It is estimated that each day, approximately 6,000 U.S. women reach menopause (over 2 million per year). Many of those women are suffering from debilitating menopause symptoms because they are still very afraid of hormone therapy (HT). I want to help answer some of the most common questions that I receive about HT. This way together with your menopause specialist, you can make your healthcare decisions based on facts instead of fear and misinformation.
There was a lot of media sensationalism and confusion centering around the initial reporting of the 2002 WHI (Women’s health Initiative). Many women went cold-turkey off of their HT as a result. Almost overnight the relief from their hormone symptoms was abandoned. That is a very sad, scary fact. YIKES! Can you imagine suddenly finding yourself sleepless, foggy, hot flashing, and trying to function at work, at home, and maintain healthy relationships with the ones you love? I can’t imagine the suffering that women experienced. The feeling that they had no options but to suffer in silence.
Since the WHI, there have been lots of different reports and studies relating to HT, but sadly, once something is learned it is hard to undo – especially if fear is associated with it. I wish we could get all the perimenopausal and menopausal women in the US assembled together, and wash out all the old HT info in their brains, and start fresh in educating women about hormone therapy. Oh, and it wouldn’t hurt to have many of the practicing gynecologists and ob/gyn residents and in the room, too! You would be shocked to learn how little quality information so many of them have been taught about menopause and HT. A 2013 study by John’s Hopkins University, surveyed 510 ob/gyn residents and found that fewer than one in five had received formal training in menopause medicine, even though seven in 10 would like to receive it.
On the bright side of things, I was excited to interview Rebecca Brightman MD, FACOG (yes her name fits her!), at the Eastside Women’s OB/GYN Assoc. She is a NAMS (North American Menopause Society) Menopause Practitioner (NCMP). Her particular areas of interest are perimenopause, menopause, general gynecology, and office based surgery.
I asked Dr. Brightman some of the most common questions that I receive from women all over the world:
o What is the diff between oral and transdermal HT?
“Oral hormones are taken in pill form and transdermal hormones are administered thru the skin as either a gel, foam, cream, or transdermal patch.”
o What is the difference between bioidentical HT and non-bioidentical HT?
“Bioidentical HT are hormones that structurally are identical to the hormones that are naturally produced by a woman’s own body. Non-bioidentical hormones are synthetic hormones that act similarly to bioidenticals but they differ on the molecular level. Synthetics tend to be less expensive than bioidenticals. Many women are confused when it comes to bioidenticals. While there are many FDA approved safe bioidentical options for women, some prefer to use products that are produced by compounding pharmacies. There is a lot of controversy surrounding the use of compounded bioidenticals as these products are not held to the same quality control standards as the hormones which are FDA approved. However, there are some women who do not tolerate FDA-approved HT, or components of HT, whether it be a sensitivity of an allergy. Those women may benefit from products offered by a reputable compounding pharmacy.”
o Most women are confused about when to start HT. They experience many debilitating symptoms during perimenopause. What are the thoughts on going on HT during perimenopause?
“HT is intended to treat the VMS (vasomotor symptoms) that occur once a woman is menopausal. By definition, a woman is post-menopausal when she has gone for a full year without a menstrual period. While hormonal blood levels may suggest that a woman is menopausal, these levels can fluctuate in the perimenopausal years leading up to menopause. Women still ovulate during the perimenopausal tradition, so for many of these women, a low dose birth control will both alleviate their symptoms as well as regulate any irregular bleeding that they may have. They may continue on oral contraceptives until they are 51 (the average age of menopause in North American women). If they are not yet menopausal, they may be continued on OCPs. If a perimenopausal woman is started on HT, the HT will not suppress ovarian function and HT alone may not provide hormonal stabilization and in addition, may result in the nuisance of irregular bleeding.”
o What symptoms are best treated with HT?
“While HT is FDA approved in the US for treating vasomotor symptoms and are the most effective way of treating night sweats, hot flashes. In addition, many women on HT report an overall improved sense of wellbeing, mood stability, maintenance or improved bone density, prevention or treatment of vaginal dryness, maintenance of skin elasticity.”
o Heart disease, not breast cancer is the #1 killer of women. We know that the decline in estrogen may increase total cholesterol, decrease plaque formation or improve the inner layer of the artery wall. It makes sense that low estrogen is a factor in the increased heart disease seen in postmenopausal women. If a woman has a history of heart disease in her family, why wouldn’t physician recommend HT earlier to prevent plaque build-up?
