Menopause Today & Tomorrow

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Alison Grafton

When Elizabeth Friedmann was in her early 50s, she began to have terrible trouble sleeping. “Some nights I would wake up every hour or two drenched in sweat and feeling feverish and claustrophobic,” says the retired market research company owner, now 65. “I’d throw off the blankets and then wake up again a bit later freezing and shivering. I felt like I did when I had pneumonia once. It was crazy making. Sometimes I wept in frustration.”

Elizabeth didn’t get much sympathy from her family, who took the position that the transition to menopause is not a disease requiring medication and a woman should just “get through it” — as women have done for millennia. “So I tried exercise and soy products and red clover and black cohosh. I know some women get relief from these,” she says. “And I felt really virtuous but I still couldn’t sleep. Here I was at the height of my career and coping with a 10-year-old and two teenagers at home as well. I needed my rest.” Elizabeth was right: sleep disturbance and deprivation can contribute to serious health problems, as sleep apnea sufferers can attest.

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Like Elizabeth, about 70% of Canadian women will experience perimenopausal and menopausal symptoms, and in approximately one-third of these women, symptoms are sufficiently severe that their quality of life is tangibly affected. “Some people dismiss these symptoms with a sort of “just suck it up” attitude, which is very unfair and unkind to those women who have them,” says Dr. Jennifer Blake, chief of obstetrics and gynaecology at Sunnybrook Health Sciences Centre in Toronto. “In comparing these adverse effects in terms of quality of life with those of other diseases, women with severe menopausal symptoms rate their quality of life at the same level as do women who are on chronic kidney dialysis.”

Although she resisted the idea at first, Elizabeth finally sought relief with hormone replacement therapy (HRT). “I could get a good night’s sleep and I could face exhausting business travel and 11-hour workdays without panicking,” she says. She took HRT intermittently for eight years, stopping at age 59. “I was starting to develop a skin allergy to the adhesive used in the transdermal patch, and then the negative results of the Women’s Health Initiative came out, so I felt it was time to stop.”

In 2002, the Women’s Health Initiative (WHI) study noted small but significant increases in the risks of blood clots, stroke, heart attacks and breast cancer with HRT, but these findings applied more to older women and long-term users. Recent analysis of WHI data has reported a higher risk of death from non-small-cell lung cancer in some HRT users, especially smokers. Other research has suggested that HRT may protect against lung cancer, especially in younger women. “The time of initiation of therapy seems to be important,” says Blake.

According to the Ottawa-based Society of Obstetricians and Gynaecologists of Canada, HRT is a safe and effective option for up to five years for the relief of moderate to severe menopausal symptoms, including hot flashes, night sweats, sleep disturbances, vaginal atrophy and mood changes. What’s more, with careful monitoring, HRT may even be safely used by women at higher risk of breast cancer.

“As for dose, method of delivery and duration of therapy, these should be tailored to the individual patient,” says Blake, who is also a professor and associate chair of obstetrics and gynaecology at the University of Toronto. She notes, interestingly, that the amount of estrogen in HRT is far lower than that in low-dose birth control pills and lower than the natural endogenous level in a premenopausal woman’s body during most of her menstrual cycle.

Emerging data suggests that HRT may protect the hearts of younger women with healthy blood vessels in the early menopausal years, as opposed to those of older women starting therapy later when vascular damage is already present and other cardiovascular risk factors such as obesity, diabetes and hypertension may have set in. It may also protect younger women against cognitive impairment and dementia. “There may be an early window of opportunity for protecting the brain and heart,” says Blake. “But we are not recommending hormone therapy for the prevention of disease.” For that, the recommendation is healthy lifestyle choices, especially diet and exercise, as the first and best line of defence.

While Elizabeth found relief with HRT at a demanding stage of life, her mother took the view that she was just postponing the inevitable. “In her opinion, I’d only have to face having these symptoms later, once I stopped HRT,” she recalls. That is not generally true, says Blake. “Symptoms may reappear after a woman stops HRT, but they will be milder and of shorter duration.”

Elizabeth still gets occasional hot flashes, especially when she’s cooking or in bed. With the help of a small bedside fan which keeps the air around her face moving, she’s able to get a decent night’s sleep. For some women, hot flashes are still present in their 70s and 80s, notes Blake, “because after menopause, our thermal regulation system in the brain is never quite as good as it was. So the room is always too hot or too cold, and the covers are going on or off.”

What about the future? What can the young girls of today expect when they approach this reproductive rite of passage several decades from now? As Blake points out, our life expectancy is lengthening. According to a recent estimate, half of today’s children will live to be centenarians, potentially making menopause a relatively early event in a woman’s life-span. “If senior women are going to be able to live independently and not in care, we have to think about preserving their brains and hearts — and their skeletons so their bones do not crumble away,” she says. Improved menopausal therapies may play a role in that protection.

Newer more effective versions of non-hormonal drugs such as today’s selective estrogen receptor modulators (SERMs) — which have estrogen-like benefits for bones and protect against breast cancer but for many increase hot flashes — may target a greater array of symptoms. Other non-hormonal medications that may ease hot flashes and night sweats include the new wave of antidepressants of the selective serotonin reuptake inhibitor (SSRI) type.

SERMs and newer drugs maybe able to mimic estrogen in tissues where this hormone is beneficial, such as those of the brain, blood vessel walls, skeleton and vagina, but not in tissues where it can be harmful such as the breasts and uterus. Perhaps customized designer transdermal hormones will be available, tailored to each woman’s biochemical profile.

With so much research under way, chances are that by the time today’s teenage girls reach menopause, they’ll have an array of finely tuned drugs to manage bothersome symptoms — treatments perhaps based on knowledge of their specific  genetic makeup. “A woman genetically susceptible to breast cancer, for example, will be treated quite differently from a woman who isn’t,” says Blake. “The point is that treatment will be individualized to the patient. Our greatest challenge today is understanding how to apply the results of trials in a million women to any one of us.”