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 A Personal Perspective from Dr.Wulf Utian, Founder and Executive Director of the North American Menopause Society and Consultant Gynecologist, The Cleveland Clinic.
CBS Cares has asked me to provide my personal perspectives on menopause and to address certain questions that are frequently on the mind of menopausal and perimenopausal women. I am very glad to do so. First, I would like to commend CBS for taking such a leadership role, by creating what I believe are the first television network public service messages on menopause, and - through engaging and challenging interviews with experts - providing this extensive and valuable resource for women.
Many questions about menopause and its appropriate management remain unanswered. Nonetheless, a lot more is known than most people realize.
Menopause has always been a fascinating but contentious subject in women's health causing heated debate and arguments, not only among women but also with men and doctors. We need sometimes to look back from where we have come from in order to appreciate where we are now, and might be getting to in the future. One episode in my career exemplifies this. My first book on menopause, probably one of the first ever on this specific subject, was published in England in 1978 as "The Menopause Manual", a wonderful little book long out of print now. I was approached by publishers in New York City in 1979 to publish an American edition. At a meeting with them in Manhattan, myself and about 8 women, I was told the title needed to be changed. "No self respecting woman in the United States would be seen dead reading a book with the word Menopause on the cover!" That was just 25 years ago. The book was published as "Your Middle Years". Yet, in 2005 the bookstores are flooded with titles including the M word, advising women on everything from yoga to herbs to hormones to meditation. Unfortunately, this greater availability of material often creates more confusion.
The good news is that credible scientific organizations have completed a lot of work, meticulously reviewing all the current evidence and presenting very well balanced position statements reflecting best current medical practice. The best of these, in my personal opinion, hopefully not biased, is the series of Position Statements put out by The North American Menopause Society (NAMS). Their latest position statement can be accessed through the link provided by CBS Cares at the end of its menopause section.
QUESTIONS AND ANSWERS - MY PERSONAL STAND ON THE ISSUES
Let me plunge into the debate with my personal interpretation of the scientific literature on some of the current most frequently asked questions.
Q. What are the true symptoms specifically related to menopausal hormone changes?
A. Believe it or not, the real direct hormonal-related symptoms include only those related to hot flashes and night sweats, associated sleep deprivation as a secondary effect, and those related to vaginal thinning (vaginal dryness, discomfort, or pain with intercourse). While this might be surprising, other symptoms such as irritability or forgetfulness are not direct menopause related symptoms, but rather, if they occur, really result from disturbed sleep and fatigue.
Q. Does menopause affect mood?
A. This is a difficult question to answer. However, as already mentioned, if a woman is suffering from night sweats, causing interrupted sleep, it is very likely she will be fatigued in the morning. If this continues night after night, it would not be surprising for symptoms of irritability, sense of forgetting things, feeling blue and the like to develop. Clearly then, this is not the menopause itself doing this, but its negative effect on sleep. The answer then is to treat the night sweats and all the other problems are then likely to resolve. Having said this, my own research, later substantiated by others, has shown that reduction of estrogen after menopause is associated with a reduced sense of well-being, feeling blue, but not with any level of full blown depression. The latter actually occurs most frequently in women of reproductive age in their thirties and forties.
Q. Do women put on weight after menopause?
A. Yes. Strong evidence suggests that declining estrogen levels appear to be associated with reduction of muscle mass, increase in fat mass and a gradual weight increase. As Dr. Schiff, a leading authority on menopause, indicates in CBS Cares' interview with him, more research is needed to finally prove this point, but there is much existing evidence. As Dr.Schiff has also said in this interview, it IS clearly established that menopause causes weight redistribution. There is also an age related contribution to weight gain and weight redistribution, and separating the relative contribution of each is extremely difficult. The bottom line message is that after menopause, as well as hopefully before, the best way to maintain weight is to eat less and exercise more.
Q. Does hormone therapy cause an increase in weight?
A. No. The overwhelming evidence, and there is good data, shows hormones to actually cause a reduction in weight through reversing some of the above factors.
Q. Is disturbed sleep and sleep deprivation due to the night sweats or does estrogen loss itself have an impact on sleep?
A. Both may well be true, but research in this area is in its infancy and no definitive scientific conclusions can be drawn right now. There appears to be a snowball effect in symptom production, with disturbed sleep and sleep deprivation leading to fatigue and then on to symptoms like irritability, anxiety, short temper, complaint of forgetfulness and so on. Some researchers have demonstrated that good quality sleep is negatively impacted by the reduction in the estrogen that occurs with menopause. Others are debating whether the night sweats themselves actually interrupt sleep. In either event, there is good evidence that estrogen therapy actually helps restore the good quality sleep, and in turn by reducing morning fatigue will contribute to a better sense of well-being.
