Hope and hormones

Press, 18 November 1981, Page 12

Hope and hormones

CHRISTINE DOYLE

discusses oestrogen and the menopause

The generation of women who were sexually emancipated by their pioneering Use of the pill in the late 1950 s and 1960 s are now near or in the age range where again tney may consider taking a hormone every day. These women, accustomed to daily pill-taking, may well insist on a prescription for oestrogen, if they believe it will liberate their middle years from the worst , menopausal symptoms. For years thousands of American women have sought relief through oestrogen, and many hoped it would help them hold onto their fleeting youth. In Britain, in spite or the growth of menopause clinics (about 26 in England and Wales), women have been less enthusiastic.

Reappraisal has followed reappraisal; There is also the apathy of doctors and a tendency by some of them to see the menopause as a ‘natural’ event and say ‘every woman has to, go through it.’ . This is borne out by many letters to Woman’s Health Concern, a small information unit that recently received a modest government grant. As with oral contraceptives, an accumulation of evidence has not resolved the controversy over the risks and benefits of. oestrogen treatment, but several new studies are helping to define more precisely who may benefit and how. • The problem is that the menopause is more natural for some than for others. Once the ovaries stop egg-

making, levels of oestrogen decline, sometimes smoothly to allow a gentle transition, but sometimes • abruptly to produce severe symptoms — hot flushes and drenching sweats, each day or night, depression, fatigue and irritability. The oestrogen decline can be virtually, total and the symptoms overwhelming. Menopausal women often complain of dry and uncomfortable vaginas and sexual difficulties — in some the vagina actually atrophies. A stimulating life, sexually and physically active, may help to ginger up the adrenal glands so that they produce a useful alternative supply of oestrogen. This may be where the theory that “successful” women somehow have an easier “change,” comes from, but'There may well be more good luck than good management involved.

That oestrogen does help to relieve severe and prolonged flushes and sweats, and severe vaginal dryness, is now firmly accepted by many doctors, though the length of treatment ' may vary enormously.

No two women have the same biochemical make-up,

and reactions to the menopause are also influenced by stress and worry. However, depression, which is particularly prevalent during the menopause, is probably not- helped by oestrogen. Dr Jean Coope, a general practitoner at Macclesfield in Cheshire, whose study of 55 depressed menopausal women was published recently in The Journal of the Royal College of General Practitioners, found that, although other symptoms improved significantly, depression and feelings of wellbeing were little altered. Professor Christopher Nordin of the Medical Research Council’s mineral metabolism unit in Leeds, is now analysing a five-year followup of women who took oestrogen for one or more years from 1975. He agrees that true depression is probably not relieved, but finds that, besides

welcome relief from physical symptoms, ‘the most outstanding effect was the boost in self-confidence.’ He strongly, maintains that “women gain bone time” with oestrogen treatment: about one woman in four suffers from thinning bones — osteoporosis — but may not realise it until the first painful break of a brittle bone, perhaps in their sixties, by which time it is too late for prevention. Bone loss may. be 50 per cent by the age of 70 in women, compared with about 25 per cent by the age of 90 in men. Three American studies show that the fracture rate can be halved among thosetaking oestrogen. Danish research published recently in The Lancet suggests that, even if oestrogen is taken for only three to four years, bone loss is arrested during that time and resumed when treatment stops, ', Oestrogen cannot be given to everyone on the off-chance that she has thinning bones, and much stress is laid on the importance of exercise, particularly walking, to keep bones strong. Calcium in the diet is also vital.

Professor Nordin is confident that it will be possible in the near future for general practitioners to screen women fbr serious bone loss. Tests, for example; for high rate of excretion of calcium in the urine, which seems to be linked with low oestrogen levels, may indirectly reflect bone loss The risk of womb cancer always comes into discussions about oestrogen therapy. High doses of oestrogen for more than five years are firmly linked with an increased risk, but it is not established beyond doubt, and the high rate of hysterectomies in the United States has not helped the statisticians. In two recent reviews in the medical press, doctors conclude that the cancer risk may have been overstated, and that it is much reduced if oestrogen is always given in conjunction with progestogen — one of the two hormones contained in combined oral contraceptives — so that a mock menstrual cycle is produced. This washing out of the womb helps to avert precancerous changes in the womb lining.

Controversy over whether oestrogen may protect against heart disease continues unabated. Women’s risk goes up after the menopause, but they are still less at risk than men. And, although oestrogen is related to fat levels in the body, the medical consensus has been that it confers no special protection. A challenge to this view was published in The Lancet a short time ago. American researchers in Los Angeles found that Californian women given oestrogen suffered fewer heart attacks than a carefully matched control group.

But criticism of the study is gathering. Were the women in this study less at risk before they took oestrogen? At what age was the protection mainly conferred? If it was when the women were aged 80, but not when they were aged 60. would that be a good thing?

The entire issue is also obscured by the fact smoking entails a major risk of heart disease.

If agreement on this seems far away, it is generally thought that perhaps one woman in four could be helped by taking oestrogen at ' some stage during the menopause.

There is also virtually no dispute as to how the drug should be taken. The golden rule is ‘for the shortest possible time and at the lowest possible dose.” Copyright, “Observer,” London.