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 Interview with Dr. Isaac Schiff, Joe Vincent Meigs Professor of Gynecology at Harvard Medical School and Chief of the Vincent Obstetrics and Gynecology Service at the Massachusetts General Hospital.
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CBS CARES: What are the typical symptoms of menopause itself?
DR. SCHIFF: Well, every woman is different, and symptoms can even differ according to nationality. For example, Asian women complain more of joint pain than of hot flashes.
In the U.S., women can experience some or many of the following range of symptoms: hot flashes, insomnia, fatigue, anxiety, irritability, problems focusing. There's also usually vaginal atrophy and dryness because of the loss of estrogen. Some women's skin may become drier and less elastic, because lower estrogen levels result in less collagen production, and collagen is what keeps the skin elastic and supple. Though hair loss could have a genetic component, it may be associated with menopause.
CBS CARES: That's quite a litany of potential symptoms. Anything else for women in the U.S.?
DR. SCHIFF: Yes. After menopause some women, especially if they have had children, have trouble with bladder control. The muscles around the bladder become weaker. Thus, if a woman coughs and increases the pressure in her abdomen, and it gets transmitted to the bladder, the urine will be forced out of the bladder. If there is not adequate muscle contraction around the urethra to prevent that, urine will be lost. Kegel exercises, which involve contracting and releasing pelvic floor muscles, can strengthen those muscles and improve bladder control.
There can also be an increase in urinary tract infections. Drinking cranberry juice can help reduce urinary tract infections.
In addition, many women may experience a decreased libido; the cause of which can be complicated.
CBS CARES: Well, why can the cause of a decreased libido be complicated?
DR. SCHIFF: Well, vaginal atrophy and decreased lubrication can cause sexual relations to become painful instead of being pleasurable. This can certainly contribute to a lack of desire. Or, a menopausal woman may need more time to reach orgasm, while men don't have as much time on their side. Decreased libido can also be caused by anti-depressants in the SSRI category. Of course, if a woman is in a bad relationship, that, too, is a factor. In addition, there are lower levels of testosterone, the hormone responsible for sex drive, apparent at menopause, which can certainly decrease libido. So, it's multi-factorial.
CBS CARES: When typically is the peak testosterone production in a woman?
DR. SCHIFF: Peak production for a woman's testosterone is around age 20, and it falls by 50 percent by age 40. So, testosterone is falling long before menopause. And, if you remove the ovaries, there will be a further reduction in testosterone. Some people think that the post-menopausal ovaries produce testosterone, and others don't.
CBS CARES: Can testosterone replacement, such as in patches or cream, help restore a woman's libido just as it can for men?
DR. SCHIFF: Yes, in fact testosterone replacement can help with libido. The initial studies were done in women who had their ovaries removed and were given estrogens and still had decreased libido. They continued to receive estrogens and were prescribed either a testosterone patch or a placebo patch. The women who received the testosterone patch had an improvement in their libido. More recently, testosterone patches were used for menopausal women with decreased libido who still had their ovaries, and it was found that they had increased frequency of relations compared with the women who received placebo. However, the FDA has asked for more long-term safety data before considering approval of it.
CBS CARES: Are there other ways to treat a woman's decreased libido?
DR. SCHIFF: Well, to the extent that vaginal atrophy reduces libido, regular sexual intercourse is thought to help with vaginal lubrication...making sexual intercourse more enjoyable.
CBS CARES: Does menopause cause weight gain?
DR. SCHIFF: There is definitely a tendency to gain weight in menopause years and some evidence to suggest that menopause could in part be directly responsible. But, there is still some debate on the subject and more research needs to be done to definitively resolve this issue. I should add that weight gain is also age-related. Over time, metabolism slows and gravity weighs us down. There's more fat deposition and less lean muscle mass, and the development of fat in the abdomen and the buttocks. Whether weight gain is linked to menopause itself and/or age, the important thing is that a clinical trial has shown that weight gain in menopause years can be prevented by diet and exercise.