Q. Does menopause negatively impact quality of life (QOL)?
A. Depends on who you ask and how you ask the question. Many women report the postmenopausal years as part of the best years of their lives. This was confirmed in a Gallup Survey conducted through NAMS. But women with severe vasomotor symptoms (hot flashes and sweats) or vulvo-vaginal atrophy are likely to report decreased QOL. There is also a relationship with psychological and socio-economic factors. We should remember that to many women there are other factors that will affect their sense of well being or quality of life, and these include skin quality, dental health, sexual desire and response, visual health, and so forth. These may all be enhanced by hormones, and some women will see a trade of current good quality of life being a fair return for a small risk of some other problem in the distant future. Furthermore, many factors unrelated to menopause will also impact sense of well being such as sense of self-worth, life circumstance satisfaction, job security, supportive friends, outside interests and so forth. It is my clinical observation that these latter circumstances may actually benefit by estrogen therapy which increases "energy" in enhancing personal activities.
Q. What are we to believe about hormone therapy after the Women's' Health Initiative ("WHI") Study?
A. Probably that not everything is as it first appears. It must be emphasized that the WHI was not a study about menopause. It was a study undertaken to see whether women after menopause could be protected against developing heart attacks by starting hormone therapy. As a result, well over two thirds of the women were more than 10 years beyond menopause. The average age of starting the hormones was 63, and in fact some women were first started on the medications at age 79!
There are nonetheless lessons to be learned from WHI. My personal brief summary of the current medical evidence is that both the potential major risks and benefits are actually very low in women of normal perimenopausal age (45 - 60), the women most affected by symptoms. I believe that the major focus, therefore, should be on current quality of life. While every woman's benefit and risk profile should be assessed in consultation with her own physician, I personally believe that a woman with moderate to severe symptoms - and who doesn't fall within a specific risk category for hormones - can really take them with little fear for at least 4 years.
Q. Are so-called "bio-identical hormones" safer?
A. No! This is a marketing gimmick with very little scientific substantiation. In fact, estradiol and progesterone are available as FDA approved products and are bio-identical to the natural estradiol and progesterone produced by the body.
The other "bio-identical hormones" being marketed separately as "natural hormones" are the actually the same chemicals as those produced under scrutiny by the FDA and sold by pharmaceutical companies, except for one major difference. The compounding pharmacy is creating a new mixture, a sort of personal recipe of different quantities and combinations of estradiol, progesterone, and other substances, which results in a new "multi-ingredient" compound that has no safety and efficacy study to back up the unwarranted new claim for safety. There are many women who swear by bio-identical hormones and many reputable doctors who prescribe them. But, it is important that women know that there has been no scientific testing on the safety or efficacy of "bio-identicals". I suggest sticking to the existing products that are well tested for safety and effectiveness as well as being monitored for purity and consistency in production.
Q. Should the dose of hormone therapy be monitored with saliva testing?
A. No. Saliva testing is essentially useless. Save your money for something worth while.
Q. Are over-the-counter products effective in reducing hot flashes?
A. Generally, no. There is a remarkable phenomenon in testing drugs for efficacy called the "placebo effect". In every hot flash study comparing active drugs to sugar pills, women on sugar pills show between 30 and 50% reduction in hot flashes. We do not understand this. The over-the-counter products thus work as effectively as the sugar pills. This includes the soy products, herbal products, and the so-called homeopathic remedies. It is not an exaggeration to say that rubbing Vaseline into one's navel could be as effective a placebo if you're willing to believe it works… and a lot cheaper.
Q. Are new drugs in development?
A. Yes, definitely yes. But the bar for safety and efficacy has been raised pretty high by the FDA, and it is likely to be some time before any of a wide range of exciting new medications with very specific effects come to market. One exciting group of new drugs is called SERMS. These are really designer hormones, carefully being developed in an attempt to retain the beneficial effects of estrogen while selectively eliminating the negative effects. The first of these, raloxifene, is already available, but does not meet all the objectives. Others are in various stages of drug development, but it is going to be some time before they are released to the public. Trying to create the perfect drug is extraordinarily difficult.
Q. What is the main message of menopause?
A. Menopause is simply the final menstrual period, the end of the chapter of life called the reproductive years, and the beginning of a new chapter that I believe should be termed the productive years. It is the time to take control of your life and health. Get a comprehensive check-up, commit to planned healthy living, take pharmacotherapy only selectively and if there is a really legitimate indication, and plan what you want to accomplish in the second half of your life. Then just go for it!
Dr.Wulf Utian - Biography
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