CLIMACTERIC AND MENOPAUSE

The climacteric is the term used to describe the progressive decline in gonadal (ovarian or testicular) function that occurs with increasing age. In the female, the final event is menopause, the cessation of menstruation. Menopause occurs when ovaries are exhausted of eggs and is associated with a marked decline in estrogen levels. The decline in estrogen production results in not only significant symptoms (e.g. hot flashes, night sweats, depression, vaginal dryness, etc.) but also in metabolic changes leading to osteoporosis and lipid abnormalities that increase the risk of coronary artery disease. Menopause is an estrogen deficiency disease.

Menopause may occur at any age and may result from surgical removal of the ovaries, their destruction by disease, drugs or radiation, or the natural depletion of eggs. Whatever the cause, the treatment of menopause is hormone replacement therapy with estrogen. In women who have retained their uterus, it is necessary to periodically administer progesterone, the other female sex hormone. If the woman has previously undergone a hysterectomy, progesterone is not necessary. Therapy of menopause is directed not only toward diminution or relief of symptoms but also toward providing enough estrogen to prevent osteoporosis. Measuring blood hormone levels serves as a means to both diagnose menopause and to regulate its therapy.

In the male, a gradual decline in the male sex hormone (testosterone) occurs with increasing age, but it is uncommon for a true deficiency to occur. When it does, either from testicular disease, other hormonal interference with testosterone production or surgical intervention, the affected male experiences not only impotence and declining libido but also hot flashes, night sweats and difficulty concentrating. A testosterone deficiency, similar to estrogen deficiency, also results in osteoporosis.

Impotence is often considered the major symptom of a male climacteric, but may result from numerous other causes. Conditions such as diabetes, pituitary tumors, vascular disease and neurological deficits may also produce impotence. In some instances, the condition is psychologic in origin. Consequently, evaluation and therapy of impotence and male climacteric require a team effort of appropriate specialists.

Management of Menopause

The most important step is the precise diagnosis of menopause by determination of blood hormone levels. The treatment is relatively simple, requiring only replacement therapy with an appropriate estrogen and, when necessary, progesterone. The type and dose of the replacement therapy will vary with individual patients. Treatment must be individualized and monitored by appropriate periodic evaluation of blood hormone levels and other tests.

Recently, a considerable amount of publicity has been devoted to the problem of osteoporosis in postmenopausal women. In order to prevent osteoporosis it is important to diagnose menopause at the earliest possible moment and institute an appropriate management program even if the woman still has occasional menstrual periods. Sensitive tests are available to determine the time when treatment should commence. A woman less than 45 years of age who has had her ovaries removed is particularly sensitive to estrogen deficiency and at risk for osteoporosis. Treatment should begin immediately after surgery. New medications are now available that are of significant aid in the restoration of bone strength in the osteoporotic patient. It is well-established that appropriate hormone therapy (estrogen in women and testosterone in men) and management of the factors contributing to the maintenance of bone strength leads to a significant increase in longevity as well as to better quality of life.

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