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Menopause & Perimenopause Ask The Expert

ASK THE EXPERT
Questions answered by
Ronald Barentsen, MD, PhD, Netherlands
Chairman of the OBGYN.net Menopause Advisory Board

[Dr. Barentsen]

Are these symptoms of Menopause?
Am I experiencing Perimenopause?
What should I expect from HRT?
Doctor, What should I expect from HRT? 
 
Q:  I am a 48 year old female with relatively normal periods,  however , I suffer from most of the perimenopausal symptoms, night sweats, irritability, crying, anxiety, bloating, water retention, low libido, tender breast, etc.  I also take synthroid 125 mg daily. Two months ago my doctor started me on micronized progesterone 200mg. once a day for 14 days. The first month went well. However this past  month my period was totally abnormal with spotting lasting eight days instead of a normal period for five.. now just two days after starting the progesterone again, I am spotting again. This appears to be a continuous period. yuk!!  Is this normal with progesterone supplements?  Should I continue on for a month or two, or accept the fact that  my body does not need progesterone supplement at this time?  I need advise on how to proceed with this hormonal treatment. 

A: Micronized progesterone 200 mg for 14 days is the usual dose for postmenopausal suppletion with continuous estrogens. In your situation with still normal periods, your ovaries produce enough estrogens. Symptoms as described are caused in that phase of lif by fluctuating hormone levels or by a shortage of progesterone. With high endogenous estrogens, the dose of progesterone has to be increased when cycle disturbances are seen. At least 300 mg or a more potent progestagen such as norethindrone 2.5 or 5 mg.

Q:  I was diagnosed with breast cancer at age 35. I  agreed to participate in a protocol which entailed an upfront chemotherapy regimen of 4 rounds of adriamyacin and cytoxin followed by four rounds of taxotere, along with daily tamoxifen. Once finished with the chemo, I had surgery (mastectomy and node sweep) and learned that my breast cancer was wholly ductal carcinoma in situ without a trace of invasive cancer, and no positive nodes.  

My family doctor sent me for a mammogram after a routine physical; the mammogram showed spots of calcification which were then biopsied by fine-needle aspiration and determined to be cancerous. Because my initial mass was estimated to be 4 centimeters, the oncologist to whom I was referred felt sure that my cancer was invasive and strongly encouraged me to proceed to treatment immediately to increase my chances of survival. At the time I did not know how important a core biopsy is in the diagnosis of breast cancer, and one was NEVER done. Also, because the sample was so small, an estrogen receptor test on the sample was never done. By my reckoning, I was treated for a type of cancer I never had. 

The downsides are many, but the one that is toughest is that the chemo has thrust me into early menopause, complete with cessation of menses and hot flashes and night sweats. Here is my question: since I never had invasive cancer, is HRT an option? I am awake at least an hour every morning sometime between 2:00am and 4:00am because of the discomfort of the hot flashes, and I am seeking relief. Can you help?

After the chemotherapy I did in fact have not one but TWO children: I have two healthy girls, ages two and a half and 11 weeks. In between the births I experienced symptoms of menopause.

A:  You are certainly not postmenopausal. With a baby of 11 weeks, nothing can be said of the actual situation. Maybe the menstrual cycle restores completely to normal. Such things happen. It is important to diagnose the actual hormonal situation with determination of FSH, LH and estradiol. But, wait for 2 to 3 months to see if your menstruations return. During the weeks after delivery hypoestrogenity is quite usual, especially with breastfeeding. A history of breast cancer is a containdication for HRT. But in certain circumstances HRT is even described to those women, but only after extensive discussion and informed consent. This is a matter of discussion with your personal doctor and/or oncologist, and cannot be advised on a distance.

Q:  Do you have any information on the relation between estrogen replacement therapies and dry-eye syndrome?  I heard a very short medical announcement in which 70-80% of women taking drugs like Prempro, etc. develop dry-eye syndrome.  If you have any information, I would appreciate reading about it.  By the way, my mother-in-law has developed a problem with dry eyes and I am wondering if it is her HRT medication?

