Menopause, bone density, and heart disease

Important consequences of menopause are osteopenia, a minor reduction in bone mass, and osteoporosis, a severe reduction in bone mass that is associated with a tendency to sustain fractures from minor stresses. In women (and men) bone density is maximal at about 30 years of age, after which it gradually decreases, except for a period of accelerated bone loss that occurs at the time of and for several years after menopause. This acceleration is associated with decreased production of estrogen and other sex hormones at the onset of menopause.

Another important consequence of menopause is an increased risk of heart disease. Increased risk of cardiovascular diseases such as atherosclerosis, a chronic condition affecting the arteries, is attributed to decreased levels of estrogen that lead to increased serum cholesterol and triglyceride concentrations and to changes in vascular function and the production of blood clotting factors.

Estrogen therapy

The administration of estrogen is effective for treating many problems associated with menopause, including hot flashes, breast atrophy, vaginal dryness, and psychological symptoms. Estrogen is also effective for increasing libido. In addition, estrogen increases bone density, thereby decreasing the risk of fracture. Although estrogen therapy causes a decrease in serum cholesterol concentrations, it does not appear to reduce the frequency of cardiovascular disease, and it may actually increase the risk of developing it. Estrogen therapy increases the risk of uterine cancer, which can be avoided if estrogen is given in conjunction with a progestin, and it slightly increases the risk of breast cancer.

There are important practical aspects of estrogen therapy in menopausal women. It can be given orally or applied to the skin (transdermal estrogen) or to the vagina. Estrogen that is applied to the skin is absorbed into the circulation and has effects throughout the body, though it is less active in the liver than oral estrogen and therefore has fewer effects on serum lipids, hormone-binding proteins, and blood clotting factors that are produced in the liver. Estrogen that is applied to the vagina is not well absorbed and acts mostly on local tissues. Because of the risks of irregular vaginal bleeding and uterine cancer, any woman who has not had a hysterectomy (removal of the uterus) who is given estrogen should also be given a progestin. The two hormones are usually given together continuously, which results in uterine atrophy. They also can be given cyclically, with estrogen administered most of the time and progestin administered for 7 to 10 days each month, in which case there often will be vaginal bleeding after the progestin is stopped. (For more information about estrogen therapy in postmenopausal women, see hormone replacement therapy.)

There is no reason to treat menopausal women who have no symptoms. Bone loss can be minimized or prevented by exercise, good general nutrition, vitamin D and calcium supplementation, avoidance of smoking, and drugs such as bisphosphonates, which block the resorption of bone.