CBS CARES: Well, does menopause cause weight redistribution as opposed to weight gain?
DR. SCHIFF: Yes, there is very compelling evidence to that effect. Women's waists tend to get wider, hips narrower in menopause and there can be central accumulation of weight. Again, this can be helped, even prevented, by a healthy lifestyle… essentially exercise and diet. In fact, because central accumulation of weight increases heart attack risks, exercise and a healthy diet are essential.
CBS CARES: Does hormone therapy itself cause weight gain?
DR. SCHIFF: Hormone therapy does not cause weight gain when given to postmenopausal women. Weight gain, loss of lean body mass and central redistribution of body fat is a nearly universal occurrence throughout adult life. This can be modified by exercise. Long-term control of blood sugar is not adversely affected by hormone therapy.
CBS CARES: Thanks. Turning to the subject of headaches…do peri-menopause or menopause cause these?
DR. SCHIFF: There was a study in England where it was shown that women can get migraine headaches a few days before their periods start, because of a big decline in estrogens. And, if you give them a small amount of estrogen in a patch and avoid major fluctuations in hormones, you could avoid migraines. And the migraines would therefore tend to decrease in menopause, because - if the woman is not taking hormones - you don't have those fluctuations.
CBS CARES: So, a menopausal woman on hormone therapy who has severe migraines should speak to her doctor about the dosage of hormone therapy, because it might explain her migraines?
DR. SCHIFF: Yes, it could well explain them and hormone dosage adjustment may be appropriate if the headaches are severe or frequent.
CBS CARES: Is it fair to say that going back 50 years ago, a lot of women going through menopause were misdiagnosed as having psychological problems?
DR. SCHIFF: Yes. There used to be a diagnosis of melancholia, or melancholy of menopause. Up until 20 or 30 years ago, there was that whole concept that menopause was associated with depression. And there weren't many antidepressants around, so these women were likely to be treated with electroshock therapy. But you've touched on an important point that needs to be emphasized: we have no evidence that there is a chronic depressive syndrome at menopause.
CBS CARES: Besides potential symptoms, are there any increased health risks associated with menopause?
DR. SCHIFF: Yes. While menopause itself is not a disease or health risk, postmenopausal women, due largely to loss of estrogens, are more vulnerable to osteoporosis.
CBS CARES: Do other parts of the body continue to make estrogen after the ovaries have stopped or are removed?
DR. SCHIFF: That's the whole basis for why women who have had breast cancer have their ovaries removed. Even after the ovaries are removed, the adrenal glands continue to make androgens or male-like hormones. These male-like hormones go to the liver or fat-like tissue and are converted by the enzyme aromatase into estrogen. That is why a woman who has had breast cancer and has her ovaries out may be given Tamoxifen, which blocks the receptors for estrogen. But, we know Tamoxifen only works for about five years and then has a counterproductive effect. After the five years they would be switched to an aromatase inhibitor, which essentially reduces any estrogen production at all.
CBS CARES: Can we turn now to the much debated subject of hormone replacement therapy?
DR. SCHIFF: Sure. Actually, conventional hormone therapy is no longer called hormone replacement therapy because we now understand that these hormones are not replacing lost hormones, but rather, using just enough hormones to treat symptoms. Both hormone therapy and estrogen therapy are used to treat women. Hormone therapy describes estrogen and progesterone, while estrogen therapy uses estrogen only. As I touched on earlier, women who have had a hysterectomy receive estrogen therapy only, because the progesterone component in hormone therapy protects against endometrial cancer, or cancer of the lining of the uterus, and women who have had hysterectomies are not at risk for endometrial cancer.
CBS CARES: What percentage of menopausal women require hormone treatment?
DR. SCHIFF: About 20 percent of women experience symptoms that require hormone treatment. And then there are some women who glide through menopause without ever experiencing a single symptom.
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