Effects of Premature Menopause on Cognition
Posted by on May 7, 2014 - 9:57pm

The average age of menopause in the United States is around 51 years old, but the onset can widely vary. Premature menopause refers to menopause of onset at or before 40 years of age. This can occur because of  a variety of causes, including surgery (i.e. bilateral oophorectomy, removal of ovaries), chemotherapy or pelvic radiation treatments for cancer, chromosomal or genetic defects, and spontaneous premature ovarian failure.

For women undergoing premature menopause, symptoms can be similar to those of regular menopause. Symptoms include  hot flashes, night sweats, vaginal dryness, and mood changes. Longitudinally, however, the symptoms may different between those who undergo premature menopause and those who undergo menopause at roughly the average age. New research shows that premature menopause may be associated with long-term negative effects on cognitive function.

A study based on a sample of 4868 women tested cognition at baseline, two, four, and seven years, and it also looked at the effects of the type of menopause, whether natural or surgical, could play a role.

Natural menopause was reported by 79% of the 4868 participants, 10% underwent menopause from surgical causes, and 11% reported menopause from other treatment causes including radiation or chemotherapy. Approximately 7.6% of the women in the study had a premature menopause, and the study further delineated 12.8% of the women had an early menopause (between 41 and 45 years of age).

Results showed that women who underwent premature menopause had a more than 40% increased risk of poor performance on verbal fluency and visual memory tasks, compared to those who experienced menopause at or after the age of 50. Women who underwent premature menopause also were associated with a 35% increased risk of decline in psychomotor speed. There was no significant association with the risk of dementia.

Both premature menopause secondary to surgery and premature ovarian failure, were associated with long-term negative effects on cognitive function, which cannot entirely be answered by hormone therapy. Researchers agree more studying needs to be done to better understand the potential benefits using hormone therapy.

Healthcare professionals should be aware of the potentially significant impact premature menopause can have on cognitive function in later life. Professionals should also consider these effects when aiding younger women in the decision-making process of undergoing oophorectomy. To learn more about how menopause can affect you long-term, visit Northwestern's menopause website here.

Source: J Ryan, J Scali, I Carrière, H Amieva, O Rouaud, C Berr, K Ritchie, M-L Ancelin.Impact of a premature menopause on cognitive function in later life. BJOG: An International Journal of Obstetrics & Gynaecology, 2014; DOI: 10.1111/1471-0528.12828

Hot Flashes Years After Menopause
Posted by on February 5, 2014 - 5:53pm

New long-term research shows that hot flashes continue, on average, for five years after menopause. More than a third of women can experience hot flashes for up to ten or more years after menopause.

A recent study evaluated 255 women in the Penn Ovarian Aging Study who reached natural menopause over a 16-year period. The results indicate that 80 percent reported moderate to severe hot flashes, 17 percent had only mild hot flashes, and three percent reported no hot flashes.

Hot flashes are momentary episodes of heat that can occur with other symptoms including sweating and flushing. Changing hormone levels after cessation of menses are believed to cause hot flashes as well as other menopausal symptoms including insomnia, anxiety, joint and muscle pain, and memory problems.  Hormone therapy repletes the hormones estrogen and progesterone the body stops making during menopause, and it has been proven an effective treatment for hot flashes.

Although hormone therapy is highly effective, it is not recommended for all women. In addition, concerns about health hazards linked to hormone therapy have made some physicians hesitant to prescribe it, or to adhere strictly to recommended duration guidelines; current guidelines suggest that exogenous hormones should not be taken for more than five years. This new research on the long-term persistence of hot flashes suggests that women should collaborate with their physicians to determine the risks and benefits of different hormonal and nonhormone therapies available for menopausal symptoms. Women should be able to individualize their treatment to appropriately minimize the the symptoms they may have, no matter how severe or how persistent. To learn more about the variety of treatments available for menopausal symptoms, visit Northwestern's Menopause website here

Source: Ellen W. Freeman, Mary D. Sammel, Richard J. Sanders. Risk of long-term hot flashes after natural menopause. Menopause, 2014; 1 DOI:10.1097/GME.0000000000000196

Effects of Hormone Levels on Cognition after Menopause
Posted by on January 2, 2014 - 11:23pm

Do hormone levels in postmenopausal women affect cognitive function? New research sheds light on the postmenopausal brain.

