CHAPTER 2
Medical Aspects:
Symptoms and Effects in Women
Vasomotor symptoms
Hot flashes, or flushing, are vasomotor symptoms that appear as an immediate response to a reduced level of estrogen in the bloodstream; since this reduction precedes the onset of the changes brought by the menstrual cycle, one or two isolated flashes may occur even when the cycle is still apparently regular. The intensity and frequency vary from woman to woman: for some, they are little more than an annoyance, while for others they represent a real problem, owing to the feelings of awkwardness that come with them. We should not overlook the effects of a hot flash when it comes “in public”, because the redness and sweating are embarrassing, and make evident a situation that one would prefer to keep private. When these occur in the middle of a working day, they limit the ability to concentrate, make one feel inadequate, produce anxiety, and end up interfering in one’s professional life and social relations. It seems that greater acceptance of hot flashes is associated with a positive mental outlook, good family relations, and general emotional well-being. They manifest with brief and sudden episodes of intense heat, located especially in the torso, the neck and the face, accompanied by redness and profuse sweating.
Their occurrence is extremely varied; they may represent a fleeting phenomenon, or begin before changes in the cycle, and remain for many years. When symptoms are severe, it becomes necessary to intervene with medication, to lessen the frequency and intensity of the episodes, so as to improve the patient’s quality of social life, or else to allow them an adequate night’s sleep – something not to be underestimated! Hot flashes are caused by the reduction in estrogen, but they present most frequently when a person is going through a stressful time.
However, findings from research studies observing patients from various different ethnic groups present us with differing realities. The symptoms of Chinese women are mainly tiredness, muscular pains, irritability, sleep disturbances, and muscular pains, which are also common among Japanese women, who, in turn, complain of memory loss and stress, but do not have hot flashes, instead reporting episodes of cold, which are another aspect of menopausal vasomotor instability. The incidence of hot flashes seems completely different in South American women; indeed, more than half report serious or very serious vasomotor symptoms. Other studies confirm that only 10–20% of Filippino women have hot flashes or episodes of night sweats, unlike 60–90% of women in Europe and the US. Initial observation suggests that ethnic variations cannot easily be explained, even if one takes into account high soya consumption among Asian women, as a protective factor.
What do patients ask for?
Requests for help for vasomotor symptoms (so difficult to accept) are very common in a gynecology clinic. Before resorting to medicine, it is right and proper for the patient to try to alleviate them with a lifestyle that pays attention to clothing, the environment, and nutrition. General advice valid for all women includes dressing in layers, so as to avoid feeling hot, lowering the temperature in the rooms where one lives, especially in the bedroom, getting mild but constant exercise, and avoiding spicy foods, wine, and cigarettes. It is important to maintain a suitable body weight, because overweight women are those who suffer most from these disturbances.
Women who cannot resolve the problem often look to nutritional supplements for a solution. These include soya isoflavones and red clover, which have a bland estrogen action, while cimicifuga (actaea) racemosa (black cohosh) is a serotonin agonist, a substance that regulates the response of the nervous system.
Low doses of new-generation antidepressants seem to work better than soya derivatives, but they can have unpleasant secondary effects on sexual behavior, because they slow down orgasm, and so they must be chosen on the basis of individual needs and preferences.
Naturally, hormone replacement therapy (HRT), which we will discuss later on, represents the most effective intervention, but a family history of breast cancer and risk factors for cardiocirculatory diseases mean there are contraindications over its use, and it is right that a patient should try possible alternative solutions before resorting to hormonal preparations.
Even though vasomotor symptoms do not harm the organism, they are truly irritating. However, the discomfort ultimately proves to be a welcome event, because it leads women to their doctor, giving them the opportunity to get advice about the real conditions, such as genital atrophy or osteoporosis, which must be tackled with preventive measures.
Cardiovascular diseases
Cardiovascular pathologies, and in particular coronary disease, are the most frequent cause of death in women. The pathological mechanism is similar to that in men, but with a number of characteristics specific to the female gender, depending on the amount of estrogen3 in circulation, the reduction in which represents an important risk factor. This information is not taken on board by the public at large, and breast cancer, rather than cancer in any other organ, is the event most feared by middle-aged women. This fear is understandable if one thinks of the devastating impact that a cancer diagnosis has for a person, whatever organ is affected, and the special meaning that the breast has for any woman. However, it is not justified by the statistics. Indeed, a cardiovascular event is the most frequent cause of death in women (46% of cases), more than tumors, respiratory conditions, infectious diseases, cerebrovascular events and traumas. After the age of 50, causes of death in women are ischemic conditions, tumors, and neuromuscular degenerative diseases. Progress in the early diagnosis of tumors is improving the chances of survival, and increasing the incidence of ischemic conditions. Up until age 40, ischemic disease is less frequent in women, but after 50 it increases considerably, probably because with menopause one loses the protective effect of estrogen on the cardiovascular system.
3 Female sexual hormones produced by the ovarian follicles.
The natural history of cardiac disease in women is different from that in men. Its first manifestation occurs with angina pectoris (chest pain caused by myocardial ischemia), instead of with a heart attack (65% and 35% respectively). The symptoms can remain less severe for years, and indeed women who suffer a heart attack are 7 or 8 years older than men.
After the age of 64, hypertension is the most frequent cause of cardiac stroke. Smoking is also an important risk factor in determining coronary disease and atherosclerosis in women without other health problems. Obesity, diabetes, and an altered lipid profile are factors that worsen damage caused by hypertension and smoking. Obesity by itself does not represent a direct risk for cardiovascular disease, but it does cause metabolic conditions such as hypercholesterolemia, and it worsens hypertension, events which have knock-on effects, contributing to coronary damage.
Oral contraceptives, such as the pill, only very rarely cause non-fatal heart attacks in women without other risk factors, but who are over the age of 40, or in younger women who are carriers of congenital heart disease, malign hypertension and cardiomyopathy. The most serious side effect caused by these drugs, is phlebothrombosis; for this reason, they are advised against in women with obesity and hypertension, or in women with an altered lipid profile4.
4 Johansson-Vedin-Wilhelmsson, Myocardial infarction in women in “Epidemiologic Reviews”, vol. 5, 1983, pp. 67–95.
The association between cigarette smoking and coronary ischemic damage is, however, well known. Around 30% of deaths from heart attacks can be ascribed to smoking, which is the biggest independent risk factor that can be changed, both for men and for
