Menopause treatments

Menopause and its effects on women’s health

Hormonal changes during menopause

Menopause is characterized by a gradual decline in the production of femalesex hormones , mainly estrogen and progesterone . This hormonal decline is due to the exhaustion of the ovarian follicles, the structures responsible for egg and hormone production. Typically, this process begins between the ages of 45 and 55, with an average age of around 51.

The transition to menopause, known as perimenopause, can extend over several years. During this period, hormone levels fluctuate irregularly, leading to unpredictable menstrual cycles. These hormonal variations are at the root of many of the symptoms characteristic of menopause.

Common menopause symptoms

The manifestations of menopause vary considerably from one woman to another, both in terms of intensity and duration. Among the most common symptoms are :

• Hot flashes and night sweats
• Vaginal dryness and libido problems
• Sleep disorders and fatigue
• Mood swings and irritability
• Weight gain, hormonal imperfections and changes in body shape

These symptoms can have a significant impact on women’s quality of life, affecting their physical and emotional well-being as well as their personal and professional relationships. It is often to relieve these discomforts that women turn to hormonal treatments.

Long-term impact on bone and cardiovascular health

Beyond the immediate symptoms, menopause-related estrogen deficiency has long-term health consequences. The two main systems affected are :

The bone system : the reduction in estrogen accelerates bone loss, increasing the risk of osteoporosis and fractures. It is estimated that women can lose up to 20% of their bone mass in the 5 to 7 years following menopause.

The cardiovascular system : Estrogen plays a protective role for the heart and blood vessels. Their reductionSource leads to an increased risk of cardiovascular disease, which becomes the leading cause of death in women after the menopause.

These long-term risks are also taken into account when deciding whether or not to use hormone therapy.

Hormone treatment for menopause

What is hormone replacement therapy (HRT)?

Hormone replacement therapy (HRT), sometimes called hormone replacement therapy (HRT), aims to replace the sex hormones, mainlyestrogen and progesterone, that the body produces in smaller quantities after menopause. By reintroducing these hormones, HRT can help reduce various menopausal symptoms.

Estrogen helps maintain skin elasticity, bone density and vaginal lubrication. Progesterone, on the other hand, balances the effects of estrogen and reduces the risk of endometrial cancer associated with excessive estrogen exposure.

Composition and administration of HRT

Conventional hormone replacement therapy (HRT) aims to replace hormones that the body no longer produces in sufficient quantities. It generally consists of :

• Estrogen, to relieve menopausal symptoms and prevent osteoporosis
• Progesterone (or progestins), to protect the uterus against the risk of endometrial cancer associated with estrogen alone.

HRT can be administered in various forms: tablets, transdermal patches, gels, sprays or vaginal rings. The choice of route depends on patient preference and medical recommendations.

Indications and recommended duration of treatment

HRT is primarily indicated to relieve the debilitating symptoms of menopause, particularly severe hot flashes. It is also effective in preventing post-menopausal osteoporosis. However, current recommendations recommend :

• Use at the minimum effective dose
• The shortest possible treatment time
• Annual reassessment of the risk/benefit ratio

The optimal duration of treatment is the subject of debate, but is generally limited to a maximum of 5-7 years, except in special cases.

Menopause hormone therapy (MHT)

Differences between HRT and HRT

The term“menopausal hormone therapy“(MHT) is often used interchangeably with HRT. However, some authors make a subtle distinction:

• HRT aims to “substitute” missing hormones
• HRT is said to “treat” menopausal symptoms

In practice, these terms often refer to the same type of treatment, the difference lying mainly in the conceptual approach.

Potential benefits of THM

The potential benefits of THM are numerous and include:

• Significant reduction in hot flashes and night sweats
• Improved sleep quality and mood
• Prevent osteoporosis and reduce the risk of fractures
• Improvement in genitourinary symptoms (vaginal dryness, recurrent urinary tract infections)

Some studies also suggest a possible protective effect against cardiovascular disease if treatment is initiated early after menopause.

