I’m Still Hot — It Just Comes In Flashes Now
When I decided to become an ObGyn, I was sure that the best part of the specialty was going to be the delivering babies part. Taking care of pregnant mothers, helping them to grow a healthy baby, and then bringing that new life into the world had to be the absolute best and most satisfying part of this specialty. And it is fun…and fulfilling…..and also exhausting.. In the last few years, my interests have moved in a slightly different direction. I became very interested, and intent on becoming proficient and skilled at taking care of a “lost” segment of the population — — the peri- and post-menopausal woman. After hearing so much sadness, so much resignation, and so much confusion about what menopause IS, and what women should and could expect during their transition to, and their life while in menopause, I decided that I would make it my business to be able to address and help this important part of the population. I have found THIS to be at least as fulfilling if not moreso.
Nowadays, with women living longer, and the average age of menopause at 51, we can expect to live 30–40 years (or more) in a menopausal state — and there is NO reason that these years have to represent a steady decline — in physical and emotional health, well-being, attitude, and relationship satisfaction.
When someone comes in to my office for a “menopause consult”, they are often not sure what to expect. They sometimes are not sure if they are even IN menopause. One of the first things we do is talk definitions. Menopause, by definition, is 12 continuous months without a menstrual period, and usually occurs around the age of fifty. Menopause can occur after surgery to remove ovaries, or after chemotherapy for cancer, or from other medical conditions, way before 50 — and if any of those conditions are present, it can be termed Premature menopause or Post-surgical menopause. (It can also be called Ovarian Failure — but I choose to not speak about ovaries in such derogatory terms) In general, when a woman has been without a period for an entire year, they can be pretty sure they are in menopause. We can also define menopause by certain blood tests, checking hormone levels and ovarian function, but it is usually not necessary to do that.
We then do the all-important “Review of Menopausal Symptoms”. (I bring out my “checklist”) The ovaries are responsible for making three main hormones in the young reproductive lives of most women: Estrogen, Progesterone, and Testosterone. As we age out of the reproductive years, these hormones are produced in smaller and smaller amounts, until they stop being produced altogether. Many classic symptoms in menopause are caused by the lack of Estrogen. Hot flashes, night sweats, irritability, lack of energy, dry skin, hair loss, vaginal dryness, bladder irritability, and painful intercourse can all be traced back to absent Estrogen levels. A lack of Progesterone can be associated with difficulty falling and staying asleep, bloating, breast tenderness, irritability, depression, and a feeling of “PMS”, or the sensation that the period is about to come, but it never does. Lack of Testosterone is particularly responsible for decreased energy and libido, aches and pains in the joints, and a lack of muscle strength (sometimes in spite of adequate exercise and weight training)
As I go down this “checklist” of symptoms, it is not unusual for women to say, “Those are ALL my symptoms”. It is important to know which symptoms women are having, because hormones are made to treat symptoms. If we decide that hormones are going to be a part of our ongoing menopause treatment program, they will be geared to relieving that individual woman’s individual symptoms — -there is no “one size fits all”.
Most women are candidates to use hormone replacement, with a few exceptions — those who have had Estrogen-related cancers like breast or uterine cancer, are likely not candidates for hormone therapy. Women who have had Estrogen-related blood clots are not candidates for hormone therapy. Women who have had prior problems while on Estrogen therapy — severe nausea on birth control pills, or abnormal liver function while on some type of Estrogen may not be candidates for hormone therapy. Women with undiagnosed abnormal vaginal bleeding are not candidates for hormone therapy. That is a pretty short list — which means that most women really are candidates for hormone therapy programs. So why are so few women, even women with terrible menopausal symptoms, NOT on hormones? Very simple — — — fear, and misinformation. Fear comes from having heard that hormones are BAD — — that they cause cancer, heart attacks, blood clots, and death. Fear because they know someone who took hormones and then got breast cancer — -so of course it HAD to be the hormones that caused the cancer, right? Misinformation — which comes from family, friends, the internet, Doctor Google — which convinces them that it is better to “tough it out” and suffer through their menopausal symptoms, then to avail themselves of safe hormonal treatment plans that could greatly improve their quality of life — their relationships, their moods, their sleep and their cognitive function. They don’t have that person to dispel the myths, give them the correct information, and follow them on a comprehensive treatment plan that will make those thirty-or-so menopausal years NOT a steady decline, but a vital, healthy & energetic “next stage”.
I am that person.
The biggest reason for the fear is a large study that was published about 15 years ago, called the WHI, or Women’s Health Initiative. That was a study on menopausal women which was actually sponsored by the makers of a particular type of oral hormone replacement. They had to stop part of the study midway through, when they found that the products they had put these women on, did lead to an increase in breast cancers, heart attacks, blood clots and stroke. They headlines were huge — — ”Hormones cause cancer!!” among many others. I never had so many patients call my office in great alarm, asking to be taken off their hormones. However, in deeper evaluation of the study, it has been found that those effects were found (1) because they were giving the “wrong” candidates the hormones in the first place — ie, women who were 10 years or more from their entry into menopause (2) the women’s medical histories were not well- evaluated (ie, smokers, patients who really were not candidates for hormone replacement were included), and, most importantly (3) The results were only applicable to the type of hormones these women were placed on — -oral conjugated Estrogens made from animal products, and a Progesterone that was the only available product at the time.
