Menopause occurs when menses stop and ovarian activity largely ceases. By definition, a woman is menopausal when her menses have stopped for 12 months. In North America, the median age of menopause is 51. Most women experience a variety of menopausal symptoms during the years preceding the final menstrual period (perimenopause). This transition may last many years.
The risks and benefits of hormone replacement therapy dominate any conversation about hot flashes, night sweats, sleep disturbance, vaginal dryness, urinary frequency, and a host of other symptoms accompanying menopause. There are no “absolute” answers, but high-quality research over the last 25 years has given us enough information to recommend treatment regimens for almost any combination of menopausal symptoms.
The Women’s Health Initiative (WHI), published in 2002, forever changed our clinical practice regarding long-term hormone replacement therapy in menopausal women. This nation-wide study was designed to determine the role of long-term hormone replacement therapy (either estrogen by itself or combined estrogen and progestin) in postmenopausal women’s health.
In this study, the overall risk of developing breast cancer was found to be increased in patients taking combined estrogen and progestin. The study was halted because of this finding. Later studies have confirmed this link between progestin and an increased risk of breast cancer. Patients taking combined estrogen and progestin also showed an increased risk of coronary heart disease, stroke and blood clots. These risks outweighed the decreased risks of osteoporotic fractures and colon cancer.
It is important to note, however, that NO increased risk of developing breast cancer has been found in patients taking estrogen alone.
Unfortunately, the ability of estrogen and estrogen/progestin therapy to relieve menopausal symptoms remains unquestioned and unequalled among all currently available medical or alternative therapies. In short, nothing equals estrogen in its ability to minimize these symptoms. Nothing. We have no high-quality studies showing that progesterone alone, testosterone alone, nor “bioidentical” hormones are superior to estrogen with or without progestin in alleviating menopausal symptoms.
As most every menopausal woman will tell you, these symptoms can make life miserable and the long-term effects (vaginal dryness, atrophy, pain with intercourse, and bladder symptoms) only worsen with time.
We now have a huge variety of estrogen preparations. Estrogen comes in pills, patches, creams, lotions, sprays, vaginal rings, and pellets, to name a few. Every woman responds differently to these preparations. Our task is to identify the most cost-effective and efficient mode of estrogen delivery that will alleviate your symptoms. Progesterone and testosterone can also be added to the treatment regimen when indicated.
Our goal is simple. Always, always use lowest dose of hormones that will minimize your symptoms. This is an extremely important concept. Use the lowest dose possible to minimize any potential risks. It is true of all therapies that we use, but it is especially important for hormone replacement therapy, which can result in life threatening side effects. The dose can always be increased when necessary.
If a menopausal woman still has her uterus, progestin must be used (in one form or another) along with estrogen. The progestin “protects” the lining of the uterus from the stimulating effect of estrogen. Since it appears from the WHI study that progestins may be partially responsible for the increased risks of cardiovascular disease, stroke and breast cancer, we always minimize the duration and dose of progestin treatment in postmenopausal women. The stimulating effect of estrogen can also be monitored with transvaginal ultrasound examination of the uterine lining. See our page on ultrasound for more information.
If you have experienced no menopausal symptoms, there is no reason to take hormones. None. The potential long-term benefits of estrogen have largely been disproven. The risks associated with estrogen therapy are not offset by any long-term benefits. If they made us younger and thinner, with better skin and hair, we would all be taking them.
How long should you take hormones? Based on current knowledge, you should take estrogen as long as you are experiencing menopausal symptoms that interfere with your lifestyle when you stop taking the hormone. When should you stop therapy to find out if you still need estrogen? There is no precise answer, but most gynecologists would suggest around age 60.
Since new data on hormone replacement therapy is published every month, any one of our recommendations may change during any given year. That’s one of the many things that make the practice of medicine fun and challenging. During an annual visit, we review any new and pertinent information about our patient’s medications (including hormones, vitamins, and supplement) and discuss recommendations for changes. Medicine changes daily and we must “keep up” if we are going to properly advise our patients.
To find out whether the menopausal symptoms have resolved or have become more tolerable, we recommend discontinuation of our patient’s hormones for 2-4 weeks. If the symptoms recur and are intolerable, we resume therapy, sometimes at a lower dose. If there are no noticeable changes after stopping hormones, there is no reason to restart them.
Several “natural” products have been used for the management of vasomotor symptoms. In the United States, none of these complementary therapies are regulated by the FDA and none have been tested for safety, efficacy, or purity because they are considered nutritional supplements. Studies show that phytoestrogens, herbal supplements, and lifestyle modifications are no more effective in the treatment of menopausal symptoms than placebos.
Several studies have evaluated the effectiveness of acupuncture for the management of vasomotor symptoms. A meta-analysis of six randomized-controlled studies showed no benefit over placebo for vasomotor symptoms. Similarly, reflexology has not been shown to significantly reduce vasomotor symptoms compared with nonspecific foot massage.
The following points on hormone replacement therapy are summarized from the ACOG Practice Bulletin of January 2014 (updated 2016)
- Hormone replacement therapy (with estrogen alone or in combination with progestin) is the most effective therapy for vasomotor symptoms related to menopause.
- The lowest dose of estrogen is associated with a better safety profile than standard doses and are often effective in reducing menopausal symptoms.
- It is recommended that gynecologists treat women with the lowest effective dose for the shortest duration that is needed to relieve menopausal symptoms.
- The risks of combined estrogen and progestin therapy include thromboembolic disease and breast cancer.
- Selective serotonin reuptake inhibitors, clonidine, and the gabapentin are effective alternatives to hormones for the treatment of menopausal symptoms in patients unable to take hormone replacement therapy.
- Estrogen therapy often helps the symptoms of vaginal atrophy. If the woman has only vaginal symptoms (dryness, pain with intercourse), topical vaginal therapy is preferred.
- Data do not support the use of progestin-only medications, testosterone, or compounded bioidentical hormones for the treatment of menopausal symptoms.
- Data do not show that phytoestrogens, herbal supplements, and lifestyle modifications are effective for the treatment of vasomotor symptoms.
- Non-estrogen water-based or silicone-based vaginal lubricants and moisturizers may alleviate vaginal symptoms related to menopause.
- The decision to begin or continue hormone therapy should be individualized, based on a woman’s symptoms and her individual risk–benefit ratio, regardless of age.
In summary, our responsibility is to provide our patients with current scientific knowledge of the risks and benefits of hormone replacement therapy. Each woman should use this knowledge (in combination with her menopausal symptoms and response to hormones) to determine whether to begin or continue therapy. This requires ongoing dialogue between each of us and our patients, empowering each one to actively participate with and take responsibility for her own health care.