Commentary on a NY Times article on Menopause

To my patients,

In a recent Sunday New York Times there was an article entitled, “Why do we dread menopause” by a professor named Susan Mattern from the University of Georgia.

In the article “why do we dread menopause” she highlights that if you Google search “menopause and…” you come up with a whole assortment of very negative symptoms like weight gain, depression, hair loss, etc. She goes on to state that such a bleak view of menopause is unique to only modern cultures. She goes into great length about the history of how menopause was defined in ancient times and has come to be known as a medical issue only in relatively more modern times. She describes the importance of women after their reproductive life to the family unit, often allowing care of younger children as a grandparent so that the parent will be free to occupy other important roles in the extended as well as nuclear family unit.

I could not agree more with such an assessment and hope that all of you realize that I value women in their post reproductive state and the contributions they make to their families, to our communities and society in general.

At the same time, these days many people seem to be obsessed with the concept of anti-aging. Anti-aging doctors have been giving bio identical hormones and other non-tested, non-approved substances as patients search for an antidote to aging. Ponce de Leon left Spain more than 600 years ago in search of the fountain of youth. People are still looking. The key, in my opinion, is healthy aging not anti-aging.

My problem with this excellent article in Sunday’s New York Times is that it does not acknowledge the very real medical issues that accompany estrogen deprivation after there is no more ovarian function (the medical definition of menopause). Other higher order primates live a very short time after they stop reproducing. My patients will spend more than 40% of their lives in a post reproductive state.

There are very real consequences medically of the lack of estrogen production that menopause brings. Loss of bone mass occurs quite rapidly, and osteoporotic fractures are a significant medical issue as the population ages more and more. A 50-year-old woman who does not already have cancer or heart disease has a life expectancy of 91. If a woman suffers a hip fracture her chances of being dead within the next year are 20–30% and she has a 25% chance of never living independently again.

There are also serious changes in the vagina as a result of a lack of estrogen. A change in the normal bacteria causes diminished production of lactic acid and thus the pH will change dramatically, as does the cell count. This leads to dryness and lack of normal lubrication which, in patients who are sexually active, can result in severe discomfort. Almost all of you are aware of the symptoms of hot flashes and night sweats, the most common of the menopausal transition. Fortunately, for the majority of women, these will ameliorate by 4–5 years, although some women will have these indefinitely. In addition, lack of estrogen can result in joint pains.

After the Women’s Health Initiative published its findings in 2002 showing that estrogen plus progesterone therapy caused an increase in breast cancer and heart disease, 50% of women stopped their hormones immediately but 25% went back on. The most common reason for resuming was hot flashes and night sweats as you would think. The second most common reason was joint pains. Furthermore, menopause, with its lack of estrogen, on average causes an increase of 15 -20% in total cholesterol and LDL cholesterol (the bad cholesterol). In addition, estrogen helps promote lean body mass and after menopause women tend to accumulate more fat centrally (that old “midriff bulge”).

I am not trying to medicalize menopause. However, we cannot ignore the effects of estrogen deprivation on a variety of organ systems especially as women are living longer and longer. There are new approaches to replacing estrogen without the use of progesterone. As evidenced by the Women’s Health Initiative, it is the addition of progesterone in order to protect the uterus that seems to be the culprit in causing most of the negative findings. These new approaches are, in my opinion, much safer than what we’ve done for the past half century. They involve combining the estrogen Premarin with a different category of drug than progesterone. That category is SERM (selective estrogen receptor modulator). There are a number of SERMs already on the market for breast cancer prevention and prevention and treatment of osteoporosis. 

In summary, yes menopause can and should be a time of healthy aging and continued productivity and personal satisfaction indefinitely. The pros and cons of replacing estrogen need to be individualized and discussed on a case by case basis. 

If you or anyone you know would benefit from this knowledge, please share this with them. 

Dr Steven R. Goldstein is a Past President of the International Menopause Society, past President of the North American Menopause Society, a Certified Menopause Practitioner and a Menopause Specialist in NYC .