Menopausal endocrinology and management

Entry into menopause is associated with a severe diminution of ovarian estrogen and progesterone secretion and a reduction of circulating androgens, although, in the presence of ovaries, a degree of testosterone secretion persists. Menopause is associated to a varying degree and severity, with hot flashes--a disorder of central thermoregulation--progressive sex tissue atrophy, and accelerated bone mineral loss that eventually leads to a substantial prevalence of osteoporosis, with spine, hip, and radial fractures, particularly in thin, inactive smokers with low calcium intake. Treatment with estrogens eliminates hot flashes and sex tissue atrophy and prevents osteoporosis. Unfortunately, oral estrogen therapy results in overstimulation of the liver, producing secreted proteins and an increased risk of endometrial carcinoma and gallbladder disease. The addition of a progestogen will diminish the risk of endometrial carcinoma, presumably by reducing estrogen-receptor concentration and increasing estradiol dehydrogenase activity but will usually result in vaginal bleeding in women with uteri. The use of estrogen therapy with or without a progestin should be an informed joint decision of physician and patient that must be reevaluated regularly as new information becomes available.