A:  The Journal of the American Medical Association (JAMA) has just released an article about dry eye syndrome and HRT in the issue of November 7, 2001. This observational study suggests that the use of estrogens alone increased the syndrome with 69% and the combination of estrogens with progestagens increased the problem with 29%. This means that women without HRT has the problem in 5.9% and women with estrogen alone in 9.1% and women with estrogens + progestagens (like Prempro in your question) in 6,7%. So much less than the 70-80% in the announcement that you have heard.

Please see this article abstract, "Hormone Replacement Therapy and Dry Eye Syndrome" from JAMA for more information about your question.
Q:  My wife is 54 and in perimenopause. She was taking Bi-Est 3mg and Progesterone SR 300mg daily. She has developed some type of autoimmune disease in her mouth. The Oral Pathologist, Oral Surgeon, and Dermatologist have ruled out bacterial infections, viral infections, yeast infections, lichen planus, pemphagoid, etc. They now believe that she is having an allergic reaction to her hormones. Do you have any information on "Autoimmune Progesterone Dermatitis" as it relates to the oral mucosa region of the mouth. This is the only "diagnosis" I can find that is even close to what is occurring in her mouth.

A:  Allergy to progesterone is described, but also to estrogens. It is a rare condition. But allergy to progesterone does not mean automatically allergy to progestagens. When HRT is necessary another combination can be tried with medroxyprogesterone or norethindrone as a progestagen. But let the dermatologist first test the chosen compounds.
Q:  Help.  I am overwhelmed and confused with all the info being given to me. I had a total hys.  What hormones do I need to replace?  I am getting conflicting info.  Dr. says only estrogen.  Everything else I'm finding and reading disagrees. I am only 36 and whatever I do will have to be long term.

A: Total hysterectomy is in this case hysterectomy with removal of both ovaries. Most times only estrogens are sufficient  after such a procedure. Sometimes libido problems arise because of low androgens after ovariectomy.  In such situation a combination of estrogens and androgens are advised.  Progesterone is not necessary.
Q:   I had a total hysterectomy about 6 months ago.  I had my uterus, cervix and ovaries taken out as well as a rectocele repair.  I feel great and really haven't had any problems.  I was put on premarin (estrogen) and everything seems to be fine except for the fact that my blood pressure has risen (mild hypertension).  Could the estrogen be the reason for this?  If so, what would the remedy be for this - should I stop taking it and just rely on my diet or should I consult my doctor for other medications?  Could you please give me your opinion on this.

A:  A rise in blood pressure due to taking premarin is extremely rare, but possible. It is even rarer with transdermal estrogens. So, switch to transdermal estrogens and treat the hypertension if necessary with antihypertensive treatment.
Q:  My mom had a stroke at age 40.  She is now 49.  She is currently going through menopause.  Her doctor prescribed Vagisem for her vaginal bleeding due to thining of the lining of her vagina.  She is very concerned because of her previous stroke and the risks associated with these hormone caplets.  What are your thoughts?

A:  Vagifem tablets contain only 25 micrograms of estradiol. A very low dose of a potent estrogen. In this dose you can expect hardly any systemic effect but an excellent local vaginal effect. No concerns for stroke.
Q:  I am 51-years-old and have had essential hypertension since my early 20s.  At 48 I had a complete hysterectomy due to a lipoma on my ovary. Not knowing if it was carcinoma, they took both ovaries.  However, it was benign, and by the time we found out they had gotten both ovaries. Now I have to take HRT.  I had all the classic side effects of post menopause.  I tried Premarin which rendered my blood pressure medication useless.  My blood pressure shot up to 160/120 with heart palpitations. It took years for me to get the right blood pressure medication to keep my blood pressure down and eliminate heart palpitations which I had had since early adulthood.  When I was on birth control pills I had the same problem.  The doctor took me off them when I was 25 and had my tubes tied because he said I just could not take birth control because of my blood pressure.  Premarin did the same thing. We tried other types of HRT and they made my blood pressure go up, also.  However, I found Cinestin, which is a natural, and it doesn't effect my blood pressure, nor do I have heart palpitations with it.  It is great, except for one thing.  I have vaginal dryness that won't quit. I hate dealing with creams, etc.  What causes the vaginal dryness and is there another natural HRT out there that can help this problem?

