Hot flashes, night sweats, insomnia ...
If there’s a way of reducing menopause symptoms we want to know. But is hormone therapy the best solution?
Marilyn Joseph, a 59-year-old graphic designer from Portland, Ore., has strong memories of the turbulent years surrounding menopause. “ Although the hot flashes were unpleasant, they were, at least, predictable, unlike my emotions, which were all over the place,” she says. When her doctor prescribed oral estrogen therapy, Joseph thought she had a solution: “It was fantastic.
I was back to the premenopause me—levelheaded, reliable and
capable of watching a movie without bursting into tears every five minutes.”
However, within a few months, Joseph started to experience irregular uterine bleeding. In retrospect, she says, “Hormone therapy suits some women, but I had to accept that I wasn’t one of them.” Joseph eventually managed to reduce her symptoms with herbal medicine, but it took a lot of trial and error, and maybe it was just the passage of time.
Like Joseph, not all women are convinced that the benefits of hormone therapy outweigh the risks. Indeed, many women are decidedly cautious—partly due to the well-publicized results of the Women’s Health Initiative (WHI), a federally funded study of the effects of the most common form of oral hormone therapy used by postmenopausal women in the United States.
The WHI’s goal was to see if most postmenopausal women should use hormone therapy (HT) to prevent heart disease. The findings were surprising. One part of the study, which included 16,608 healthy postmenopausal women aged 50 to 79 who still had their uteri, found a small increased risk of heart attack, blood clots, stroke and breast cancer in those taking oral Prempro®, an estrogen/progestogen form of hormone therapy (EPT). A second arm, studying 10,739 older women who had had hysterectomies, found an increased risk of stroke in those taking oral Premarin®, estrogen-only therapy (ET).
In the aftermath of the findings, millions of women quit using hormone therapy. The FDA directed that estrogen products approved for hormone therapy needed to state in their prescribing information that hormones should be used for the shortest possible time and the lowest possible dose. The North American Menopause Society has published a series of position papers on hormone use. They conclude, “current evidence supports the use of ET and EPT for menopause related symptoms and disease prevention in appropriate populations … of women.”
Basically, hormone therapy continues to be prescribed because nothing seems to work as well for moderate to severe hot flashes, night sweats, sleep disturbances and vaginal changes associated with menopause.
“Hormone therapy is the drug of choice for these symptoms,” says Wulf H. Utian, MD, PhD, NAMS Executive Director and a menopause researcher. “With the information that we have, it’s a remarkably safe approach.”
The WHI also confirmed that hormone therapy helps prevent osteoporosis and bone fractures and may have a positive effect on other conditions, such as colon cancer risk.
“Because the WHI findings were based on older (average age 63), postmenopausal women with minimal symptoms, it’s unclear what the results mean for younger women whose symptoms are more severe,” says Utian.
“The chance that the serious conditions noted in women using hormones in WHI occur in women aged 45 to 55 is very, very low,” he notes.
“This is the age group that’s most bothered by symptoms.” Using the statistics from the WHI study on older women, Utian continues, “Are you going to deprive 1,000 women relief for one potential side effect that is not going to increase mortality? Nobody’s shown an increase in death rates from any of this.”
“The risks are very small,” agrees Susan Hendrix, DO, a professor of obstetrics and gynecology at Wayne State University School of Medicine in Detroit and a principal investigator in the WHI. “But they’re real risks. They’re life-altering events (stroke, heart attack, breast cancer), and they can be serious.”
The hormones studied in the WHI were oral therapies providing “systemic” levels of hormones throughout all the body’s systems. These medications are proven to be effective for treating most menopause symptoms, including hot flashes and vaginal dryness. However, if vaginal dryness is the only reason for considering hormone therapy, local estrogen therapy applied inside the vagina is the best choice. Nothing else works as well—and risks are thought to be minimal.
What’s Right for You? The decision to use hormone therapy, to try an alternative or to simply adopt a healthy lifestyle and wait out meno-pause symptoms with no treatment, is highly personal. Each woman needs—and deserves—individualized care, not a blanket one-size-fits-all prescription. Although healthcare providers con-tinue to learn more about the effects of hormone therapy on groups of women, they will never know the complete impact for each individual. What’s important is that you make your decision fully aware of what is known about any potential consequences and what is uncertain.
“What you choose should be based upon your health, symptoms, lifestyle concerns and discussions with your healthcare provider about the pros and cons, as they apply to you” says Marcie K. Richardson, MD, Director of the Harvard Vanguard Menopause Consultation Service in Boston and NAMS Editor for Changes. “I say to women, ‘These are what the benefits might be. These are what the harms might be. How scary are these harms to you? How important are these benefits?’ If the potential benefits outweigh the potential harms, then a trial of hormone therapy—starting with a low dose—has very little downside for most women.”
It’s worth remembering the effect of hormones on your bones. After menopause, without using systemic estrogen, bone strength falls off rapidly. Long-term estrogen therapy helps keep bones strong, but its associated risks limit its use for this purpose alone.
Time to End the Hormones? As you progress into menopause and your symptoms subside, reduce or stop hormones as appropriate and in consultation with your healthcare provider. If symptoms persist, hormone therapy can be resumed.
In Richardson’s practice, women had a wide range of experiences when they ended hormone therapy after WHI, she says. “Some went off and didn’t notice much of a difference. Some went off and had horrendous symptoms.” Some even had worse symptoms after stopping the medication than when they first started taking it, she said.
Richardson advises her patients to taper off, although she admits there are little data on whether this limits symptoms.“If a woman doesn’t want to go back on estrogen, I try to help her find alternatives,” she says. “If someone’s symptoms are making her miserable, and she understands the potential risks, I help her go back on hormones, identifying the lowest dose that provides enough relief of symptoms to make her comfortable.”
Hot flashes generally end eventually, usually a few years after menopause is reached, although sometimes they go on longer. Vaginal dryness can continue to worsen as women age. As you progress beyond menopause and your symptoms subside, it may be time to rethink your options—again. |
