by Ibrahim B. Syed, Ph. D.
Islamic Research Foundation International, Inc.
7102 W. Shefford Lane
Louisville, KY 40242-6462, USA
"Such elderly women as are past the prospect of marriage, there is no blame on them if they lay aside their (outer) garments, provided they make not wanton display of their beauty; but it is best for them to be modest; and Allah is One Who sees and knows all things". Qur'an, Surah An-Nur, 24:60.
Older Muslim women who are past the prospect of marriage are not required to wear "the outer garment." Here the women who are past the prospect of marriage refer to those women who have attained menopause and who cannot bear children.
Menopause is defined as the time when a woman stops having her monthly menstrual cycle. The period from menopause until death when a woman is no longer able to conceive a child because her ovaries have stopped releasing eggs and estrogen is called “Climacteric.“ Almost 220 million Muslim women are presently in the postmenopausal or climacteric stage of their lives.
Natural menopause can occur as early as age 38 or as late as age 60, the average being 50 years. Women whose ovaries or uterus have been removed surgically or whose ovaries have been irradiated with large doses of X-rays or gamma- rays will experience their menopause immediately after the operation and sometime later in the case of irradiation.
Menopause is a gradual process, which in most women lasts about two years. It is a normal event in every woman’s life and should not be thought of as a disease.
It is now known that most women continue to produce small amounts of estrogen often up to thirty years after their menopause, although the ovaries do not secrete it directly. The estrogen is manufactured in glands other than the ovary, in the brain and bone and especially in fat tissue in the postmenopausal woman’s body.
Symptoms of Menopause
No two women experience the menopause in the same way or at the same time. It is not known what exactly triggers the “change of life, even though it is probably related to hormone levels that are adjusting to general aging process in the body. Changing hormone levels account for hot flashes, a symptom that about half of menopausal women experience. A hot flash usually lasts a few minutes and is preceded by a chill followed by heavy sweating. Sometimes, rapid heart beating, numbness and tingles also occur. Only about one in twenty women have hot flashes that are extremely debilitating. These women are unable to sleep at night and may be very tired, nervous or irritable because of the discomfort of the flashes. Luckily most women have hot flashes that are mild, and infrequent and do not disturb their life to any significant degree. One should not forget that a woman’s experience of menopausal symptoms could be influenced by a number of personal and social factors, such as how she feels about aging, her general health and her involvement with activities that enable her to feel productive and worthwhile. Hot flashes are not life threatening and, in most women they go away without treatment such as estrogen therapy.
Another problem that some menopausal women experience is vaginal dryness, which is caused by the thinning of the cells in the vagina. This condition may cause pain during sexual intercourse. As with the hot flash symptom, there is great variation among women in their encounter of vaginal dryness. These changes often do not occur until a woman reaches her late sixties or seventies. Much lower doses of estrogen are needed to relieve vaginal dryness than to relieve hot flashes. In majority of cases, vaginal dryness can be remedied using a non-irritating lubricant before sexual intercourse.
Emotional problems in the menopause, such as anxiety, depression and nervousness are based on social and cultural factors rather than changes in estrogen levels. Fortunately Muslim women do not consider middle age to be a stressful time in their lives and do not become especially anxious or irritable around the time of the menopause.
Some psychiatrists have, in. the past, implied that menopausal depression is due to hormonal changes by defining a type of mental illness which is allegedly caused by shrinking breasts and vaginas in menopausal women. This diagnosis contributes to the fear that women have traditionally had about the menopause
There is no scientific evidence to justify the use of hormone therapy for those psychological difficulties that may arise during the menopausal years. Estrogen
cannot give a woman self-confidence or emotional self-control. Loneliness, lack of energy, tension and crying spells may occur at anytime in a person’s life; estrogen therapy cannot relieve menopausal women from such feelings. Acknowledging these feelings and talking about them with a sympathetic family member, friend or doctor may provide increased self-understanding and relief from these “bad” feelings.
Hormone therapy (HT) for the management of menopausal symptoms and as a preventive measure to guard against health problems of older age, has dominated discussions about menopause in recent years. Hormone ‘replacement’ therapy has been around since earlier this century. It was first developed as estrogen only, but it was found to cause cancer of the endometrium (the lining of the uterus) and fell from grace. More recently progestin was added to the estrogen in order to make the therapy safer. At menopause hormone levels drop as part of the natural process, so the concept of ‘replacing’ them is misleading. Giving hormones at or after menopause treats menopause as an estrogen deficiency disease rather than as a natural occurrence in a woman’s life. For accuracy, the term ‘hormone therapy’ will be used in this article.
