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Menopause symptoms due to estrogen deficits, include memory problems, trouble finding words, inability to pay attention, mood swings and irritability, in addition to the more well known symptoms. These symptoms are often overlooked or left untreated but should be addressed. Treatment will not only result in symptom remission but may also, in my opinion, have preventive value. Some common questions I have encountered in my practice about estrogen and memory loss include the following:
Q: Do I have Alzheimer's disease?
A: This unspoken fear is often the reason why women suffer in silence when they experience cognitive symptoms during menopause. Scared about what they may discover, many women opt not to seek treatment. However, menopause related memory and cognitive disturbances are being increasingly described in scientific literature and are generally responsive to treatment. They can and should be addressed and treated.
Q: Does estrogen have an impact on functions of the mind?
A: Yes. Estrogen influences language skills, mood, attention, and a number of other functions in addition to memory.
Q: How does estrogen affect the mind?
A: Estrogen docking sites are present in several regions of the brain, including those involved in memory (such as the hippocampus). When activated by estrogen, these sites, in turn, activate processes that are beneficial to the brain. In addition, estrogen may, in effect, raise levels of certain brain chemicals (neurotransmitters). These include the neurotransmitters acetylcholine (implicated in memory), serotonin (implicated in mood), noradrenaline (implicated in mood and other autonomic functions), and dopamine (implicated in motor coordination). Thus, estrogen facilitates networking between nerve cells, promoting their ability to "talk to" one another.
Q: Does this mean that my recent irritability, apathy, 'foggy' state of mind, trouble finding words, constantly losing my keys, inability to function at my job, etc. may be related to estrogen deficit?
A: Given estrogen's myriad role in brain processes, it should come as no surprise that it can influence many of the mind's functions. However, a careful history and a thorough examination are needed to sort through symptoms and rule out other conditions. You should plan to spend about an hour with your physician to discuss the issues related to menopause, symptoms and treatment options.
Q: If estrogen replacement corrects my memory and other cognitive symptoms, do I need to do anything more?
A: Generally, if hormone replacement treats one's difficulties, your physician may decide that a further work-up is not necessary.
Q: I am on hormone replacement and my symptoms persist. What next?
A: If your symptoms do not resolve with hormone replacement, you may need to discuss the dosage and type of hormone replacement you are on with your doctor. Sometimes, changing to another preparation is helpful. If problems still persist, you might want to seek further help from a physician who specializes in this area.
Q: What are other treatment options for my problems?
Estrogen related cognitive deficits may be differentiated from those associated with other conditions through a careful history, examination and testing. During this time in a woman's life, many problems coexist, including treatable causes (e.g.: depression, hypothyroidism). Neuropsychological testing is useful in this regard to help delineate the nature of the problem. Testing will also establish a cognitive baseline for future comparison. Treatment options will depend on the cause(s) of the memory loss.
Q: Ideally, what areas should be covered in neuropsychological testing?
A: As estrogen affects various cognitive functions, comprehensive testing should assess all aspects of language (reading, naming, understanding, word fluency), memory (both short and long term memory, visual and verbal memory), and other cognitive functions (problem solving skills, visuospatial skills, etc). Simple screening tools, such as the mini mental status examination, will most often remain normal in peri- and post-menopausal cognitive loss. A good neuropsychological battery of tests should establish a cognitive baseline for future comparison and allow monitoring of treatment response.
Q: Will my depression get better if I go on estrogen?
A: If the mood changes are related to estrogen deficiency, they usually will respond to hormone or estrogen treatment. If the mood changes persist, you need to discuss this with your physician.
Q: Is estrogen useful for preventing memory loss?
A: Various naturalistic studies have suggested a preventive role for hormone replacement with estrogen for memory loss. However, more rigorous trials to investigate this are now under way and need to be concluded before consensus recommendations can be made.
Q: I have heard that estrogen prevents Alzheimer's disease. Is this true?
A: The results of several naturalistic studies suggest that estrogen may reduce risk for Alzheimer's by up to 50% although other studies did not find this benefit. The more significant of these studies involved looking at risk in large populations (epidemiological studies). However, controlled clinical trials are needed to confirm this observation before a decision of estrogen's benefit in this regard can be reached.
Q: My friend's mother has Alzheimer's disease. Will estrogen or hormone replacement help in this case?
A: Data in this area is conflicting. An multi-center trial found that conjugated equine estrogens was not helpful in treating Alzheimer's. A smaller study, using an estradiol patch found a beneficial effect. In my opinion, further work still needs to be done in this area.
Q: Is there a beneficial effect from consuming naturally occurring estrogens found in substances like soy milk: the so-called phytoestrogens?
A: There is not enough data on the use of these naturally occurring substances for treatment of cognitive symptoms of menopause.
Q: Why do I need hormone replacement? Isn't it the natural order of life that women go into menopause?
A: The average age of menopause is 52.3 years and has not changed much over the years. However, a century ago, life expectancy was much less for a woman than it is today. Today, the average woman will spend from a fourth to up to half of her life without the protective and beneficial effects of estrogen.
Q: What is the difference between hormone replacement and estrogen replacement therapy (HRT vs. ERT)?
A: Hormone replacement therapy is a combination of estrogen and progestogen and is generally given to women who have not undergone hysterectomies.
Q: If there is a family history of breast cancer, should I not take estrogen?
A: A family history of breast cancer does not preclude treatment with estrogen. Every person needs to be evaluated on an individual basis. Risk in each person varies and you will need to discuss this with your doctor.
Q: Does my risk for breast cancer increase if I am on estrogen?
A: The data in this area is conflicting. Some studies have not noted an increased risk, while others have found an increase in certain types of breast cancer. You need to discuss this issue with your physician. Additionally, every woman on estrogen or hormone replacement should undergo periodic breast self examinations and mammograms as determined by her physician.
Q: What is the difference between a patch and an oral preparation?
A: Skin patches are often used when oral estrogen is not tolerated. Skin absorption bypasses the liver circulation and is more easily titrated.
Q: If my blood hormone levels are normal on testing, but my periods are becoming irregular, am I going through menopause?
A: Hormone levels fluctuate monthly during the menstrual cycle and during the course of a woman's reproductive life. The current guidelines for a diagnosis of peri-menopause and menopause are based on a woman's history and examination. Blood hormone levels may be normal during peri-menopause and early in menopause.
Q: How does estrogen affect other organ systems?
A: Estrogen keeps bones healthy and prevents osteoporosis. It may also be helpful with cardiovascular diseases, although studies in this area are less unanimous.
Q: What are the risks of taking estrogen or hormone replacement therapy?
A: The most common concern for women deciding on estrogen or hormone replacement therapy is fear of increased risk for breast cancer. Several large, prospective studies have yielded varying results, including increased risk for certain kinds of breast cancer, although some studies found that the total risk for breast cancer of all kinds may not be increased. This is an area that you would need to discuss carefully with your physician. Other more common side effects include spotting, some bloating, breast tenderness and mood changes.
Q: Should I take estrogen or hormone replacement?
A: This is a question that every peri-menopausal and menopausal woman needs to discuss with her physician. Pros and cons of estrogen use in an individual woman vary.
Women need to be well informed about all options available to them as they undergo menopause.
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