“Prior to 2002, it was felt that HT decreased a women’s incidence of cardiovascular disease. The WHI study of 2002 showed an increased risk of cardiac disease in women over the age of 60 who were taking conjugated estrogen and the progesterone medroxyprogesterone acetate (non-bioidentical HT). These findings pertained to an older group of women who started HT well after menopause. Additional studies have been performed since 2002 and the WHI study data has been revisited. It is now felt that there is a cardioprotective benefit if women start HT during early menopause within 5-10 years of their final period. This has been referred to in the medical literature as “the timing hypothesis” The use of HT has to be individualized and the above woman doesn’t have a personal history of cardiac disease or certain cardiac risk factors, she might benefit from HT.”
o Today, many post-menopausal women over 60 years old have been on bioidentical HT for years. They feel great, they’re functioning great at work and life — but fearful if they go off their hormones they will start being sleepless, hot flashing and have their cholesterol rise? How long is it safe for them to stay on these hormones?
“I revisit the pros/cons of various HT regimens with my patients on an annual basis. We review their individual medical history and discuss whether anything has changed over the prior year. The annual appointment is a good time to re-visit the medical literature and determine what is best. As long as there aren’t any contraindications to HT, if a woman is doing well, she may stay on HT. The quality of life is a very important concern and if one is feeling well, the therapy should be continued. That being said, I have patients in their 80’s who have been regularly counseled on the pros/cons and potential risks/benefits to HT and they continue with their HT.”
o If you are a cancer survivor and experiencing vaginal atrophy is it safe to use LET (local estrogen therapy)?
“Yes! Studies have shown that there isn’t a rise in estrogen levels when women use vaginal estrogen for managing the genitourinary changes associated with menopause. I always defer to a woman’s oncologist. I take care of many women who have had breast cancer and they have been greatly helped by LET. The quality of life is extremely important and LET had made such an impact on women’s sense of well-being, sexuality, and urinary function.”
o Does LET have the same risks vs benefits are systemic hormone therapy?
“No, LET is localized estrogen therapy to treat the vaginal walls and vulvar tissues. As noted above, studies do not measure significant blood estradiol levels, so if there is any systemic absorption it is negligible. Unlike systemic HRT, LET will not treat VMS, bone density, or offer a cardioprotective benefit.”
o What effect does HT have on the thickness and the collagen content of skin in postmenopausal women?
“As women age, their skin thins and collagen content declines. Women lose about 30% of their collagen within the first 5 years of menopause. The change in skin quality can be very dramatic for women as the aging process of skin has a lot to do with heredity as well as sun exposure. As a result, many women complain that they notice their skin isn’t as moist, supple and resilient as it once was. While we can’t fight or reverse the aging process, women on HT notice less of a change in their skin during the menopausal years.”
o One of the greatest concerns of women who are considering hormone therapy is the relationship between hormone use and breast cancer. After the initial reporting in 2002 reported an increase in breast cancer from HT. Most women threw their HT down the toilet! It is now 2016, there is new information and reporting on the study and other studies giving us more information. It is important to note, that the absolute risk of breast cancer in the WHI EPT (Estrogen plus Progestin Trial) was rare. According to the National Certification Corporation, There were only 4-6 additional cases of invasive cancer per year, per 10,000 women, after 5 or more years of use. Women in the WHI ET (Estrogen-Alone Trial) arm had no increased risk after 7.1 years of use, with fewer than 8 cases per 10,000 women per year. (Writing Group for the Women’s Health Initiative Investigators. “Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women.” JAMA. 2002; 288(3): 321.)
What advice can you give women to help them evaluate the risks vs benefits of HT?
“The findings of estrogen alone are very reassuring for those women who have had hysterectomies. In those women who have an intact uterus, the progestin is necessary to provide protection to the endometrium which is the lining of the uterus. Without progesterone, the uterine lining can thicken and there is an increased risk of endometrial hyperplasia and potentially endometrial cancer.
I spend a lot of time with my patients when they are deciding whether or not to start HT. The most important question is how bothered is a woman by VMS? What does her bone density look like? Are there any other bothersome symptoms? Then we address HT as well as non-hormonal options for managing these symptoms. Are there contraindications to HT such as a family or personal history of estrogen-dependent cancers, a history of clotting abnormalities, or other medical problems that may make HT the best option. The care of menopausal women has to be individualized. It is important for women to find a healthcare provider who is comfortable and well-versed in prescribing HT and taking care of women during the menopausal years. Many physicians and health care providers are fearful of HT and don’t give consideration to its many benefits.”
Ladies, all hormones are not created equal. Nor is there a one-size-fits-all approach to menopausal symptom relief. Be sure you have a menopause specialist, such as Dr. Brightman to help ensure that you make the best healthcare decision to fit your individual needs.
My Motto: Suffering in Silence is OUT! Reaching out is IN!
If you need help finding a specialist, download my free eBook, MENOPAUSE MONDAYS The Girlfriend’s Guide to Surviving and Thriving During Perimenopause and Menopause.