In a recently published study, researchers found that estrogen levels after menopause may have no impact on cognitive skills, but progesterone levels might. Progesterone had some association with global cognition and verbal memory among newly postmenopausal women.

643 healthy postmenopausal women were part of the study, ranging from 41 to 84 years old. Neuropsychological tests were done to assess cognition and memory, and hormone levels were determined including estradiol, estrone, progesterone, and testosterone. The findings showed no association between estrogen and cognitive skills. However, women with higher levels of progesterone had better outcomes on the verbal memory and global cognition tests, particularly in those who had started menopause less than six years prior. None of the hormones appeared to have any association with depression or mood either.

More research must be done to confirm the new findings regarding progesterone levels. Also, there is no way to directly measure hormone concentrations at the brain level, but this research implies that estrogen therapy may not have a significant effect on cognitive skills. To learn more about when hormone therapy is beneficial , visit Northwestern's menopause website here.

 

Source reference: Henderson VW, et al "Cognition, mood, and physiological concentrations of sex hormones in the early and late menopause" PNAS 2013; DOI: 10.1073/pnas.1312353110.

Relaxation for Hot Flashes
Posted by on November 1, 2013 - 12:49pm

Hot flashes: most menopausal women have them, and all menopausal women hate them. For one in ten women, hot flashes occur for five years or longer, signicantly affecting multiple aspects of their lives including relationships and sleep. While hormone replacement therapy has largely addressed the issue of hot flashes in many women, other women have sough alternatives. Alternatives including yoga, acupuncture, exercise, and applied relaxation have all been helpful in women undergoing menopause.

Applied relaxation, in particular, has recently been studied in a small Swedish pilot study and proven to be beneficial. 60 women were divided into two groups: one was given relaxation exercises  to practice daily at home, and the other received no treatment whatsoever. After three months the treatment group lowered their number of hot flushes per day from an average of 9.1 to 4.4. The control group also noticed a decrease in hot flashes per day, but only from an average of 9.7 to 7.8.

Relaxation techniques include breathing exercises, guided imagery exercises, and calming music. Consider applying relaxation in replacement of or in addition to your hormone replacement therapy. For more information on how to incorporate relaxation into your therapy for hot flushes, visit our Northwestern menopause website here.

Joint Relief with Estrogen
Posted by on October 19, 2013 - 1:01pm

Hormone therapy can be used to ease the many symptoms of menopause, including night sweats, hot flashes, and mood swings. New research indicates that hormone therapy, specifically estrogen, can also be used towards joint pain.

Estrogen therapy improves joint pain in post-menopausal women who have had a hysterectomy. Studies looking at the Women's Health Initiative (WHI) trial analyzed 10,000+ post-menopausal women. 77% of these women reported join pain and 40% experienced joint swelling. After just one year, frequency of joint pain was lower among women who received estrogen-only therapy, compared to women who were in the placebo group (76.3% s. 79.2%) After three years, the subset of women who received estrogen continued to have joint pain less frequently than the placebo group.

The difference was seen only in women who received estrogen alone, vs. women with intact uteruses who took estrogen-progesterone combination therapy. Regardless, these findings give light to the many potential therapeutic values of estrogen. Post-menopausal women who are thinking about estrogen to alleviate their joint pain should consult their healthcare providers, and they should still follow the lowest dose of estrogen for the shortest amount of time needed to achieve the therapeutic goals desired. To understand more of the potential benefits (and risks) of estrogen or estrogen-progesterone therapy, visit our menopause website here.

Strong Bones with Calcium and Hormones
Posted by on August 13, 2013 - 8:50pm

After the age of 30, the creation of new bone cannot keep up with the rate of bone loss in your body. The estrogen depletion that comes with menopause results in an increased risk for low bone mineral density, osteopenia and osteoporosis. For 5-10 years after menopause, this bone density loss accelerates into a gradual weakening of your bones and can lead to an increase in the risk for fractures and other injuries.

