For instance, the incidence of osteoarthritis increases at the time of menopause; women who have never experienced joint pain suddenly become symptomatic. In addition, women with pre-existing arthritis find that their symptoms get worse. Many women reaching menopause complain of increased stiffness in their hands and shoulders as well as low back pain.
The lack of sex hormones also affects muscle tone. Muscles throughout the body tend to sag and lose tone after menopause. Women tend to be very conscious of pelvic muscle tone loss, as well as sagging of the facial and arm muscles. The loss of pelvic muscle tone can affect sexual pleasure and the ability to hold urine. Facial drooping can appear fairly rapidly within a year or two of menopause. This change can be a cause of distress in many women who don't like this visible sign of aging. Other tissues, such as the breasts, lose their tone and droop more. The lack of estrogen is probably also responsible for the increase in low back and pelvic pain that women experience around this time.
Another visible sign of aging for many women after menopause is a change in body shape as the distribution of weight on the body changes. The waist and upper back get thicker, while the hips and breasts tend to lose some of their fat. The result is that the female shape changes from an hourglass figure to a pear shape. Many women find that not only does their figure shape change, but they gain weight more easily (10 to 15 pounds in the year or two following menopause isn't unusual). This can occur no matter how diligently they diet or how much they exercise. The lack of female hormonal support plus the slowing of the metabolism are probably responsible for these changes. Women after menopause don't burn calories as efficiently as during their younger years. Careful attention to diet and regular exercise can certainly help, but may not entirely correct, these physical changes. Examine the self help chapters in this book for more in-depth information.
The skin and hair undergo many changes after menopause due to loss of estrogen. There is a gradual tendency toward thinning and dryness of the skin. Skin pigmentation becomes uneven which affects coloration. Some women may lose their even skin tone and notice patches of lighter and darker skin. As collagen production in the skin slows down, the skin loses its elasticity. The underlying muscle and fat tissues that help give skin its underlying support begin to shrink. There is also a reduction in sweat gland activity and decreased tolerance to temperature changes. As a result, many visible signs of skin aging become apparent such as pronounced wrinkling and creasing. Many women find these changes cosmetically unappealing and employ a variety of dermatologic aids in an attempt to make their skin look younger and healthier.
Women who smoke, have poor nutritional habits or have had excessive exposure to sunlight are more likely to show signs of skin aging at a younger age. Conversely, women who tend to carry a little extra weight or have reached menopause at a later age will have better looking skin. This is because they have had higher circulating levels of estrogen in their bodies for more years than a thin woman who enters menopause at an early age.
Lack of estrogen also affects the hair. With menopause, hair on the head and in the pubic area becomes drier, coarser and sparser. Women may also notice the growth of darker or coarser hair in areas where they've never had hair before, such as the chin, upper lip, chest or abdomen. This unusual growth of hair is due to the stimulation of the hair follicle by low amounts of androgens, a type of male hormone. High estrogen levels block the action of these male hormones on hair follicle receptors. However, after menopause, these low amounts of androgen may not decrease to the same extent that estrogen does in certain women. These unopposed androgens can then affect the pattern of hair growth and hair loss, taking on a more malelike pattern.
Therapies for Osteoporosis and Other Structural Changes
Osteoporosis and other age related changes in the joints, muscles, skin and hair can be treated through the use of HRT. Other medications and supportive measures may also play a useful supporting role for certain conditions.
Hormone Replacement Therapy
Medical studies show that hormonal therapy not only helps prevent osteoporosis but also protects women against further bone loss. Both estrogen and progestins by themselves are protective, but used together they may provide benefits exceeding the use of either hormone alone. A Danish study done in 1991 showed that a combination of estrogen and a progestogen, given no later than three years after the onset of menopause, completely prevented bone loss in 18 women. In contrast, untreated women suffered significant bone loss.
Hormonal replacement therapy with conjugated estrogens (Premarin) at a dose of 0.625 mg per day has been shown to prevent osteoporosis in 90 percent of postmenopausal women who had no pre-existing osteoporosis. However, in one study done by Dr. Bruce Ettenger, even minimal estrogen supplementation (0.3 mg) prevented bone loss. If osteoporosis is already present, then a high dosage of estrogen is utilized, normally 1.25 to 2.5 mg per day. The estrogen oral tablet and transdermal patch appear to be equally effective in preventing bone loss. The vaginal cream should not be used for this purpose because absorption into the bloodstream may be erratic.
Various studies comparing women using estrogen with control women not on ERT showed significant differences in bone health. In one study done in Scotland by Dr. Robert Lindsay, women on ERT maintained their normal stature, while control women had a significant loss of height. Another study of 1,000 women treated with ERT for 15 years found a 70 percent reduction in wrist fractures from the expected rate. Even more striking was the observation that no hip fractures were seen in these women over the same 15 year period. A study was done at the Mayo Clinic comparing vertebral fracture rate in postmenopausal women treated with various combinations of estrogen, calcium and sodium fluoride. The group utilizing ERT had, by far, the lowest rate of vertebral fractures.
