The Estrogen Element
Once her estrogen production drops with menopause, a woman’s chance of developing CVD rises rapidly. A 60-year-old woman has the same heart attack risk as a 50-year-old man. By her late 70s, a woman has the same heart attack risk as a man her age. To date, much of this changing risk has been attributed to the aging process, but some preliminary evidence indicates that hormones may play a bigger role than once thought. Recent results from the Postmenopausal Estrogen/Progestin Interventions (PEPI) study, a longitudinal study of how various hormone replacement therapies (HRTs) affect cardiovascular risks, indicate that HRT may reduce CVD by as much as 12 to 25 percent. In this study, HRT seemed to reduce a woman’s risk for CVD by raising HDL cholesterol levels and lowering LDL cholesterol levels. Even when their total blood cholesterol levels are higher than men’s, women may be at less risk because they typically have a higher percentage of HDL.
But that’s only part of the story. It’s true that women age 25 and over tend to have lower cholesterol levels than do men of the same age. But when they reach 45, things change. Most men’s cholesterol levels become more stable, while both LDL and total cholesterol levels in women start to rise. And the gap widens further beyond age 55.
Before age 45, women’s total blood cholesterol levels average below 220 mg/dl. By the time she is 45 to 55, the average woman’s blood cholesterol rises to between 223 and 246 mg/dl. Studies of men have shown that for every 1 percent drop in cholesterol, there is a 2 percent decrease in CVD risk. If this holds true for women, prevention efforts focusing on dietary interventions and exercise may significantly help postmenopausal women.
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The process of recovery from hysterectomy is extremely variable as illustrated by the experiences of Rosa and Denise, neither of whom had any postoperative complications. The day after her hysterectomy Rosa helped make beds in the hospital ward and, five days later, she was ready to leave. Within a few days she was doing all the housework and three weeks after surgery she was swimming and cycling. In contrast Denise was unable to leave her bed for fourteen days after her hysterectomy. She convalesced slowly at home and finally returned to work thirteen weeks after surgery. The variation in the physical recovery of Rosa and Denise demonstrates why it is difficult for a surgeon to provide a fixed schedule for post-operative recovery.

To do so might put the brakes on the recovery of some women and unduly tax the capabilities of others.

Women recover from hysterectomy at different rates for many reasons. These include the nature and severity of the problem for which the operation was carried out, the type of operation performed and the extent to which it interfered with various organs of the body, the skill of the surgeon, the general physical and psychological health of the woman pre-operatively and the effect of anaesthetic agents on her.

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This digestive disorder, which is not just a female disorder, is an intolerance to gluten which is found in grains such as wheat, rye, barley and oats. Before diagnosis the intolerance causes malabsorption and can therefore leave you deficient in vital nutrients. Many deficiencies have been noted in sufferers of coeliac disease, including folic acid, vitamins A, D, E, Ê and the  vitamins, zinc (essential for fertility) and selenium. It is known that women with coeliac disease can be sub-fertile and this is yet another indication that having the correct levels of vitamins and minerals can play an important role in increasing fertility.

Natural Treatment

If you have been diagnosed with coeliac disease you first need to remove gluten from your diet. You will probably have been given dietary advice with the diagnosis which means that you will have to eliminate wheat, rye, barley and oats and substitute other foods like rice cakes, gluten-free bread and also pasta made without gluten such as corn and millet pastas. Then you need a nutritional assessment (see Useful Addresses) to ascertain which supplements are required to correct any deficiencies. Remember that any food supplements (e.g. multivitamin and mineral for pregnancy) must be gluten-free.

Polycystic Ovary Syndrome

There is a difference between having polycystic ovaries and having polycystic ovary syndrome. When ovaries are seen on an ultrasound scan, they can look polycystic, which means that a number of partially developed follicles can be seen. Of course, follicles have to be present for eggs to develop adequately, and so that ovulation can occur. However, with polycystic ovaries, the ovaries are larger than normal and the undeveloped follicles resemble a bunch of grapes. This is very common and does not necessarily present a problem. It is only when the polycystic ovaries lead to a hormonal imbalance that a woman is said to have polycystic ovary syndrome (PCOS) where she will probably not be ovulating and can be overweight and have excess body hair, skin problems and mood swings. The hormone imbalance is produced by having high levels of LH (luteinising hormone) and a higher than normal level of free testosterone, particularly in overweight sufferers.