Physicians and organizations left and right have tried to specify a regimen to  help slow down the weakening of bones in postmenopausal women. The National Osteoporosis Foundation states that both types of hormone therapy, Estrogen therapy and combined Estrogen and Progesterone therapy, reduce the risk of osteoporosis. But what about supplements?

This past February, the US Preventive Services Tasks Force (USPSTF) stated there was insufficient evidence regarding calcium and vitamin D supplementation for bone fracture prevention in postmenopausal women. Now, a new analysis shows the evidence that may very well alter this recommendation.

The North American Menopause Society conducted a trial with 27,347 postmenopausal women, of which 8,000 took supplemental calcium (1,000 mg) and vitamin D (400 mg) daily, and 8,000 took look-alike placebos. These women came from all the hormone groups in the study: on HRT combinations, those on HRT estrogen alone, and the rest on hormone look-alike placebos.

Researchers then studied the hip fracture incidents among women who took hormones and supplements, women who took hormones alone, and women who took neither one. Of the women on both hormones and supplements, there were 11 hip fractures per 10,000 women per year. Of the women solely on hormones, there were 18 hip fractures per 10,000 women per year. And of the women who took neither, there were 22 hip fractures per 10,000 women per year.

Although the researchers could not specify how much of calcium and vitamin D should be taken, they concluded that postmenopausal women taking hormone therapy should also take supplemental calcium and vitamin D to reduce the rate of bone loss. The benefits of calcium and vitamin D seem to increase with increasing total intake, but also depend on the side effects of too much calcium, such as constipation.

So consider taking calcium and vitamin D supplements in combination with your hormone therapy, but don't stop drinking your milk! Continue trying to meet your daily calcium needs with your diet. Furthermore, did you know that weight bearing exercise can also improve your bone health? To learn more about how you can manage your bone health and overall health in menopause, visit http://menopausenu.org/

 

Breast cancer, HRT, and Alcohol
Posted by on September 7, 2012 - 8:02am

An analysis among more than 40,000 postmenopausal women who were in the California Teachers Study was carried out to determine if there were differences in risk of breast cancer among women consuming alcohol according to their previous or current use of hormone therapy (HT).  In the cohort, 660 women were diagnosed with invasive breast cancer during follow up.

Results showed an increase in risk of breast cancer among alcohol consumers of more than 20 grams of alcohol per day (about 1 ½ to 2 typical drinks) who were current users of HT but not among those who were ex-users of HT.  The authors conclude: “Following the cessation of HT use, alcohol consumption is not significantly associated with breast cancer risk, although a non-significant increased risk was observed among women who never used HT.  Our findings confirm that concurrent exposure to HT and alcohol has a substantial adverse impact on breast cancer risk.  However, after HT cessation, this risk is reduced.”

Forum reviewers considered this to be a very well done analysis on a large group of post-menopausal women with repeated assessments of alcohol consumption and HT use.  However, results from even very large studies on the relation between alcohol, HT, and breast cancer risk have often been conflicting.  Even with numerous studies on this topic, we still have very poor predictors of which women will develop breast cancer.  There is some increase in risk for women with a family history of such cancers and those who are obese.  However, the percentage increases in risk associated with HT, alcohol consumption, and other environmental factors are generally small (unlike the many-fold increase in the risk of lung cancer among smokers in comparison with never smokers).  This may explain why the results of individual studies may reach apparently conflicting conclusions.  While the present study suggests that women who consume alcohol may have a decrease in their risk of breast cancer if they stop taking hormone replacement therapy, our current understanding of factors affecting breast cancer risk remains quite inadequate.

