FEATURE — There are many safe and effective ways to treat the symptoms of menopause, including hormone replacement therapy. But there is a lot to know about the treatment before considering it for yourself.

What is menopause?

Let’s start with the basics. The start of menopause is defined as one year of having no menstrual cycles.  The ovaries permanently stop ovulating, and estrogen and progesterone levels drop significantly. This a pretty loose definition and not one that is important to make per se. If the transition is smooth, you don’t need to officially diagnose it. The average age for women to begin menopause is 51, though anywhere between 45-55 is common.

Hormone levels are not useful as there is no threshold below which you would treat or not treat. Hormones are pulsatile in an active ovary, and the level you get may change within the hour.

After menopause starts, if symptoms of low estrogen are becoming bothersome, like vaginal dryness, hot flashes, fatigue, emotional instability and sleep disturbances, treatment can be sought. These symptoms typically last on and off for about seven years after the onset of menopause, then you are at your baseline for life. Most of the bone loss you will have is also in those seven years, so being proactive with activity is hugely important.

At the turn of the 19th century, life expectancy was in the 40s, so menopause didn’t get that much attention. We know a lot more about it now. It just varies so much from woman to woman. For some, it is a very easy smooth transition. For others, it is a very uncomfortable ride. However, there are treatments, including low dose hormone therapy.

Is hormone replacement therapy safe for menopausal women?

Here’s the long answer, based on what we know currently.

1993 — The Women’s Health Initiative Study started to test the long term health effects of hormone replacement therapy.

2003 — Due to initial concerns regarding possible negative cardiac effects, the U.S. Food and Drug Administration put a “black box” warning on estrogen products saying that they should not be used to prevent cardiac disease and should be used in the lowest doses possible. Hormone replacement use dropped precipitously after this.

2005 — “Bioidentical” hormones started being compounded as a potentially safer and better alternative to conventional treatment, though unregulated and non-FDA approved.

2006 — New WHI data emerges showing that women younger than 60 do not have the same risks of hormone replacement that women over 60 do. Estrogen use began to slowly increase again.

2017 — Based on further research from the WHI and other studies, the North American Menopause Society updated its position to say that for the majority of women under the age of 60, who are within 10 years of menopause and want relief from menopausal symptoms, the benefits of hormone therapy outweigh the risks.

Hormone replacement therapy: 5 things that you need to know

The internet is virtually overflowing with incorrect or outdated information about hormone replacement therapy and its two main players: estrogen and progesterone. Since it is a huge market and potentially a huge money maker, it gets complicated with pseudoscience, opinion and misinterpretation of facts. It is almost impossible to sort through all the nonsense. Here are a few facts may help sort the clutter:

Checking serum levels of estrogen or progesterone is virtually useless.

No physician organization recommends testing or following serum hormone levels. There is no standard for treatment or dosing. That includes saliva testing. The one test that is occasionally helpful in guiding therapy is the follicle-stimulating hormone, which is low before menopause and elevated once ovaries stop functioning.

Estrogen is primarily given to relieve postmenopausal symptoms.

Progesterone is primarily used to protect the lining of the uterus from undergoing malignant change. If you don’t have a uterus, progesterone is not necessary, and progesterone is associated with the risk of breast cancer. So it is typically omitted when the woman doesn’t have a uterus.

Vaginal estrogen (including DHEA precursors) to relieve dryness and atrophy is safe for all women.

It does not have any systemic effects and can safely be used by all women. It is ridiculously expensive, for reasons that I am not totally clear about, though.

Hormone replacement is more of a trial and error method, versus thyroid replacement, where there are definite therapeutic ranges.

There are standard doses to start on, and they can be moved up and down based on the individual woman and her needs through time (which typically decrease). I have found the vast majority of women do well on standard dosing, which is then weaned down as tolerated.

“Bioidentical hormones.”

Given the risks and potential side effects of traditional hormone replacement therapy, many women have looked at bioidentical hormones as an alternative. According to Harvard Health Publishing, bioidentical hormones are identical in molecular structure to the hormones women make in their bodies, but as opposed to being found in this form in nature, they are synthesized from a plant chemical extracted from yams and soy.

I will simply state what the American College of Obstetricians and Gynecologists said about bioidential hormones in 2016. Similar recommendation are made in the British Journal of Medicine:

• Evidence is lacking to support superiority claims of compounded bioidentical hormones over conventional menopausal hormone therapy.
• Customized compounded hormones pose additional risks. These preparations have variable purity and potency and lack efficacy and safety data.
• Because of variable bioavailability and bioactivity, both underdosage and overdosage are possible.
• Conventional hormone therapy is preferred over compounded hormone therapy given the available data.
• Despite claims to the contrary, evidence is inadequate to support increased efficacy or safety for individualized hormone therapy regimens based on salivary, serum or urinary testing.

Written by DR. SEAN LYNN,  St. George Women’s Health Center in St. George.

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