A: Local estrogens are excellent for treatment of vaginal dryness. But there are also non-hormonal lubricants. Replens is an excellent vaginal moisturizer. The dryness is because of vaginal atrophy with decrease of the number and size of blood vessels to the vaginal tissues.
Q:  I've been taking Estroven for about 2 or 3 months. Is that good enough? I'd really rather not take prescription drugs that use pregnant horse pee.

A:  This is a good product, like many other supplements. But the real question is: is there any need to use them. With a well balanced food no extra nutrients are necessary.
Q:  I am 51 years old and had a complete hysterectomy 2 yrs. ago.  I am currently using the Vivell dot patch.  I am very weight conscious and do exercise and have gained quite a lot of weight since the surgery and using hormones.  I tend to feel puffy majority of the time and am told by family I look puffy they think I need to change hormones to talk to my doctor.  I went off the hormones for a while and lost the weight but suffered with hot flashes etc. So went back on the patch again.   I am wondering if the shots would be better to help with the weight  problem and eliminate the puffiness?

A:  I would expect no better results with the shots. Weight gain is always a problem for women. Usually estrogens do not increase weight. But sometimes fluid retention occurs. The best way to handle this is the use of estradiol patches in a low dose, as low as is possible without flushes.
Q:  Why is the risk of stroke elevated for women taking HRT, such as birth control pills?  My mother died of a cerebral aneurysm at age 45...any increase in risk of aneurysm associated with HRT? What is the lowest recommended dose of estrogen/progesterone combination pills for regulation of hormone fluctuations in perimenopause?

A: No association of rupture of an aneurisma and HRT. HRT does not increase the risk of stroke. In the past a hypothesis of a decrease was postulated, but with HRT the risk of stroke remains unchanged. Also after a stroke no benefits or extra risks with HRt are seen on recurrence. No fixed dose for everyone exists. HRT must be titrated to a woman's need. Especially in perimenopause usually a lack of progesterone is present with abundant estrogens. Only progesterone in the second half of the cycle is sufficient then.
Q:  I am 50 years old and just starting to go through menopause with really no problems except for vaginal dryness.  I would  like to know if it is safe to pop open a regular vitamin e softgel 400 i.u. and use it each day as a vaginal moisturizer.  It seems to work well in controlling the itching and dryness but now I am not so sure that it is water soluble and will not give me any type of infection from prolonged use.  Thank you for your time.

A:  Such a moisturizer is safe. But I wonder if the softgel is just as good without the vitamin E.
Q:  I was diagnosed with primary ovarian failure at age 20. I have been on Premarin/Provera for 25 years. Recently, a doctor advised me to switch to Prempro so I wouldn't have to have periods. I would like your advice on whether to make this change.  Also, what can I expect as I reach the normal age of menopause?

A:  Continuous combined HRT is one of the several regimens of HRT. With your schedule most women experience regular withdrawal bleeds. With a continuous combined regimen about 50% of all women will have an amenorrhea. But the others will experience break through bleedings. Break through bleeds will come suddenly, unscheduled. You can try this regimen category of women you will be. Nothing can predict that. When you are really happy with your actual schedule, do not change.

Time will come to consider the end of treatment. My personal opinion is to continue until age 51 (the mean age of menopause). The main question at age 51 will be: is it necessary to continue HRT when the natural menopause age has been reached? Only with a high risk of osteoporosis, or very high risk of cardiovascular disease, will the answer be yes. Otherwise, stop HRT. If hot flushes start, restart the HRT for 2 years and try again to stop, etc.

 

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Note: Opinions expressed here are for educational purposes only and, as such, do not constitute and should not be interpreted as initiation of a physician-patient relationship. This information is not intended to supplant the need for you to consult with your physician prior to choosing therapeutic options and/or interventions.