Definition and specific features of bioidentical hormones

Bio-identical hormones are laboratory-synthesized molecules whose chemical structure is identical to that of hormones naturally produced by the human body. They are often presented as a more “natural” alternative to the conventional hormones used in HRT.

Advocates of bio-identical hormones claim that they are better tolerated and safer than traditional hormones. However, these claims are controversial in the medical community.

Controversy over efficacy and safety

The controversy surrounding bioidentical hormones focuses on several points:

• Lack of large-scale studies on long-term efficacy and safety
• Lack of standardization in production, especially for magistral preparations
• Questioning their superiority over conventional treatments

Health authorities, such as the FDA in the United States, warn against making unproven claims for these products.

Indications for local treatments

Local hormone treatments, mainly in the form of creams or vaginal ovules, are specifically indicated to treat the genitourinary symptoms of menopause, such as :

• Vaginal dryness
• Pain during intercourse (dyspareunia)
• Recurrent urinary tract infections

These treatments deliver low doses of estrogen directly to the tissues concerned.

Advantages over systemic treatments

Local treatments offer several advantages over systemic treatments:

• Minimal systemic absorption, reducing the risk of side effects
• Targeted efficacy for genitourinary symptoms
• Long-term usability with a favorable safety profile

These treatments are often preferred for women presenting only local symptoms, or for those for whom systemic treatment is contraindicated.

The contraceptive pill in the perimenopausal period

Using the pill to relieve symptoms

Some perimenopausal women choose to continue or start taking the contraceptive pill to manage menopausal symptoms. The pill can :

• Regulate irregular menstrual cycles
• Reduce hot flashes and night sweats
• Maintain bone density

However, the use of the pill for therapeutic purposes in the perimenopause must be carefully evaluated by a physician.

Specific risks for women over 40

The use of the contraceptive pill in women over 40 carries specific risks:

• Increased risk of venous thrombosis, particularly in smokers
• A possible increase in the risk of breast cancer
• Potential interactions with other drugs frequently prescribed at this age

These risks must be carefully weighed against the potential benefits, and alternatives may be considered.

Risks associated with menopause treatments

Breast cancer and hormone therapy

Data from epidemiological studies

The relationship between menopausal hormone treatments and the risk of breast cancer has been the subject of numerous studies. Current data suggest that :

• Combined HRT (estrogen + progestin) slightly increases breast cancer risk
• Treatment with estrogen alone (in hysterectomized women) seems to have less impact on this risk.
• Risk increases with duration of treatment

It is important to note that the increase in risk remains relatively small in absolute terms, but must be taken into account in the therapeutic decision.

Factors influencing individual risk

The risk of breast cancer associated with HRT varies according to several individual factors:

• Age at start of treatment
• Family history of breast cancer
• Breast density
• Lifestyle (diet, physical activity, alcohol consumption)

A personalized assessment of these factors is essential to determine the benefit/risk ratio of treatment for each patient.

Venous thrombosis and pulmonary embolism

Hormonal menopause treatments, particularly oral ones, increase the risk of venous thrombosis and pulmonary embolism. This risk is higher :

• During the first year of treatment
• Overweight or obese women
• For smokers
• In the event of prolonged immobilization

The use of transdermal treatments (patches, gels) seems to be associated with a lower risk of thrombosis than the oral route.

Impact on coronary heart disease

The effect of hormone therapy on cardiovascular risk is complex and depends on a number of factors, including the age at which treatment is started. Current data suggest that :

• In women under 60 or within 10 years of menopause, HRT may have a protective effect on the cardiovascular system
• In older women or long after menopause, HRT may increase cardiovascular risk

These observations have led to the concept of a “window of opportunity” for the initiation of HRT.

Effects on the endometrium and cancer risk

The use of estrogen alone (without progestin) in non-hysterectomized women considerably increases the risk of endometrial cancer. This is why :

• Women who still have their uterus should always receive a combined treatment (estrogen + progestin).
• Hysterectomized women can be treated with estrogen alone

The risk of endometrial cancer associated with HRT also depends on the type and dose of progestin used. Regular endometrial surveillance is recommended for women on HRT.