Reference:  Horn-Ross PL, Canchola AJ, Bernstein L, Clarke CA, Lacey JV, Neuhausen SL, Reynolds P, Ursin G.  Alcohol consumption and breast cancer risk among postmenopausal women following the cessation of hormone therapy use: the California Teachers Study.  Cancer Epidemiol Biomarkers Prev 2012. [Epub ahead of print]

Menopause Society Supports Extended Hormone Therapy
Posted by on March 5, 2012 - 10:27am

Menopausal hormone therapy doesn't have to follow "the lowest dose for the shortest time" strategy for all women anymore, the North American Menopause Society said today.   The group endorsed a flexible approach to duration that takes into account the type and timing of therapy and individual patient characteristics in a statement in its journal, Menopause.

For women in their 50s, the absolute risks are low; younger women without a history of breast cancer can use replacement hormones at least until the normal menopause age around 51, and longer if needed for symptom management, according to the guidelines.

"No 'one size fits all' approach is acceptable anymore," JoAnn E. Manson, MD, DrPH, NCMP, of Harvard, and president of the society, said in answer to a query from ABC News and MedPage Today.

Manson's position is somewhat surprising since she was a principal investigator for the Women's Health Initiative, the landmark randomized trial that derailed the hormone therapy movement when it reported a link between Premarin (estrogen/progestin) and increased risk of breast cancer and thromboembolic conditions.

The new guidelines loosen up on timing, agreed Michelle P. Warren, MD, NCMP, of Columbia Presbyterian Medical Center in New York City, who was also involved with the guidelines.   Women who need hormone therapy can use it for as long as needed, she said in an interview.    That shift should be reassuring for many women, Manson suggested.

When the Women's Health Initiative studies indicated elevated breast cancer and heart disease risk with hormone therapy in its postmenopausal population a decade ago, prescriptions dropped precipitously across the country.   Recommendations followed suit, urging cautious, sparing use of the drugs.

Fear of prescribing to women with any suggestion of heart disease, even the common symptom of palpitations, led to "a whole generation of women who were really suffering," Warren noted.

Now with longer-term follow-up available from that and other studies, perspectives are changing, explained Manson, who serves as an investigator with the ongoing Nurses' Health Study, an observational study that was once used to bolster use of hormone therapy.  Last summer, the Endocrine Society also called for rethinking the established line on menopausal hormone therapy, stating that risks and benefits vary by age and time since menopause.

The menopause society's consensus group concluded that the estrogen-only (ET) formulations (typically used for women without a uterus) can be used for seven years without increasing risk of breast cancer, while combination estrogen-progestin therapy (EPT) increases that risk after three to five years of use.

The recommendation for duration of therapy differs for EPT and ET. For EPT, duration is limited by the increased risk of breast cancer and breast cancer mortality associated with three to five years of use; for ET, a more favorable benefit/risk profile was observed during a mean of seven years of use and four years of follow-up, a finding that allows more flexibility in duration of use.

The Women's Health Initiative and Nurses' Health Study both pointed to a possible reduced risk if use didn't start immediately after menopause.   However, the evidence for this "gap theory" (also called the critical window hypothesis)  isn't very solid and menopausal symptoms are usually worse in the first two to five years, Warren said in an email to ABC News/MedPage Today.

The bigger clinical impact from the guidelines is likely to come from its conclusions on cardio- and cerebrovascular risks, she suggested.   With estrogen alone, women in their 50s in the Women's Health Initiative actually had a reduced risk of combined endpoints including coronary heart disease and total myocardial infarction.

With combined estrogen and progestin, that trial showed an absolute increase in heart disease by an estimated eight cases per 10,000 women per year, whereas observational studies had found a longer duration of use associated with a reduced risk.

The potentially reduced coronary heart disease risk among women who used hormone therapy for five or more years was "not conclusive and should be considered in light of other factors altered by duration of therapy, such as breast cancer," the statement warned.

There was a clear differentiation in risk by timing of hormone therapy after menopause, though, in the opposite direction than for breast cancer risk.  Both unopposed estrogen and estrogen with progestin were associated with elevated coronary heart disease risk when therapy started more than 10 years after menopause.

For stroke, hormone therapy had appeared to raise risk overall, with eight additional strokes per 10,000 women per year of combined hormone therapy and 11 extra with estrogen only.  But recent analyses of the two together found no significant stroke risk for women ages 50 to 59 at initiation, the statement noted.

