Many women have misconceptions about what menopause is, and confusion as to what to do about it. The process of menopause begins as a women releases the last few follicles (i.e. eggs) from her ovaries. When the last one is spent, there will be no more menses – at an average age of 51. One year of no menses completes the passage into menopause. The withdrawal of hormones – primarily estrogen and progesterone – that subsequently occurs, results in the symptoms associated with menopause. Typical symptoms include hot flashes, night sweats, mood changes, decreased libido, dry skin, painful intercourse, and decreased sense of well-being. Menopause is an individual experience. Many women have minimal or no symptoms, and some have most of the symptoms.
How does a women decide what to do about menopause?
It is a matter of quality of life. Women with minimal or no symptoms can just sit back and enjoy this new season of life with no menses and no need for birth control. Women whose quality of life takes a dive should seek relief of their symptoms.
What helps with menopausal symptoms?
Lifestyle changes including regular exercise, maintaining a healthy body weight and eating a healthy diet will minimize the impact of menopause for many women – I know, these items always seem to be the answer. There is a multitude of over the counter products that claim to help menopausal symptoms. They are for the most part harmless and I have had several patients say they have helped them, so I’ve suggested they continue using them. These products have no scientific studies to prove their effectiveness, are often inconsistent in their ingredients and do not have to be scrutinized by the FDA. One very popular product, black cohash (which I often recommended), did undergo scientific study recently. It was found to be no more effective than a placebo.
What about prescription hormones?
Hormone replacement treatment (HRT) is the most effective treatment for menopausal symptoms. This involves use of both estrogen and progesterone. The estrogen is the primary hormone to relieve menopausal symptoms while the progesterone is added mainly to counteract over stimulation of the uterus from the estrogen. Women without a uterus may be treated with estrogen only (ERT). HRT/ERT reduces bone fracture and colon cancer. More importantly in the ‘50s, there was a reduction in cardiovascular disease.
What about the risks of HRT?
A study in 2002 called the Women’s Health Initiative (WHI) concluded that the risks of HRT were greater than the benefits primarily because of an increased risk of breast cancer and blood clots. The study group included women 50 to 79 years old, mean age was 63. Subsequently, following that report, millions of women stopped HRT and thus suffered with menopausal symptoms and decreased quality of life as a consequence.
The actual increased risk of breast cancer is less than one person per 1000 women on HRT. It is less than a woman who drinks two glasses of wine a day or a woman who is overweight. More recent analysis shows there is actually a reduced risk of mortality in women younger than 60 years old, no increased mortality in women 60-70 years old, and a slight increased mortality in women older than 70 years old.
HRT may increase risk of cardiovascular disease if started later in life – over the age of 60 – but data strongly suggests cardio protection when started in younger patients. It has been reported that an additional 40,000 to 80,000 women died from heart disease as a result of the discontinuance of HRT after the WHI was reported to the public.
THE GOOD NEWS
The data from the WHI has been further dissected out, leading to what is called the “Timing Hypothesis.” The essence of this hypothesis is that HRT is much safer than suggested by WHI if it is started within a few years of the onset of menopause and used primarily in the ‘50s. The symptoms of menopause usually subside within 7-10 years of onset, so HRT can be very effective in this decade and have minimal risk.
Also, a sidearm of the WHI study containing only women that had removal of their uterus concluded that women taking only estrogen had no increase in breast cancer. Better yet, there was a 20 percent decrease compared to women on no hormones. HRT appears to have a cardioprotective benefit in patients younger than 60 years old. This perhaps is the reason HRT in this age group shows a reduced mortality rate.
What about bioidentical hormones?
Compounded hormones are not approved by the FDA and may vary in content, thus should be used with caution. Many prescribers will sell these products in their office, order expensive and unnecessary lab tests (salivary testing is not effective), and require frequent office visits. The primary estrogen used is the same most conventional prescriptions contain. There is no scientific evidence that bioidentical hormones are in any way superior or safer than conventional treatments. They also may result in greater expense, more time spent in appointments and in some cases increase cancer risk due to inappropriate dosing.
Are there non-hormonal prescription medications available?
Patients who have had breast cancer or have other contraindication for hormone treatment can often be successfully treated for hot flashes with anti-depressants or a few other medications that act on the brain.
What is the bottom line?
It is not complicated – you do not need a hormone specialist. If you become menopausal I like to use the saying, “if it ain’t broke, don’t fix it.” You do not need to do anything additional. If your quality of life is suffering because of menopausal symptoms and you are in your 40s or 50s, consider prescription HRT/ERT. Over the counter products and non-hormonal treatments can help some women who want to avoid prescription hormonal treatments. Menopause can certainly be an enjoyable season of life, make the most of it and do not look back.