Other potential side effects

In addition to the major risks mentioned above, HRT can cause other side effects, which are generally less serious but can affect quality of life:

• Breast tension and mastodynia
• Nausea and bloating
• Headaches
• Irregular bleeding, particularly at the start of treatment
• Water retention and weight gain

These effects are often transient, and can be alleviated by adjusting the dose or changing the method of administration.

Unraveling the truth about hormone treatments

Misconceptions about treatment efficacy

There are many misconceptions about hormone treatments for menopause. Among the most common:

• “HRT is the miracle solution to all menopausal problems”: Although very effective for certain symptoms, HRT is not a panacea and is not suitable for all women.
• “Hormone treatments inevitably make you put on weight”: Slight weight gain is possible at the start of treatment, but it is not systematic and can be controlled.
• “Bio-identical hormones are safe because they are natural”: Although presented as more natural, these hormones have not been proven to be safer than conventional treatments.

Discussing these ideas with a healthcare professional is crucial to making an informed decision.

Controversies surrounding long-term safety

The long-term safety of hormone treatments for menopause remains a subject of debate in the medical community. The main controversies concern :

• Optimum duration of treatment: some experts recommend short-term use (less than 5 years), while others maintain that longer treatment may be beneficial for some women.
• Impact on cardiovascular risk: conflicting results from different studies have led to divergent interpretations of the protective or deleterious effect of HRT on the cardiovascular system.
• The risk of breast cancer: although the link has been established, the extent of the risk and its clinical relevance are the subject of debate.

These controversies underline the importance of a personalized approach and regular follow-up for every patient on HRT.

Benefit-risk balance according to patient profile

The decision to use hormonal treatment must be taken on a case-by-case basis, carefully weighing up the benefit-risk balance for each patient. Factors to consider include:

• Patient’s age and time since menopause
• Symptom intensity and impact on quality of life
• Personal and family medical history
• Cardiovascular and cancer risk factors
• The patient’s personal preferences

A young, recently menopausal woman with no particular risk factors, and suffering from disabling symptoms, will probably have a favorable benefit-risk balance for treatment. Conversely, an older woman who has been menopausal for a long time, or who has significant risk factors, may have a less favourable balance.

Alternatives and complementary approaches

Non-hormonal treatments for menopausal symptoms

For women who cannot or do not wish to use hormonal treatments, there are several non-hormonal alternatives:

• Selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) for hot flashes
• Gabapentin or pregabalin for sleep disorders and hot flashes
• Vaginal lubricants and moisturizers for vaginal dryness
• Local hyaluronic acid treatments for vulvovaginal atrophy

These treatments may be effective in targeting specific symptoms, but do not offer the systemic benefits of hormonal treatments.

Phytotherapy and food supplements

Some women turn to phytotherapy and dietary supplements to relieve menopausal symptoms. Among the most common options:

• Soy and isoflavones: rich in phytoestrogens, they may reduce hot flashes
• Black cohosh (Cimicifuga racemosa): traditionally used for vasomotor symptoms.
• Evening primrose oil: sometimes recommended for hot flashes and dry skin
• Ginseng: to improve mood and energy

Natural remedies for menopause are gaining in popularity and are proving to be real effective alternatives.

The importance of a healthy lifestyle in menopause management

Beyond drug treatments, adopting a healthy lifestyle can go a long way to alleviating menopausal symptoms and preserving long-term health. Key recommendations include:

• A balanced diet rich in calcium and vitamin D for healthy bones
• Regular physical activity, combining endurance and muscle-strengthening exercises
• Stress management through relaxation techniques such as yoga and meditation
• Quitting smoking and limiting alcohol consumption
• Maintaining a healthy weight

Source :

https://www.medecinesciences.org/en/articles/medsci/full_html/2002/09/medsci20021811p1049/medsci20021811p1049.html