The quandary that many women find themselves in when trying to make a decision about whether or not to use HT at menopause is understandable. There are conflicting reports and claims made about the risks and benefits. Physicians of different persuasions have very differing views about the safety and efficacy of HT. Women often tell that their family physicians urge them to use HT but make light of the side effects and women’s concerns about them. Many women feel their Family Physicians doesn’t have the time to offer much information and discussion about the advantages and disadvantages of HT. Women are being encouraged to take HT, often without being given adequate information and the opportunity to explore their feelings. Many women value the opportunity to explore the pros and cons in a neutral environment without the pressure of having to make a decision then and there. There is rarely any urgency about making the decision of whether or not to use HT.
What is HT?
Hormone therapy is a medication prescribed to add hormones when the amount normally produced by the ovaries decreases as part of the process of menopause. The two main types of hormones in HT are estrogens and progestins. They are produced artificially and attempt to resemble the hormones produced naturally by a woman’s body. In HT these hormones may be prescribed together or alone. Women who have their uterus intact are prescribed combined therapy of estrogen and progestin. Women who have had a hysterectomy are prescribed only estrogen.
Testosterone is another hormone, which is occasionally used. In women, this hormone occurs naturally in small quantities. Its use remains controversial, as there is limited research into its short term and long-term effects.
Hormone therapy is very effective in reducing those symptoms of menopausal women that are related to the decreasing body levels of estrogen. Taking hormones for a short time while the body adjusts to its new hormone level frequently helps women with severe hot flashes or vaginal dryness problems. Hormones do not cure the menopause; they simply help some women who have disabling symptoms get through it more easily.
Hormone therapy, however, may prove to be helpful in. slowing one aspect of the aging process. As bones age, they become less dense and more brittle. This condition is known as osteoporosis, can lead to excessive fractures and broken bones. Bone fractures are a very significant health problem in elderly women. One-fourth of all postmenopausal women in the United States develop an unhealthy degree of bone loss. It is difficult to predict, however, which women will experience these bone changes. Women who are chronically disabled or bedridden may indeed have bone loss problem that could be helped by hormone therapy. If hormone therapy is to be of any benefit in. preventing osteoporosis and its complication, it must be given early in the menopause before a significant amount of bone is lost since hormone therapy will not cause new bone material to be produced over the long term. Many other factors, in addition to estrogen, are important for healthy bones in postmenopausal women, such as other hormones, vitamin D, calcium, genetics, body weight, exercise and diet. Because of the difficulty in identifying women who would benefit, the doctor cannot recommend that postmenopausal women routinely receive estrogen therapy to prevent osteoporosis.
The common side effects of Hormone Therapy (HT) include: sore breasts, nausea, weight gain, headaches, feeling bloated, depression or mood swings, irregular bleeding or spotting.
These side effects, while uncomfortable, are not considered medically dangerous. Often they subside within a few weeks of taking HT. If the side effects continue beyond a few weeks, an adjustment of the dosage may be required. Sometimes women need the dosage adjusted several times before finding the right combination. This may take several months or sometimes longer to sort out.
While the side effects mentioned above may not be considered dangerous in a medical sense, many women find them unacceptable. Numerous women are not prepared to feel the way they might have when they were premenstrual. Unwanted weight gain is also a worry for some women. For many, going back to having a monthly bleed is something they do not want. Only the woman concerned can decide whether any unwanted effects of taking HT are acceptable.
Serious side effects
Serious side effects include increase in the size of fibroids, activation of endometriosis, especially if located deep in the pelvic area, increased risk of developing breast cancer (numerous studies show this to be the case after 5 years of HT use). increased risk of developing endometrial cancer even when combined HT is used, thromboembolism (blood clot in the blood stream). Women should see their doctor immediately if they have any problems, particularly any abnormal bleeding, a breast lump, or any swelling and pain behind the knee or in the calf as this may be a sign of thromboembolism.
Women should not consider taking hormone therapy if they have any of the following health problems: irregular bleeding; cancer of the uterus, breast or kidney; liver disease; a history of heart disease, gall bladder disease and stroke; or a history of heavy smoking. Women who are obese or diabetic and those who have high blood pressure or migraine headaches cannot take hormones safely. When her doctor checks a woman before receiving a prescription for hormone therapy, she should receive a complete physical, including a thorough history and breast and pelvic exams to rule out any of these health problems.
