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Thursday, 28 April 2011

HRT and Menopause

Almost everyone is aware that HRT has been linked to cancer of the breast. This came out of the WHI study in UK which showed that those women who took HRT for more than 5 years were at greater risk from breast cancer, cardiovascular problems and stroke. There was however a flaw in the study in that it comprised predominantly women in the older age group who of course would be at greater risk of getting breast cancer in view of their age. Later, it was found that those who had combined oestrogens and progesterones were at greater risk than those who only took oestrogen. To make matters even more confusing, a new study now shows that if oestrogen is given to women in the 50's, it reduces the breast cancer risk!. It is no wonder that not only is the public confused but so are many gynaecologists!. Apparently the oestrogen gobbles up any potential breast cancer cells.

So what are we to deduce from all this. The most prudent would be to recommend HRT for no longer than 5 years, and to use the safest oestrogens and if progesterone is needed, micronised progesterones. Regular mammograms should be routine in those on HRT, and maintaining a healthy lifestyle free of smoking and drinking and excercising regularly

Other alternatives such as black cohosh, isoflavones, dong qui, etc however have not been shown to have a significantly greater effect than conventional HRT in improving symptoms. They all act on oestrogen receptors and therefore have the same risks as HRT of breast cancer.

Monday, 25 April 2011

Premature Menopause

As the title means, menopause before the time is due. This is usually taken as before 40 years. Not common but the incidence is rising now at 1:100. I had a young lady of 20+ the other day who stopped having periods suddenly for several months. She was studying in university and was back on holiday. Hormone tests showed that the hormones related to menopause were raised and her female hormones were low. I was hesitant to diagnose PRM and repeated the tests which came back the same. Very trepidly I broke the news to her mother. PRM is usually permanent but in about 5% of cases, a reversal of ovarian activity spontaneously is possible. That was the good news. The not so good news was that if permanent, leads to softening of bones, heart problems and depression and of cause the most devastating for a girl at that age, infertility.

PRM should be treated with hormone replacement as the advantages far outweigh the risks. She was also asked to take vitamin D and calcium supplements, excercise, and avoid smoking and drinking as a long term measure to prevent bone loss.

A little biology on ovarian activity. Every woman is born with thousands of immature eggs. From the time puberty starts, there will be a crop of eggs each month that grow and one egg will be released from either ovary. Therefore every month of a woman's life, there will be a depletion of eggs. When a woman reaches her 30s and 40s, there will be a gradual reduction of ovarian activity resulting in a fall in oestrogen, the female hormone. Menopause begins when ovarian activity ceases. There may be a long period termed the perimenopausal phase when the symptoms of menopause viz. hot flushes, irritability, depression appear. These may disappear or persist depending on the individual. The average age for menopause is 47-55 years.

A later menopause is not necessarily a good thing. It is related to a higher incidence of breast cancer and uterine cancer due to the effects of oestrogen.