Just before ovulation in a normal menstrual cycle, LH levels rise dramatically. This is called the LH surge and causes an egg to be released from a follicle. If LH is high during the whole of the follicular phase (the phase before ovulation), then the LH surge does not take place and an egg is not released. High levels of LH have been implicated in both infertility and miscarriage.161 Doctors have not yet found out why high levels of LH may cause infertility or miscarriage, but research is continuing.

In summary, a woman with PCOS can have:

• high levels of LH

• high estrogen

• higher than normal male hormones (androgens)

• Low progesterone

Diagnosis

This is usually made by ultrasound or a laparoscopy, where a narrow tube with a telescopic lens is inserted into the abdomen via a small incision below the navel. These investigations are conducted together with hormone blood tests.

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The narcotic analgesics are a group of strong analgesics that were originally derived from the opium poppy. They should only be used under strict medical supervision in limited quantities for severe short-term pain as they are potentially addictive.

Some of the better known narcotics include Percodan, Proladone, Endone, Fortral, Pethidine, Omnopon and Morphine.

The side effects of the narcotic analgesics include nausea, vomiting, constipation, drowsiness, dizziness and mood changes.

Non-steriodal anti-inflammatory drugs

The non-steroidal anti-inflammatory drugs, sometimes also known as anti-prostaglandins, are a group of drugs that are commonly used in the treatment of arthritis, as they relieve inflammation and pain by blocking the production of prostaglandins.

The non-steroidal anti-inflammatory drugs are highly effective in the treatment of primary dysmenorrhoea and they may be effective in the treatment of dysmenorrhoea and other pain due to endometriosis.

The more common non-steroidal anti-inflammatory drugs include Ponstan, Brufen, Nurofen, Naprosyn, Naprogesic, Clinoril, Voltaren, Dolobid, Orudis, Feldene and Indocid. Aspirin and paracetamol are also non-steroidal anti-inflammatory drugs.

Some people respond to different brands but not others. You may need to try two or three brands before you find one that is effective in relieving your pain.

Most of the non-steroidal anti-inflammatory drugs require a doctor’s prescription but some, including Ponstan, Naprogesic and Nurofen, can be purchased from the chemist without a prescription, though often at a higher price.

The most common side effects of the non-steroidal anti-inflammatory drugs are nausea, vomiting, diarrhoea, irritation of the stomach and stomach ulcers. These can usually be minimized if you take the tablets with food or a drink of milk.

Tricyclic anti-depressants

A group of drugs known as the tricyclic anti-depressants are sometimes used in the treatment of chronic pain. They are used to enhance the pain-relieving effects of analgesics, by overcoming the depression which often develops as a result of chronic pain. The more common tricyclic anti-depressants used include Tryptanol, Tofranil, Sinequan, Anofranil, Prothiaden and Pertofran.

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Symptoms following the downturn of oestrogen production are variable. A Medical Women’s Federation report as far back as 1933 stated that results from a survey showed that only 15 per cent of women had a menopause free of symptoms1 However the intensity of symptoms varies from woman to woman. Symptoms seem to accompany strong variations in hormones, and disappear as the hormones are stabilised. The ovaries, adrenal glands and fat in the female body continue to make variable amounts of oestrogen for years afterwards, and the variation of this production from person to person perhaps explains the variation in symptoms.

When insufficient hormones are produced, artificial hormones are available for replacement therapy.

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Discomfort with intercourse at this time was once thought to be a psychological symptom, and women were blamed for not being interested in intercourse. But there is an actual change in the cells of the vagina that can be observed under a microscope. With the application of oestrogens, these cells revert to their oestrogenised state.

At menopause the tissues atrophy and become dry, and the vagina becomes, in some instances, shorter and more rigid. This condition is aggravated if there is no sexual activity.

Lack of lubrication can certainly affect libido because of sheer discomfort. In addition the oestrogen-deficient, less-acid vagina is more prone to infection, and, with vaginal thinning, it may bleed due to friction during intercourse. This dryness of vaginal tissues in some women comes on gradually, and in others it appears more suddenly. It may occur within weeks if the ovaries are removed surgically.

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What are the alternatives if contraception is still necessary under the age of fifty? Just as in the selection of contraceptives at any age, you and your partner must work out with your doctor what best suits you, taking into consideration the general health factors of your age group. The physical condition of a woman with, for example, raised blood pressure and cardiac disease becomes more important, and if the woman also smokes, problems with these conditions also increase.

