estrogen applied locally may suffice for vulvovaginal or urinary disorders that are secondary ta ovarian deficiency. Parenteral administration of estrogen is rarely required. Oral contraception should not be prescribed. Occasionally, I have prescribed an amphetamine when depression was evident. Rarely, I have resorted ta use of androgen. Androgen may be indicated in cases of fibrosis, endometriosis, or cachexia. Given buc ally, it increases libido and has less tendency ta cause mastalgia and uterine bleeding than has estrogen. The patient should, however, be informed regarding possible side effects ofhirsutism and deepening of the voice. Administration of estrogen tends ta depress the rate of bane resorption and may lead ta reduced urinary excretion of calcium and a positive calcium-phosphorus balance. If postmenopausal osteoporosis is a principal concern, a therapeutic dose of estrogen may be given along with a high-calcium diet supplemented with calcium tablets, such as calcium carbonate, 600 mg three times a day. A multiple vitamin tablet may be added ta this regimen. In many patients, estrogen relieves osteoporotic pain and reduces the chance of fracture. Recently, interest in the use offluoride for postmenopausal osteoporosis has been increasing. Administration of sodium fluoride in doses of 40 ta 60 mg per day has been suggested. As yet, however, this method of treatment is in an experimental stage and has been approved by the FDA only for investigational use. In 10% ta 20% ofthose patients in whom this therapy has been tested, joint symptoms and stiffness similar ta arthritis have developed. In sorne patients, gastric and duodenal ulcers have appeared. When fluoride therapy has been given for five years or more, fluorosis has developed, with calcification of the ligaments and connective tissue. Occasionally, estrogen and androgen have been used together with sorne success in the treatment of vasa mo tor instability. When a patient with osteoporosis has been unable ta
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tolerate estrogen therapy, the use of a synthetic anabolic hormone such as oxandrolone (Anavar, 2.5 mg) has been suggested. Oxandrolone, a spinoff from testosterone, has few masculinizing properties. Basic ally, the controversy about use of estrogen after menopause is a matter of philosophy. The dispute concerns whether the menopause constitutes a physiologie stage in a woman's life or whether it is a quasipathologie state of endocrine imbalance. No laboratory test can accurately measure the magnitude of systemic change occasioned by the menopause or indicate exactly what therapy is needed. U nfortunately, menopause-related disorders do not begin just when menses stop but may antedate this event by various intervals. Summary
Menopause usually occurs in the flfth decade of a woman's life. Although about 50% of women do not seem to be adversely affected, others face many years of experiencing the symptoms and sequelae attributable ta menopause. Symptoms include hot f!ashes, night sweats, chills, insomnia, and fatigue. Osteoporosis is one of the most important pathophysiologic changes. The cardiovascular system may be affected. Whether ta offer estrogen replacement therapy ta symptomatic postmenopausal women is a debated question. Estrogen administration tends ta depress the rate of bane resorption and relieve osteoporotic pain, and its local application may suffice for vulvovaginal or urinary disorders secondary ta ovarian deficiency. However, there is sorne question conceming the role of estrogen replacement therapy in carcinoma of the endometrium, and women who take estrogen orally are at increased risk for vascular accidents and thromboembolic disease. Each physician therefore must make a personal decision concerning estrogen replacement therapy after weighing the available evidence and relating it to the needs of the individual patient. • Address reprint requests to Edward A Banner, MD, Department ofObstetrics and Gynecology, Mayo Clinic, Rochester, MN 55901.
References 1. Wilson RA: Feminine Forever. New York, M Evans &
Co, Inc, 1966
POSTGAADUATE IIEDICIIIE
o June 1976 o Vol. 59 o No. 6
