the progesterone that is commonly used in oral HRT is synthetic, it takes longer to be broken down by the liver, and may accumulate in the body, causing more side-effects. I have never thought that it was physiological (natural) to give hormones by mouth for this reason, unless we require oral contraception. It is much more physiological to give hormones in a way that bypasses the liver. To achieve this, we must administer hormones through the skin (which is called transdermal administration), via implants, sprays, vaginal creams or rings, or injections. Transdermal administration can be achieved by using hormone creams, gels or patches. Some doctors use lozenges (troches) that are designed to be placed between the upper gum and the cheek, so that the hormones they contain are absorbed directly into the blood vessels under the lining of the cheek. This way we are meant to avoid swallowing the hormones and thus absorbing them from the gut and then through the liver. Some women tell me that it is difficult to avoid swallowing some of the lozenge, especially since they come in several hundred delicious flavours!I personally feel more comfortable prescribing transdermally-absorbed hormones via the creams and/or patches, especially for long-term use or for women with risk factors for HRT. The beauty of the creams is that they can be tailor-made for the individual woman, to contain the combination of natural hormones that she needs as determined by her blood tests, medical examination and history.
Although there are some very favourable clinical trials evaluating the use of hormone creams for various hormonal problems, there are no very long-term studies available on their safety for use as HRT for the post-menopause.
The use of any form of HRT is the choice of the patient, and it must be based upon informed consent. Women need to know that we cannot give them 100 per cent guarantees of safety, and that, generally speaking, it is wise to find the lowest dose of HRT that will relieve unpleasant symptoms and improve well-being. This can be compared to taking the oral contraceptive pill – women know about the risks, as they are printed on the packet. However, millions of women choose to take the Pill, because its advantages often outweigh the disadvantages in the individual woman.
Communication is the key – doctors need to treat women as intelligent human beings. Women need to take some responsibility in helping their doctor to decide if they will use HRT. They can only do this if they know and understand all their options. Luckily you do not have to be a rocket scientist to work out the advantages of different types of HRT. Common sense and realistic expectations should be explored. It is always possible to prescribe HRT for a short period (less than a one year), choosing a transdermal application just to see if it really makes a difference. Then you can weigh up the absolute risks, if any, of long-term use before deciding whether to continue.
Just because yet another hormone controversy has raised its head does not mean that all women will stop wanting to take HRT. Today’s menopausal woman has a much longer life span, and totally different expectations of life, than women who lived 100 years ago. She does not want to –
age rapidly
stop being sexually alive
embrace old age mentally and physically at the tender age of 50.
There is no doubt that hormones can help us feel and look younger and keep us sexually young. Just imagine if men ran out of their sex hormones at the tender age of 50 – well, there would be a hormone shop in every suburb!
Yes, ‘hormones make the world go round’ and, controversial or not, they are not going to become strictly taboo!
The average age of the start of the menopause is 51; however, some women will go through the menopause many years earlier than this. Fertility starts to decline after the age of 35, due to the gradual reduction in the number of healthy follicles (eggs) in the ovaries. The incidence of hormonal imbalances is more common after the age of 35, simply because the ovarian follicles are ageing.
You are more likely to experience Premenstrual Syndrome (PMS) during the years from age 35 up to the menopause. This is because, after ovulation, the ovaries may not always produce adequate amounts of the female hormones called oestrogen and progesterone.
During the peri-menopause it is more common for progesterone production to be inadequate, which can result in symptoms of relative oestrogen excess such as:
heavy and/or painful menstrual bleeding
growth of fibroids and uterine polyps
growth of endometriosis
irregular menstrual cycles
premenstrual depression and mood disorders
premenstrual headaches
fluid retention
abdominal bloating
breast tenderness and lumpiness
hair loss
The Peri-menopause
This phase of a woman’s life is defined as the several years before and after the menopause. Hormonal imbalances are common during the peri-menopausal years.
The menopause is said to have occurred when menstrual bleeding has been absent for 12 consecutive months. Because the age of the menopause varies considerably, the time of onset of the peri-menopause also varies. The majority of women will go through the menopause between the ages of 45 and 55.
The years following the menopause are called the post-menopause. During the post-menopause, the production of sex hormones from the ovaries continues to decline, and may eventually become non-existent.
What Causes the Menopause?
The human female is the only creature known to live much longer than her sex glands and reproductive capacity. We could ask ‘Why us and not men?’ or ‘Did Mother Nature have a design fault?’
These questions are valid, however the fact remains that our ovaries simply run out of follicles (eggs). It is the follicles that produce the vast majority of the female sex hormones, and thus we are no longer able to produce these hormones in adequate quantities. The age at which the supply of ovarian follicles becomes exhausted varies between women; this is why we see such a large variation in the age at which the menopause occurs.
IS THERE A TEST FOR THE MENOPAUSE?
The menopausal ovary being devoid of follicles is unable to manufacture significant amounts of the female sex hormones. If a blood test is done to measure the levels of oestrogen and progesterone, they will be found to be at very low levels. In menopausal and post-menopausal women, blood oestrogen levels (which are measured in the form of oestradiol) are generally less than 160pmol/L. The term pmol/L means picomoles per litre, and is a standard laboratory measurement.
Typical Results of the Hormone Levels in Menopausal and Post-menopausal Women
| HORMONE | BLOOD LEVEL | |
| FSH | greater than 30U/L | |
| Oestradiol | less than 160pmol/L | |
| Progesterone | less than 3nmol/L |
Oestradiol is the most potent form of oestrogen produced by the ovary. Other types of oestrogen produced by the ovary and the fat tissue are weaker, and consist of oestrone and oestriol.
The function of the ovaries is under the control of the pituitary gland, which is situated at the base of the brain and acts as a