The combined pill using the lowest dose possible is a reasonable choice with regard to recent reports of the hazards of the pill to those over thirty-five. With these facts in mind, permanent methods of contraception, such as tubal ligation for women or vasectomy for men, are being suggested to more and more couples. Barrier methods using condoms or diaphragms combined with creams are coming back into fashion.

The intra-uterine device (IUD) has a place if the woman does not experience irregular bleeding. Although it has a 4 per cent failure rate, failure would declare itself by a missed period.

Termination could be sought, if desired, at an early stage.

The mucus method of contraception has a place for the well-trained couple, but again, irregular periods are a problem. In this case a woman who misses a period may suffer undue anxiety that she may be pregnant.

The progestogen-only pill does not usually produce regular periods, therefore pregnancy would not be so obvious so soon. It has a four per cent failure rate. Spotting, which is often associated with this pill, is also a problem with this age group of women as spotting may indicate other problems that should be investigated.

These are only a few basic points. Other considerations must obviously be taken into account, and these can only be assessed by you and your own doctor. One worry that women raise when hormones are used after menopause, and particularly when periods are reintroduced, is ‘Can this mean that I can get pregnant?’ The answer to this is no, provided periods have been absent for twelve months.

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Bleeding is the most common side-effect of hormone therapy and it is vital that it be clearly distinguished from any other cause of bleeding such as cancer of the genital tract. On continuous oestrogen, with progestogen at regular intervals, you will almost certainly bleed after the progestogen. However, if you bleed at any time other than after the progestogen, you must tell your doctor who will almost certainly suggest dilatation and curettage, or suction curettage-an outpatient procedure. (Your doctor will also almost certainly suggest this if the bleeding is heavy or prolonged, even if it is at the expected time.)

Do not panic if abnormal bleeding occurs. This is almost always due to the oestrogens that you are taking. These bleeds while on oestrogen do not necessarily mean there is any serious cause, and in fact they may be beneficial, as investigation may show up something small, like a polyp, which is easily corrected, or they may alert your doctor to some trouble that might, if no oestrogen had been taken, have remained undetected until much later.

Could oestrogen stimulate a cancer already present? Cancer of the endometrium is stimulated by oestrogens. A full history and medical examination will always be done by your doctor before oestrogens are given. If a history of irregular or excessive bleeding is present the doctor would investigate it by dilatation and curettage or suction curettage.

Does a Pap smear diagnose cancer of the endometrium? A Pap smear is a test only for the cells of the cervix, not for the lining of the uterus. However, cells shed from the lining of the uterus may be present in the smear and may give useful information that an abnormality is present in the endometrium. This would be reported with your smear test and investigated by your doctor.

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Definitely not, but some tablets given at the menopause are a cocktail of oestrogen (female hormones), and testosterone (male hormones). These certainly may cause hair growth because of the presence of the male hormone. If this has occurred don’t panic. Once the male hormones are stopped and the hair removed, this hair growth will not recur unless the same tablets are recommenced.

Do oestrogens improve the hair on your head?

Hair is said to be improved in texture by oestrogen therapy but this is hard to measure. You can only assess this for yourself. Some patients come to the clinic complaining that their hair is falling out or losing its body and in some instances this condition improves markedly with oestrogen therapy.

Effects of oestrogen on the skin

You have only to look at English skins from moister climates and compare them with our own to see the problem behind our dry and wrinkled skins. With any luck, ours will be the last generation which will be so badly affected by the sun. The next generation have available some wonderful sunscreening creams which have been developed recently, and these are available in pharmaceutical as well as luxury lines. People are more conscious now of the harmful effect of the sun, not only in producing cancer of the skin, which is increasing markedly in this country, but also of the harm it does to the elastic fibres in the deeper layers of the skin, which helps to increase the wrinkles.

There is also, of course, a natural ageing process, and with the decrease in ovarian function this seems to increase.

Can oestrogen replacement improve your skin or prevent it from wrinkling?

Oestrogen increases the layer of subcutaneous fat, giving your skin a softer, smoother texture. The reverse effect occurs when oestrogen levels are falling. Such an effect will occur gradually unless there is a sudden cut off in the supply of oestrogens, as when both the ovaries are removed at operation. Some women in our clinics refuse to give up oestrogen because of the beneficial effects on their hair and skin. These effects difficult to monitor but it is; worth reporting as a clinical fact. Two papers have reported these effects.

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