Emi

Hormonal Disorders:
PCOS, the Most Common
Hormonal Imblance for Women
Menstrual cycle dysfunction (experienced by 30% of women during their reproductive years) can be associated with metabolic complications, posing a silent yet serious health risk. Polycystic ovarian syndrome (PCOS) is the most common hormonal/endocrinal disorder in women of reproductive age (22% experience a mild form; 10% experience the "full blown" syndrome). In this syndrome, a number of follicles form a "necklace" around the periphery of the ovary. An imbalance of hormones occurs, resulting in menstrual irregularity, lack of ovulation, and possible infertility. Increased hair growth (on the face, chest, thighs, and abdomen) and obesity (50% gain) may also occur, as can skin changes (the development of a black pigment under the armpits and around the neck). At the same time, a mild increase in male hormones occurs, along with a decreased sensitivity to insulin, resulting in a condition called insulin resistance. The higher insulin levels that ensue may stimulate the male hormones occurring in the ovaries and are associated with metabolic abnormalities, including atherosclerotic heart disease and diabetes. Diabetes is more common in Hispanics, Blacks, and women of Mediterranean origin.

PCOS becomes worse with weight gain and may in fact first become apparent when a woman experiences a large weight gain. However, the development of PCOS is usually foreshadowed by problems during puberty including menstrual irregularities, acne, hair growth, and weight gain--largely cosmetic issues with psychosocial complications that negatively affect body image and self-esteem. Other problems related to PCOS include:

Pre-cancerous changes of the endometrium (uterine lining) due to lack of ovulation and constant stimulation by estrogen. Among women with these changes, the mean age for developing endometrial cancer is 32. Pre- cancerous endometrial changes can be pre- vented by progesterone or a progestin intake on a regular basis.
The incidence of heart disease with the approach of menopause is 6 to 7 times greater in women with PCOS than in the normal population.
Women with PCOS often have high cholesterol, triglycerides, and LDL (low density lipoprotein).
The risk of diabetes mellitus is three times greater among women with PCOS than in the average population (20% have impaired glucose tolerance). Among women who have PCOS or diabetes, there is often a history of diabetes in the family or a history of gestational diabetes (diabetes during pregnancy).
The risk of hypertension is three times greater than normal among women who have PCOS.
Individuals with PCOS should be counseled and considered for therapy, which may after menopause include HRT (hormone replacement therapy), SERMS (selective estrogen receptor modulators), and statins. Treatment with insulin sensitizing agents may reverse the syndrome and is very promising. In addition, PCOS-related problems increase significantly with weight gain and can often be reversed by losing weight. Exercise is extremely important, since even if there is no weight loss, insulin resistance will be reduced, helping to prevent coronary artery disease. This reduction in insulin resistance may be associated with a reduction in acne and a return of regular menstrual periods.

Early Menopause

Early menopause (occurring during or before a woman's early 40s) may also be associated with health problems.

Women who experience early menopause have a greater incidence of heart disease. Lack of sex hormones may prevent relaxation of the coronary arteries, or occlusion may occur due to a build up of atherosclerotic plaque. Even with normal heart function test results, women may experience angina or they may have coronary artery disease due to abnormal functioning of the arteries.

Premature osteoporosis may also develop. Exercise and calcium (at a dose of 1500 mg daily) help prevent excessive loss of bone during menopause, but these are usually not enough to reduce the risks associated with below-normal bone mass, and other therapy is recommended. Estrogen therapy, which has been shown to protect against excessive bone loss, can also improve vascularity of the vagina and treat vaginal dryness in estrogen deficient women. Male hormones given in addition to estrogen may improve libido, particularly in women with early menopause.

Menopause: A Third of Life?

Experts predict that the number of people over 65 in the U.S. will more than double in the next 20 years. Many women in the U.S. can now expect to live until their late 80s or early 90s, but the age of menopause is not changing. These women are living a third of their lives in the menopausal state, which can have a substantial impact on their health and lifestyle.

Menopause, while a natural occurrence, is an important risk factor for women, as it is associated with an acceleration of aging changes, urogenital and sexual changes, and neuropsychiatric changes. Depression may surface in the perimenopause. Hot flashes, night sweats, chills and insomnia often occur, resulting in a significantly impaired quality of life. Additionally, in some cases, cognitive function may deteriorate. In women afflicted with these perimenopausal problems, hormone replacement therapy (HRT) has shown great benefits in improving quality of life. Many tissues in the body are affected by HRT, including the brain, skin, muscles, gastrointestinal tract, breasts, uterus, and reproductive organs. The use of HRT has resulted in relief of hot flashes, improvement in depression, and prevention of chronic disease such as osteoporosis, cardiovascular illness, and Alzheimer's disease (the brain appears to be protected by estrogen). In addition, a significant decrease in macular degeneration (a disease of the elderly and the most common cause of blindness) and colon cancer has been observed among patients on HRT.

In addition to the conventional method of HRT administration, hormones can also be taken locally with the use of vaginal creams or a ring inserted and left in the vagina; this ring releases estrogen but is not absorbed in circulation. This treatment improves vaginal lubrication, sexual function, and urinary continence. Progesterone gel administered vaginally is an excellent way to provide progesterone to the uterus locally with little systemic circulation.

Progesterone is used to counteract the effects of estrogen on the uterus, since continuous use of estrogen leads to overgrowth of the endometrium and can cause precancerous changes.

Studies show that hot flashes can also be minimized through the use of some soy derivatives called isoflavones. These soy derivatives, taken in 40 mg to 60 mg daily doses, are useful in dealing with hot flashes, but are not as effective as estrogen and must be taken for 5 to 6 weeks versus only 1 to 2 weeks for estrogen therapy.

The possible link between estrogen therapy and breast cancer risk has been extensively studied. Estrogen therapy appears to be associated with a very small increase in breast cancer risk. The nurses' health study shows a slightly increased relative risk of 1.3 (normal risk = 1). This means that 6 of 100 women of 50 years of age will develop breast cancer if they are not on estrogen for 20 years versus 7.5 in 100 who are on estrogen. The breast cancer that develops in women on estrogen tends to be benign in more cases than when it occurs in women not on hormones.

SERMs (selective estrogen reception modulators) show great promise in providing benefits similar to those of conventional estrogen therapy but without some of the potential risks. SERMs act like estrogen at certain receptors in the body but are antagonists (blocking the receptors) at others such as the breast and uterus. One SERM has been approved for prevention and treatment of osteoporosis. This therapy does not increase the risk of breast and endometrial cancers; there is no vaginal bleeding as there is no stimulation of the uterine lining; and there is also an improvement to the lipid profile. However, SERMS can cause an increase in hot flashes and leg cramps.

Estrogen is not for everybody, and counseling is suggested if there is a positive family history of breast cancer.