Older women and hormones.
Text: Irène Dietschi
When it comes to women’s health, geriatric medicine has been focusing on reproductive organs and hormonal aspects for decades. Yet healthy aging is first and foremost a mental and psychological process, according to Professor of Gynecology Johannes Bitzer, former chief physician at the Women’s Health Clinic, University Hospital Basel.
Back in 1963, everything seemed so simple. In the USA, the bestselling book Feminine Forever by gynecologist Robert A. Wilson encouraged all women entering menopause to “take hormones!” Wilson defined the female body as “deficient” when its ovaries stop producing hormones. Something was lacking – so supply had to be restored. “Hormone replacement therapy” was born and with it, the prospect of a fulfilled sex life without an expiration date. Millions of older women bought the book, ascertained a “deficit” in their reproductive organs, and started taking hormones.
Now, 55 years later, the situation is a little more complicated. The mere question of when a woman starts “aging” is already contentious. “It’s not clearly defined these days,” says Professor Johannes Bitzer, Professor emeritus of Gynecology and Obstetrics and former chief physician at the Women’s Health Clinic at University Hospital Basel. Bitzer has been working in the fields of psychosomatics and sexual medicine for many years. Since his formal retirement, he has been working in a group gynecological practice.
Dwindling levels of estrogen
“According to geriatric medicine, the older phase of life starts at about 60,” says Bitzer. Yet in women, changes commence much sooner than that – at an average age of 52, when menopause begins. “Menopause marks the beginning of a phase when hormone-related conditions increase,” Bitzer explains.
Most of these are cardiac and circulatory issues: The body stops producing estrogen, which protects the blood vessels from arteriosclerosis during the fertile years. Other hormonal changes are a loss of bone density, which can cause osteoporosis, and the “urogenital syndrome” – vaginal dryness, weakened bladder control, and frequent urinary tract infections. “These are the typical symptoms that cause many older women to seek our help,” says Bitzer.
In addition to hormonal symptoms, there are other conditions that are unrelated to hormones and affect women and men alike. These include most cancers, as well as – once again – arteriosclerosis. According to Bitzer, cardiac and circulatory conditions are the leading causes of death for both genders.
So what is the current status of this “hormone replacement therapy” that Robert Wilson used to promote so ardently? Perhaps the major change compared with the 1960s is this: “Today, we just call it hormone therapy,” says Bitzer. They dropped the word “replacement”, which implies a possible deficit in the female body. In modern women’s health, the fact that ovaries stop producing hormones at some point is considered a natural condition. Period. And: “For women, taking hormones to ease age-related ailments is one option – but not the decisive one.”
Drama about a study
Then, there was the drama about a study by the Women’s Health Initiative, short WHI, whose ripple effects are still felt today. This large-scale study with a price tag of 625 million US dollars and 160,000 participating test subjects was launched in the USA in 1991, yet it involved women from around the world, also in Basel. Bitzer has mixed feelings when he recalls this time in the early 2000s when hormones were suddenly considered the work of the devil.
“At University Hospital Basel, we never thought that hormones should be mixed in with the drinking water, so to speak,” Bitzer says. “We only prescribed them to patients with clear symptoms, and we took risk factors into account. Yet when the initial results of the WHI study became public, the pendulum swung all the way in the opposite direction: The women became scared; they categorically rejected hormone therapy – even those who would have clearly benefited from it.”
What happened? Let’s go back a little: It is known that hormones help ease menopausal issues such as hot flashes, sweats, or the urogenital syndrome. Yet the WHI study did not focus on these therapeutic effects. Rather, the initiators from the National Institute of Health wanted to explore whether hormones help protect from cardiovascular risks. “WHI saw hormone therapy as a preventative measure: They hoped to show that it can prevent cardiac deaths in geriatric patients,” Bitzer explains.
A hidden flaw
The opposite occurred: Cardiac deaths increased in the WHI study. Making matters worse, taking hormones seemed to also increase the risk of breast cancer. More heart attacks, a threat to breast health – of course, women with menopausal symptoms did not want anything to do with this kind of “therapy” anymore. What was completely lost in the barrage of alarming news: The initial results contained a major flaw caused by the design of the study. The error: Most test subjects were not in menopause, but considerably older, 63 years old on average.
“Some of these women may have already been suffering from arteriosclerosis,” Bitzer explains, “and for these test subjects, the study unfortunately showed a negative effect of hormones: In the bloodstream, hormones encourage blood platelets to attach to plaque.” As a result, blood clots increase, obstructed sections become even narrower. Depending on the affected area, this can lead to a heart attack or stroke.
In the years after the initial report in 2002, the WHI data underwent numerous follow-up studies, some of which are still ongoing. Meanwhile, the authors have revised their initial statements: Hormone therapy is still associated with a minimally elevated risk of breast cancer. “But the bottom line of the benefit-risk balance is significantly more favorable, especially in terms of cardiac conditions,” Bitzer says. It is important to start the therapy at the onset of menopause, so women experiencing symptoms can truly benefit from it. In other words: “Hormone therapy for older women is appropriate if it is really warranted,” Bitzer says. “And that’s it.”
Healthy life philosophy
What is aging, really? Bitzer unfolds the palms of his hands as if he were presenting a treasure. “Healthy aging involves many aspects,” he says. Most of all: plenty of exercise, but also a balanced diet, no smoking, maintaining a healthy weight, and alcohol only in moderation – the usual recommendations, because they really help. “Yet the most important things occur in the mind and psyche,” says Bitzer. Leaning slightly forward, he adds: “It’s about developing a life philosophy that helps you grow into this phase.”
These are the main issues that arise at the menopause consultation at the Women’s Health Clinic: How to deal with losses and accept that certain things are over and gone. How to recognize new opportunities such as grandchildren, new aspects of life, a different sexuality, a slower pace. “What’s not helpful at all is this notion of ‘forever young’ or ‘feminine forever’,” Bitzer says. It is important to accept aging and seize the opportunities it brings.
Johannes Bitzer is Professor emeritus of Gynecology and Obstetrics at the University of Basel and former chief physician at the Women’s Health Clinic, University Hospital Basel.
The Women’s Health Clinic at University Hospital Basel offers sexual health consultation where patients of both genders and couples can seek help with sexual problems.
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