Management of the menopause

Abstract

Dr. Harry Gold: Considerable ground was covered in this conference on the treatment of the menopause. The discussion involved both theoretic and practical issues and threw light on a large number of problems: Who is best equipped to treat the menopause; the relation between the symptoms of the menopause and the disturbance in hormones; the use of estrogens and androgens, and combinations of the two; estrogen therapy and cancer; the vaginal smear; the psychiatric disturbances of the menopause; the choice of preparations of estrogens, dosage and route of administration; natural versus synthetic estrogens; regimen for treatment; sources of confusion in the bio-assay of estrogens; and the question whether estrogen therapy prolongs the menopause. The essential hormonal changes involve a urinary increase in gonadotrophic hormone of the pituitary and a marked reduction in circulating estrogen. Estrogen deficiency is the factor which appears to be related to the menopausal symptoms. The significance of the psychologic aspects of the menopausal syndrome was stressed from the standpoint of their role in the severity of the symptoms and the response to treatment. The patient's emotional and personal needs are considered more crucial than her medicinal needs. Nevertheless, substantial improvement may be anticipated from the appropriate use of the estrogens. Attention was called to the utility of these drugs in some cases of involutional depression related to the menopause, and signs to differentiate these from cases not likely to respond were given. The natural estrogens were preferred on the basis of the fact that when large doses are necessary they are less apt to produce disagreeable side effects than synthetic stilbestrol. It was pointed out that smaller doses at more frequent intervals are more effective than massive doses at very long intervals. The oral route was preferred and the belief was expressed that the alleged superiority of the parenteral route is due to the psychologic effect of an injection. The vaginal smear was described as an extremely valuable guide to estrogen therapy. A plan of intermittent treatment was outlined which insures that the full benefit of the drug is obtained. In this regimen the estrogen is administered until full replacement is observed in the smear. Then the dose is reduced by steps in the endeavor to establish the smallest dose which maintains the optimum state of improvement in menopausal symptoms. There appears to be no significant danger of cancer in the use of the estrogens for the treatment of the menopause. Attention was called to the need for pelvic examinations to insure that bleeding due to cancer unrelated to the treatment may not be mistaken for an effect of the estrogen.