"They have essentially rescinded the position concerning the heart data as long as you start within 10 years of menopause commencing," Warren summarized.

However, Marcia Stefanick, MD, of Stanford University, who had been involved with the Women's Health Initiative steering committee, took issue with that conclusion, calling it misleading.The analysis actually showed no interaction with age for stroke risk, which means all age groups are at elevated risk, she told ABC News/MedPage Today.Another problem was that the women on unopposed estrogen in the Women's Health Initiative only used the drug for an average of 3.5 years because so many discontinued.

"I don't think we have data suggesting that you can go beyond three to five years," she said. "It is misleading to say [estrogen is safe for] seven or more years."

The NAMS statement urged clinicians to consider a number of additional factors when considering hormone therapy for patients:

  • A woman's individual risk and history of venous thrombosis, heart disease, stroke, and breast cancer
  • Route of administration and dosing, as transdermal and low-dose oral estrogen are associated with lower venous thromboembolism and stroke risks than standard oral estrogen doses
  • Type of symptoms, with low-dose, local administration of estrogen when only vaginal symptoms are present

Further research is still needed, especially in interpreting individual risk and assessing long-term implications, the statement noted.

By Crystal Phend, Senior Staff Writer, MedPage Today

Primary source: Menopause: The Journal of The North American Menopause Society
Source reference:
"The 2012 hormone therapy position statement of the North American Menopause Society" Menopause 2012; 19: 257-271.

Why has Menopause Management become so Controversial?
Posted by on March 8, 2011 - 11:59am

Women, on average, live one-third of their lives post menopause.   Some women find menopause an easy transition. Other women are chronically bothered by persistent hot flashes and night sweats that impact their quality of life.   For years, hormone therapy was the answer but it has been shadowed by controversy as researchers learn more about estrogen and its long term impact on the body.    The Institute for Women's Health Research discussed this controversy in its March e-newsletter that is available at  ENewsletter March 2011final.

Hormone Therapy and Breast Cancer Risk
Posted by on February 10, 2011 - 2:24pm

Starting Hormone Therapy at Menopause Increases Breast Cancer Risk

Women who start taking menopausal hormone therapy around the time of menopause have a higher risk of breast cancer than women who begin taking hormones a few years later. The finding, from the Million Women Study (MWS)—a large observational study in the United Kingdom—adds to a growing body of evidence that the use of combined hormone therapy (estrogen plus progestin) to treat menopausal symptoms increases the risk of breast cancer and deaths from the disease. The results appeared in the Journal of the National Cancer Institute on January 28.

The pattern of increased breast cancer risk “was seen across different types of hormonal therapy, among women [in the MWS] who used hormonal therapy for either short or long durations, and also in lean and in overweight and obese women,” Dr. Valerie Beral of Oxford University and her colleagues wrote. Their findings support results from the Women’s Health Initiative (WHI), a randomized clinical trial that, in 2002, first reported evidence linking combined hormone use to breast cancer.

“The new findings underscore the idea that there’s really no safe window of time for women to take combined hormone therapy,” said Dr. Leslie Ford of NCI’s Division of Cancer Prevention and the Institute’s WHI liaison. After the initial WHI results were announced, she noted, some people had argued that hormones may be safer when started at the time of menopause. “The new findings refute that argument,” she added.

WHI and MWS investigators have both reported that breast cancer incidence rates declined rapidly once women stopped taking combined hormone therapy. “It is important for women to know that if they stop using hormones, the risk of breast cancer very quickly returns to where it was before hormone therapy began,” Dr. Ford said.

There has been a discrepancy between the WHI and MSW results to date as to whether estrogen-only therapy raises breast cancer risk in postmenopausal women. WHI reports have found little risk associated with this treatment, whereas the MWS investigators have observed a statistically significant increased risk.

Additional follow-up from the WHI estrogen-only intervention trial should help clarify this issue in the coming years, noted Drs. Rowan T. Chlebowski of Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center and Garnet L. Anderson of the Fred Hutchinson Cancer Research Center in an accompanying editorial.

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