More than 1 million women in the United States experience menopause each year. Yet we are still in the dark about what to do about the troublesome symptoms that embrace this phase of life. Those symptoms can vary for each woman but primarily consist of intrusive hot flushes and night sweats with many hours of lost sleep. Low energy and mood changes that can disrupt work and relationships. Brain fog and difficulty grasping words which cause anxiety around the question of whether you are entering the beginning stages of Alzheimer’s disease. Then there’s the weight gain (especially in the mid-section) along with hair loss, dry skin, dry nails and eyes. The worst part is the fact that these symptoms begin 6 months to 12 years leading up to a woman’s last period, known as peri-menopause. This starts when women reach their late 40’s due to hormonal spikes and dips of estrogen and progesterone as the last eggs of the ovaries start to plummet in number. Irregular menstrual bleeding can also accompany these other symptoms making this time in a women’s life unpredictable. This presents confusion about where to turn for answers and options to get their lives back. Here is what you need to know about hormone replacement therapy (HRT).
Hormone replacement therapy has been around for many years (since 1942) until it took a dramatic turn. The prescriptions for hormone therapy, which was once the most commonly prescribed treatment in the United States suddenly dropped due to a 2002 poorly designed study finding links between hormone therapy and elevated health risks for women of all ages. This single study did women a disservice in how it generalized the use of HRT as opposed to what the study really was about- the unsafe and one-size-fits-all synthetic oral hormone, Prempro. The reasonable thing to do for women who were taking Prempro was to contact their gynecologist and yes, stop that form of HRT but to then discuss other hormone options. But instead, women flushed their pills down the toilet and never looked back. The message was “Hormones are Dangerous”.
It has been a disgrace to see women not even offered the option of HRT when symptoms were quite significant and after they had suffered years of unnecessary discomfort.
Hormone therapy can carry risks as do many other medications that people take to relieve serious symptoms. But dozens of studies since 2002 have provided reassurance for healthy women under the age of 60 or within 10 years of the onset of menopause who are free of contraindications. And the message is that the use of hormone therapy is safe and appropriate. The treatment’s reputation, however has never fully recovered and the consequences have been wide-reaching. It has been a disgrace to see women not even offered the option of HRT when symptoms were quite significant and after they had suffered years of unnecessary discomfort. Instead women are offered a pill for their insomnia, a pill for their depression, a pill for their newly diagnosed osteoporosis, a pill or injection for their diabetes, a pill for their high blood pressure, a pill for achy joints, a pill for their high cholesterol and plaque (caused by endothelial damage). Is it possible that there is a treatment for all these symptoms but has been overlooked by doctors? Yup! And it’s hormone replacement therapy. I am not saying that women would be immune to these conditions if they were on HRT, but it would be significantly less, if at all. This is just another example that reflects the medical culture’s challenges in keeping up with science as well as a representation of a lost opportunity to improve women’s lives.
Rebecca Thurston, a professor of psychiatry at the University of Pittsburgh who studies menopause, believes menopausal women have been underserved- an oversight that she considers one of the great blind spots of medicine. She states “it suggests that we have a high cultural tolerance for women’s suffering. It’s not regarded as important”.
So what does this mean now? Guidelines on hormone therapy from The North American Menopause Society has recently updated their 2022 position statement from 2017. It states that treatment should be individualized using the best available evidence to maximize benefits and minimize risks. Timing is important and the type of hormones are important. The risks of hormone therapy differ depending on type, dose, duration of use, route of administration, timing of initiation and whether a progestogen is used. The benefit-risk ratio appears favorable in lowering the risk of coronary heart disease, stroke, venous thromboembolism osteoporosis, depression and dementia for those that initiate treatment younger than 60 years or who are within 10 years of menopause and have no contraindications. Most women start HRT due to bothersome vasomotor symptoms (hot flushes) and genitourinary symptoms. Longer durations of therapy beyond the age of 65 are for persistent symptoms and women should be a part of the decision-making as periodic evaluation continues.
I still have patients tell me that their doctors insist they go off their HRT because they have been “on it for too long”. Do we say the same thing about a man’s testosterone or Viagra prescriptions?! Both women and their providers became very fearful after the 2002 WHI study. It is time to clarify and reassure women that hormone therapy can be given safely and effectively to relieve women’s symptoms and improve their quality of life as long as they are being monitored and the benefits continue to outweigh the risks. We also know that these hormones can delay or prevent many long-term degenerative diseases that are caused by aging. If women are expected to live on average another 30 years after menopause, let’s at least offer them the best quality of life for the years ahead.
We have come a long way…but we’re still not there. Let’s open up the discussion and allow women to voice their concerns and complaints without shame or guilt on whether their discomforts are “significant” enough. They deserve to ask questions and get reliable answers based on current studies with sound guidelines that we currently have, and not a study that was over 20 years old! More research is always needed to help navigate this topic not only for menopausal women now but for our younger generation of women moving forward.
References: Faubion, S, et al. NAMS Position Statement: The 2022 hormone therapy position statement of The North American Menopause Society. Menopause: The Journal of the North American Menopause Society, Vol 29. N0. 7, pp 767-794.
Dominus, S. Women have been misled about menopause. The New York Times magazine. February 1 2023. pp 1-19.
Kaunitz, A. Guidelines on HT have been updated by The North American Menopause Society. OBG Management. June 2017, Vol. 29, N0. 6. pp 18-23.
https://www.nia.nih.gov. Research explores the impact of menopause on women’s health and aging. May 6, 2022.