Hormone therapy is not recommended for women who have any of the following: pregnancy and lactation, estrogen dependent cancer, cancer of the breast or endometrium, undiagnosed urogenital bleeding, undiagnosed breast changes, blood clotting disorders, liver disease, uncontrolled high blood pressure. From the list of contraindications, it is clear that HT affects many organs of the body. Women are wise to carefully consider the risks and benefits before commencing HT.
Estrogen wonder drug?
Unfortunately, the case for Estrogen as a woman’s “fountain of youth” has been greatly exaggerated. Many books and articles in women’s magazines suggest that estrogens prevent everything from wrinkles and depression to heart attacks and sexual problems. Menopausal women have been pictured as sexually unattractive and useless- with facial hair, deepened voices and shrinking vaginas. Even some doctors have recommended hormone therapy to prevent dry skin, weak muscles, sagging breasts and chins, and breast cancer. Millions of postmenopausal women in America took hormones as a routine, long-term basis as a cure-all for aging skin, emotional difficulties and as a preventive measure against heart disease and cancer. It is now known that estrogen is not a wonder drug. It cannot slow the aging process or restore youth, vitality or sensuality. In addition, estrogens do not prevent heart disease or breast cancer.
Advice About Postmenopausal Hormone Therapy
While many questions remain, the new WHI(The National Institutes of Health (NIH) established the Women's Health Initiative (WHI) in 1991 to address the most common causes of death, disability and impaired quality of life in postmenopausal women. The WHI will address cardiovascular disease, cancer, and osteoporosis. The WHI a 15 year multi-million dollar endeavor, and one of the largest U.S. prevention studies of its kind.)
findings provide the basis for some advice about the use of postmenopausal hormone therapy. Here it is, along with advice for short-term hormone use to relieve menopausal symptoms:
Short-term estrogen alone or estrogen plus progestin therapy
"Short-term" means the shortest time needed to manage menopausal symptoms. The benefits of such use could outweigh any risks. Most women use the hormone therapy for 2 to 3 years. However, some may require a longer period of treatment. Women should talk with their health care provider about their personal risks and needs.
Long-term estrogen plus progestin therapy:
Estrogen plus progestin therapy should not be used to prevent heart disease. The new findings show that it doesn't work. In fact, the therapy increases the chance of a heart attack or stroke. And it increases the risk of breast cancer and blood clots.
What can be done instead? The health care provider will guide the patient about other ways to prevent heart disease and stroke that have been proven to be safe and effective. These include lifestyle changes and such drugs as cholesterol-lowering statins and blood pressure medications. Lifestyle changes include: not smoking, maintaining a healthy weight, being physically active, and managing diabetes.
Another key part of this is to follow a healthy eating plan that has a variety of foods and is low in saturated fat and cholesterol and moderate in total fat. In addition, limiting how much salt and other forms of sodium you eat will help keep your blood pressure at a healthy level.
Long-term postmenopausal hormone therapy should not be used if one already has heart disease. Such use increases the risk of blood clots. It also increases the risk of heart attack in the first year of therapy.
To prevent osteoporosis, the health care provider should be consulted with regard to personal risks and benefits that come from estrogen plus progestin therapy. Benefits should be weighed against the risk of heart disease, stroke, and breast cancer. Alternate approaches that are considered safe and effective in preventing osteoporosis and fractures should be considered. These include oral biphosphonates, such as alendronate (or Fosamax) and risedronate (or Actonel), and selective estrogen receptor modulators (SERMs), such as raloxifene (or Evista). SERMs are also known as designer estrogens. They are substances that have estrogen-like effects on some tissues and anti-estrogen effects on others.
Other steps to prevent osteoporosis include consuming enough calcium and vitamin D, (being physically active, especially with weight-bearing exercises (such as walking, jogging, playing tennis, and dancing), not smoking, and limiting consumption of alcoholic beverages Smoking and drinking alcohol increase the risk of osteoporosis.
Long-term estrogen-only therapy:
The WHI has not yet issued findings about the health risks and benefits of long-term use of estrogen-only therapy.
Whether or not a woman decides to use postmenopausal hormone therapy, she should keep regular schedule of mammograms, and breast and clinical exams. In addition to having regular mammograms, she should protect her health by having certain other tests done too. These include tests for high blood pressure, high blood cholesterol, high blood glucose (sugar), bone mineral density, and overweight. If a woman stops taking hormone therapy and her menopausal symptoms return, she should consider alternative treatments. Be aware that some of these remedies have not been proved effective or safe.