Estrogen appears to protect the bones through several mechanisms. Estrogen reduces urinary calcium and hydroxy-proline excretion which suggests it inhibits osteoclast function, the cells that break down bone tissue. Current research suggests that estrogen may even have a stimulatory effect on osteoblast cells, the cells that build up new bone. Estrogen also facilitates calcium absorption from the intestinal tract and increases parathyroid hormone and calcitonin production. The parathyroid hormone facilitates calcium absorption, while calcitonin stimulates bone formation. Estrogen appears to be critical to bone remodeling; therefore, it may well be the most essential component of prevention for osteoporosis.
The question of how long to stay on ERT is an important one for many women. Although the research data on this issue is not yet definitive, women who want to protect their bones from developing osteoporosis should consider using ERT at least ten years, possibly for life. Ideally, estrogen should be started within three years of the last menstrual period. Women already showing accelerated bone loss and considered at high risk for osteoporosis should probably make a lifetime commitment to ERT.
The longer you use ERT, the more protection your bones will have. As soon as you stop using it, your bones will begin to show signs of calcium loss and bone aging. It is never too late to begin estrogen therapy. Women in their 80s and 90s who had preexisting osteoporosis showed some benefit after starting estrogen therapy. According to one recent study, supplemental hormones benefited women 15 years after initial diagnosis of osteoporosis. In another study, estrogen therapy increased vertebral bone mass and bone density at the femoral head. Interestingly, the best response was in women farthest away from menopause who had the lowest bone mass.
The addition of a progestin to the estrogen therapy may provide even better benefits. Though estrogen alone helps protect against calcium loss, at least eight medical studies suggest that the use of estrogen and a progestin in combination has the additional benefit of increasing bone mass by promoting new bone formulation. Recent research has led to the conclusion that progesterone acts directly to stimulate new bone by attaching to the osteoblast cell receptors. Progesterone also appears to increase bone turnover. Animal studies found that bone volume was greater in animals receiving both hormones than those who received only estrogen.
One study followed women using cyclic estrogen progestin and women receiving a placebo for a ten-year period. Women who began the combined therapy within three years of entering menopause showed an increase in bone density throughout the entire study period. Women who began HRT later than three years following the onset of menopause showed some demineralization but much less than the placebo group. This study underlines the importance of beginning HRT in the early stages of menopause.
Another study compared the effects of estrogen therapy alone with combined estrogen progestin therapy on the metabolic parameters of bone. This included measurements of the blood level and the urinary calcium/creatinine ratio. All values decreased (indicating decreased calcium excretion) with the use of estrogen. The addition of a progestin, however, decreased these values even more, showing substantial bone protection.
In addition to protecting bone, HRT has been shown to help reduce symptoms of osteoarthritis. As mentioned earlier, joint pain tends to become worse in early menopause. Many women with muscle and joint pain, including low back and pelvic pain, note relief of these symptoms within two weeks of beginning HRT. As an additional side benefit, HRT may provide protection against developing rheumatoid arthritis. Reported in the Journal of the American Medical Association, one study found that there was a greater than three-fold reduced incidence of rheumatoid arthritis in 1,000 women who had taken HRT compared with those who had not taken HRT.
HRT may also benefit postmenopausal women suffering from loss of muscle tone and firmness. If these effects are particularly pronounced in the pelvic area, urinary incontinence or uterine, bladder or urethral prolapse may result. HRT helps restore muscle tone and may relieve mild symptoms of incontinence and prolapse. However, women with severe cases may still require more drastic therapy, such as surgery. As mentioned earlier, muscle pain may accompany joint pain, particularly in the low back. HRT may help relieve more generalized muscle aches and pains, too.
Although estrogen will not restore skin to its youthful appearance, it can have a significant impact on skin quality. Women on estrogen therapy usually have thicker, oilier, moister and firmer skin. ERT improves subcutaneous fat deposition, which makes the skin tighter, and collagen turnover, which thickens and firms up the skin. Estrogen also increases fluid retention in the skin, making it look moister and plumper. However, to improve skin condition estrogen should be started soon after entering menopause because it cannot completely reverse any significant skin damage that has already occurred.
ERT does not have quite as dramatic an effect on the hair, but it will balance the androgen levels in the body again. As a result, unwanted hair on chin, chest and abdomen will stop growing. Once a woman has started ERT, these hairs can be pulled out and will not regrow as long as estrogen therapy continues.
Other Therapies for Healthy Bones
Other drugs have been used besides HRT to prevent bone loss and protect against the development of osteoporosis. Some therapies have been found more effective than others.
Fluoride has been studied as a preventive therapy for osteoporosis with mixed results. On the positive side, people living in areas in which the water has a high-fluoride content have higher average bone density than people living in a low fluoride area. However, according to studies done using supplemental fluoride therapy in postmenopausal women, different types of bone show unequal changes in response to fluoride. A study done by the Mayo Clinic found that fluoride therapy increases bone density in one type of bone, called trabecular bone, but decreases cortical bone density. This may increase skeletal fragility and increase the risk of hip fractures. As a result of this study, the Mayo Clinic abandoned the use of fluoride therapy. Fluoride therapy may also cause other side effects such as anemia and intestinal disturbances.