Since that study’s release, many newer and safer Estrogen and Progesterone products are on the market, with many newer and safer ways to use them. There are very specific “rules” which I adhere to in placing women on hormone replacement, and there are now many good, evidence-based scientific studies to attest to their safety.
The Rules:
1- As already mentioned above — -hormones are made to relieve symptoms. They are not “just something to be on” for all menopausal women. Once we review the menopause symptom chart, it is (usually) obvious whether symptoms can be attributable to low levels of one or more hormones.
2-Also mentioned above — a detailed history will reveal if a woman is on the short list of people who canNOT use hormone replacement — -This is not to say that they cannot use anything to relieve their symptoms ( “alternatives to hormone therapy” is a whole other article but there definitely are some good ones) but hormone replacement would not be the plan for them.
3-The “time theory” — a woman should ideally be within 5–7 years of menopause to safely be placed on hormones. Once it has been more than this, and especially more than 10 years, the risks of hormones start to outweigh the benefits, and we may need here to also look for alternatives.
4-If it is found that the symptoms seem to be from a lack of Estrogen, and a woman is placed on Estrogen, then she must also be placed on Progesterone if she still has her uterus. Why? Estrogen’s job, whether being made by the ovaries, or taken in replacement form, is to stimulate the lining of the uterus to build a thick lining. Progesterone’s job is to stabilize that lining and to keep it from building up too much. IF we take only Estrogen, without Progesterone, (what we, in the medical world call “unopposed Estrogen”) then that lining will build up, unchecked, and can increase the risk both for irregular bleeding, and for uterine cancers and pre-cancers. This is not to say that there is never a reason to take Progesterone if the uterus is absent, but there is ALWAYS a reason to take a combination of Estrogen and Progesterone if the uterus is present.
5-If at all possible, Estrogen should go through the skin (also called “transdermal” Estrogen) There are patches, gels, sprays and creams available to get Estrogen into the system, and there are many studies which show that when Estrogen goes through the skin, it has none of the risks that were found when taking it orally. Risks of blood clots and stroke actually go down, and when the Estrogen doesn’t have to go through your stomach and intestines to work, it bypasses the liver, reducing any effect it may have there.
6-We use whichever combination of hormones relieves the symptoms, for whatever length of time they seem to be helping.There is no arbitrary “endpoint” at which people should just stop their hormones just because they are getting older. The most recent evidence-based information actually says that even past age 65, if the benefits (relief of symptoms, mainly) seem to outweigh the risks, as long as someone on hormones is being followed by a practitioner knowledgeable in hormone replacement, they can stay on them indefinitely. I have many patients in their 80’s that would simply NOT allow me to take away their hormone replacement — even when their primary care physicians (who may NOT know the latest evidence — they have so much else to keep up with) question their treatment plan!
7- If the symptoms are ONLY vaginal — -dryness, itching, burning, painful intercourse — then the safest treatment is to treat directly in the vagina — there are several different hormonal (and non hormonal) preparations to relieve only these symptoms, in very low doses which are very safe. There is even some recent evidence to say that women who cannot be on Estrogen systemically for some other reason can safely use vaginal products, but this takes an evaluation by a knowledgeable health care provider.
8- If it seems there are symptoms that are not attributable to lack of hormones, or if they are not being helped by the addition of hormones, please seek other alternatives. Depression which may seem menopausally related, which is not relieved with hormones, needs to be addressed as any other depression would be. Joint aches and pains which are not helped on a hormone program should be evaluated and addressed as any other physical ailment should be. All symptoms which may seem like they are from menopause may not be!
9- Any vaginal bleeding must be evaluated. Although sometimes starting a hormone program may result in some spotting or bleeding, the idea of a menopausal hormone program is usually NOT to see any bleeding. There may be a condition happening which was present before, or occurred during hormone use, and it should not be ignored.
10-Mammograms, or some form of breast evaluation should be undertaken with whatever regularity your health care practitioner recommends The BIG worry about hormones is how they may be related to breast cancers. Taken properly and safely, there is no evidence that hormones actually CAUSE breast cancer. BUT- if there is or was an already growing breast cancer, and if it is Estrogen sensitive, as most of them are — -the hormones will stimulate that cancer to grow. (This usually means it will be found earlier, and treated sooner — leading to an actual INCREASE in survival of breast cancer survivors who were on HRT at the time of their diagnosis) It is easy to see how people may have the misconception that the hormones actually “caused” the breast cancer — -but this is not usually the case.
Hormone replacement therapy can be a safe, and incredibly effective way to relieve bothersome symptoms which alter the quality of life for menopausal women. They should be combined with proper diet, exercise, sleep and stress management, supplements if needed, and evaluation of any other possible medical conditions. Treating menopausal patients and hearing their stories of improvements in physical and emotional health, well-being, and relationship satisfaction in this particular population has been one of the most fulfilling parts of my job. Menopause need not be a slow decline — but an exciting look forward to the next few decades of enjoying the feeling of being hot — -and NOT just from flashes!!!
