We are witnessing a growing process of medicalization of situations that were not previously considered medical entities. Some experts, in a recently published editorial, analyze this progressive medicalization of life and describe that one of the forms it can take is “reclaiming the uncontested efficacy of scientific medicine, and the goodness of all its contributions, ignoring considerations about the necessary balance between their benefits and the risks or losses they entail. This process has occurred in different aspects of the reproductive cycle of women, such as pregnancy, childbirth, and menopause.
Pregnancy or menopause are biological situations of change. The first represents the beginning of the reproductive cycle and the last, the closure.
Menopause is defined as the date of the last menstruation, which occurs as a consequence of the cessation of ovarian follicular activity. At least 12 months must pass since the last menstruation to be considered as the date of menopause. Around this date, 2 phases are distinguished, in which some women may present symptoms: premenopause or menopausal transition, which refers to the interval of 2 to 8 years that precedes it, and postmenopause, which includes 2 to 6 years after menopause.
Perimenopause is the period from 2 to 6 years before menopause and the year after the last menstrual period. All these phases are grouped under the name of climacteric.
Menopause occurs around 50 ± 2 years. If it occurs before the age of 40, it is referred to as early menopause, and if it occurs after the age of 55, it is referred to as late menopause.
According to the evidence available at this time, the decrease in estrogen is associated with changes in the cycle during the perimenopausal transition stage, and in postmenopause with 3 health conditions: vasomotor disorders, urogenital atrophy, and decreased bone mass. Each one of them can affect women in climacterics with varying frequency and intensity.
However, there is a tendency to relate most of the symptoms that occur between the ages of 50 and 65 with menopause. It can be stated, with an adequate degree of evidence, that in postmenopausal women there is no causal association with estrogen concentration: mood disorders, cognitive disorders, increased cardiovascular risk, musculoskeletal pain, decreased libido, and stress urinary incontinence.
Combined hormone replacement therapy (estrogens plus gestagens) is one of the treatments of choice for menopausal symptoms and the prevention of osteoporosis, but it is not without risks; An adequate risk-benefit balance has not always been made when it has been recommended. This treatment has been indicated in recent decades for the primary and secondary prevention of cardiovascular diseases and for the treatment of symptoms that are not causally related to menopause. In general, the therapy is explained well in bywinona.com.
It is convenient to clarify at this point that it is only correct to use the term “hormone replacement therapy” (HRT) when it is administered to women with early, surgical or pharmacological menopause to treat symptoms. In women with physiological menopause, when treatment is necessary, it should be called “estrogen treatment” (hysterectomized women) or “combined hormonal treatment of estrogens and gestagens” (women with a uterus). The term “medium-term” generally refers to the duration of hormonal treatment between 2 and 5 years; from the age of 5 is called “long term”.
The objective of this work is to answer the following question: is estrogen treatment safe in the medium-long term in postmenopausal women?
A bibliographic search was carried out in September 2003, in the MEDLINE databases through PubMed, Ovid, electronic publications, and the Cochrane Library, on systematic reviews, meta-analyses, clinical trials, and clinical practice guidelines, since during the first semester of this year Interesting data have been published from the Women’s Health Initiative (WHI) clinical trial. The literature review carried out in the last year has also been used to prepare a recently published menopause protocol.
Synthesis of evidence
Vasomotor disorders, urogenital atrophy, and decreased bone mass, which increases the risk of fracture, are the 3 clinical entities associated with decreased estrogen levels after menopause and which, therefore, may benefit from estrogen treatment.
In population-based follow-up studies in perimenopausal women, such as the Manitoba Project and the Massachusetts Women’s Health’s Study, no association was found between estrogen concentrations and depression. In a meta-analysis published in 1996, it was found that the incidence of depression does not increase after menopause, since its frequency is similar to that of other ages. With data from clinical trials, it can be stated that there is no causal association between estrogen concentrations and psycho-affective (depression, anxiety, irritability) or cognitive disorders.
Other symptoms associated with climacteric, without a causal relationship, are musculoskeletal pain, decreased libido, and stress urinary incontinence. Most of the musculoskeletal symptoms that women present at this stage of life are related to the low potentiation of the musculotendinous system and degenerative processes in the joint area.
Low libido is another symptom associated with menopause. However, the results of clinical trials concluded that there is no such relationship. The decrease in the frequency of sexual relations is more related to dyspareunia due to vaginal dryness, the loss of the partner (separation, divorce, widowhood), and the decrease in desire in the couple than with the decrease in libido in women.
Stress urinary incontinence, with features distinct from urge urination and polyuria, is related to increased parity and pelvic floor trauma at childbirth. There is no evidence that postmenopausal women have a higher incidence than premenopausal women.
Regarding the action of estrogens, in 2 clinical trials, no differences were found in the number of episodes of incontinence or quality of life. In the Heart and Estrogen/progestin Replacement Study (HERS) a worsening of incontinence was found in the group of women treated with estrogen.
The results of most of the observational studies published over decades concluded that estrogens had a cardioprotective effect and that after menopause there was an increase in cardiovascular risk, which is why various organizations and scientific societies recommended primary and secondary prevention of cardiovascular diseases with estrogen therapy in postmenopausal women. The review of these data, once the possible confounding variables were corrected, confirmed that there is no cardiovascular benefit.