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Menopausal flashes and blues

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A 51-year-old hypertensive and diabetic patient of mine, who was experiencing hot flashes and anxiety episodes, asked me if it was safe for her to take hormonal pills to relieve her symptoms.

Postmenopausal symptoms can be bothersome in women, usually between 45 and 55 years old, when their ovaries stop producing eggs and their menstrual periods end. During this period, the ovaries decrease producing the female hormone estrogen by more than 90 percent and the sudden “hormonal imbalance” can cause all known menopausal symptoms such as hot flashes, emotional lability with some experiencing severe depressive symptoms, dryness in the mucous membranes, and bone or joint problems.

Postmenopausal hormone therapy (HT) that relieves bothersome symptoms usually consists of two hormones—estrogen and progestin. Estrogen is the hormone that really helps relieve the symptoms while the progestin (a progesterone-like hormone) is also given for women with uterus to prevent the development of uterine cancer.  Estrogen also causes the lining of the uterus to thicken which might potentially lead to uterine cancer. Progestin helps neutralize this estrogen effect. For those who already underwent hysterectomy (removal of the uterus), estrogen alone is prescribed.

Double-bladed

Although HT can be very effective in relieving symptoms, it also has its own share of potential risks and side effects so it’s a double-bladed treatment and a physician has to thoroughly weigh the risks against the benefits.

The Women’s Health Initiative (WHI) was a large study initiated by the National Institutes of Health (NIH) in the United States to find out the risks and benefits of hormone therapy. Specifically, it determined if hormone therapy would reduce the risk of heart attacks (coronary heart disease), strokes, blood clot formation, hip fractures; and at the same time the study monitored for possible increases in the risk for breast and colon cancer.

The researchers said that taking estrogen-progestin in combination actually increases the risk of heart attacks, breast cancer, blood clots and strokes in older postmenopausal women.

The risks were deemed alarming by the researchers that even before the end of the study, women who were given estrogen plus progestin were told to stop taking the pills.  The reason for this was the increased risk of breast cancer in women taking estrogen plus progestin. There were also identified risks for heart attacks, strokes and blood clots to the lungs and legs. The verdict was that  the overall risks outweighed the benefits of taking estrogen plus progestin.

A benefit which was noted though was the reduced rates of hip and other fractures or colorectal cancer in women taking estrogen plus progestin.

Quantified risk and benefit

To make it easier to appreciate the risks and benefits, the NIH quantified them.

For every 10,000 women taking estrogen plus progestin pills:

• Thirty-eight developed breast cancer each year compared to 30 breast cancers for every 10,000 women taking placebo pills each year.

• Thirty-seven had a heart attack compared to 30 out of every 10,000 women taking placebo pills.

• Twenty-nine had a stroke each year, compared to 21 out of every 10,000 women taking placebo pills.

• Thirty-four had blood clots in the lungs or legs, compared to 16 women out of every 10,000 women taking placebo pills.

For every 10,000 women taking estrogen plus progestin pills:

• Ten had a hip fracture each year, compared to 15 out of every 10,000 women taking placebo pills each year.

• Ten developed colon cancer each year, compared to 16 out of every 10,000 women taking placebo pills.

Based on the robust data of the WHI, the researchers’ conclusions should be taken as gospel truth unless another larger scale study proves otherwise:

• The estrogen plus progestin combination studied in WHI does not prevent heart disease.

• For women taking this estrogen plus progestin combination, the risks (increased breast cancer, heart attacks, strokes and blood clots in the lungs and legs) outweigh the benefits (fewer hip fractures and colon cancers).

So for the diabetic and hypertensive patient who asked me about the advisability of hormonal therapy for her postmenopausal symptoms, I told her that considering her cardiovascular risk factors, it’s for her best interest that she does not. The bothersome symptoms usually wane in time, and women get to psyche themselves into accepting them as a reality they have to live with at this period of their lives.


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