The typical “mature woman” is aged 40 years or older and has completed childbearing. During their late 40s, most women enter the menopausal transition. This period of physiologic change is due to ovarian senescence and estrogen decline and is usually completed between ages 51 and 56 (Chap. 21). Menopause marks a defining point in this transition. Specifically, menopause is defined by the World Health Organization as the point in time of permanent menstruation cessation due to loss of ovarian function. Clinically, the menopause refers to a point in time that follows 1 year after menstruation cessation.
With ovarian senescence, declining hormone levels have specific effects on many tissues. Some effects lead to physical complaints, such as vasomotor symptoms and vaginal dryness, whereas others are metabolic and structural changes. These include osteopenia, osteoporosis, skin thinning, fatty replacement of the breast, cardiovascular changes, and genitourinary atrophy. As a result, postmenopausal women have specific issues associated with aging and estrogen loss that may negatively affect their individual health.
For many years menopause was seen as a “deficiency disease” much like hypothyroidism. For this reason, hormone replacement therapy has been used in one form or another for more than 100 years. The history and controversies surrounding this treatment are discussed in detail, as are current recommendations for the treatment of menopausal symptoms.
In the recent past, hormone treatment (HT) was widely prescribed, in good faith, to menopausal women for many potential health benefits, based on available observational and epidemiologic studies of the time. The general medical consensus was that HT, in addition to its beneficial role in prevention and treatment of osteoporosis, could protect against cardiovascular disease, stroke, and dementia. However, recent prospective, randomized clinical trials (RCTs) have challenged the validity of earlier observational studies as they were initially reported. Specifically, the type of population studied, the ages and risk-factor status of the women participating, and the hormonal regimens tested are important to this critique. Clinicians should practice evidence-based medicine to ensure the highest quality health care for their patients, and no single study should be relied on solely to guide clinical practice. Understanding that there is a hierarchy of clinical data, the entire literature should be sought to provide the basis on which medicine is practiced (Lobo, 2008). Thus, clinicians should understand the history and controversies surrounding HT as well as the weaknesses and strengths of clinical trials to accurately counsel their patients on the complexities and appropriate use of HT.
Early Estrogen Administration Trends
Estrogen treatment (ET) for menopausal symptom relief gained popularity in the 1960s and 1970s. Feminine Forever, the book by author and gynecologist Robert Wilson, was published in 1968. In it, he wrote that “Women who use the drug (estrogen) will be much more pleasant to live with and will not become dull and unattractive” (Bell, 1990). Wilson was a prolific lecturer. His ...