by Dr. Kate
Do you feel like yourself? Do you feel like your hormones are out of whack? Maybe you have hot flashes and night sweats which are classic peri/menopausal symptoms. But maybe you are irritable, moody, bloated, don’t sleep well and don’t think as well as you used to. Or perhaps you are having trouble losing weight. These common symptoms are likely an indication of a hormone imbalance and are very common in the years surrounding menopause.
I frequently see women with some or even all of these issues. The experience of women navigating the years before and after menopause differs significantly. Some women sail through with minimal symptoms, others struggle. A lot. For various reasons, many listed above, they just don’t feel like themselves anymore. Are you one of them? If so, you may be interested in hormone therapy. You may not. If not, is it because you are concerned about the risks of taking hormone therapy? Maybe your symptoms are tolerable, and you just don’t want to take medication. Fair enough.
Many, but not all, women on hormone therapy report an all around improved quality of life. Everything is better. Skin, hair, memory, sleeping, anxiety, sex and the list goes on. It’s all better. The improvement in their quality of life is significant. I have counseled patients for years that if you are one of the women whose overall quality of life is dramatically improved with hormone therapy; you should take it.
Of course, before 2002 the recommendation was for all peri/postmenopausal women to be on hormone therapy because we thought it protected against heart disease and osteoporosis, in addition to improving quality of life. That changed in 2002.
Women’s Health Initiative
As you may remember the Women’s Health Initiative was that big study that looked at hormone therapy in menopausal women. It was the largest hormone study ever done. It looked at three different groups of women. One was on combined estrogen and progestin; another was on estrogen alone, and the third was a group on a placebo.
One part of the study was halted in 2002 when, instead of reducing their risk of heart disease, women in the combined estrogen and progestin group had an increased risk of both heart disease and breast cancer. The rest of the study, which was menopausal women on estrogen alone and placebo, continued. Progestin is added to hormone therapy to protect the uterus from endometrial cancer. Thus, if you have had a hysterectomy, you can take just estrogen. There are reasons why, even after a hysterectomy, you may want to take progesterone instead of a progestin like Provera which is what women in the Women’s Health Initiative were taking, but I’ll get to that later.
The issues in the combined treatment group were seven more women in 10,000 were diagnosed with breast cancer and eight more were diagnosed with a non-fatal cardiac event, i.e., heart attack. So at the time this was huge news. Doctors had been recommending hormone therapy to asymptomatic women for prevention of heart disease and low and behold instead of being protective, hormone therapy caused an increase in heart disease. Yikes. But here’s where the story gets complicated.
The women in the Women’s Health Initiative were older; the average age was 61. Most women encounter the menopausal transition around age 50. The median age for completing menopause- that means not having any periods for a year- is 51. But symptoms can start much earlier, even in your late 30s. Women could not participate in the study if they were experiencing any menopausal symptoms. More data from scientific studies is coming out that shows estrogen does have a protective cardiovascular effect but only in younger women, that is women younger than 60 or within ten years of menopause. In these circumstances, hormone therapy is associated with a decrease in cardiovascular events.
The association with breast cancer gets even more complicated. Data from the original hormone study, the Women’s Health Initiative, showed that women who were only taking estrogen had a decreased incidence of breast cancer. Yes, you heard that right. DECREASED incidence of breast cancer. In fact, the women taking estrogen alone had a lower rate of all-cause mortality. Yep, less cancer and heart disease. So it looks like it’s not the estrogen that causes cancer or heart disease but perhaps the progestin.
Now other studies have shown there is still a risk of breast cancer, but it is quite small. One more woman out of 1200 will be diagnosed with breast cancer, which is a risk to be sure, but a risk equivalent to the risks of other lifestyle issues like obesity, being sedentary or drinking 1-2 glasses of wine every night.
The International Menopause Society recently updated its guidelines to reflect the current data.
“New data and re-analyses of older studies by women’s age show that for most women, the potential benefits of MHT given for a clear indication are many, and the risks are few when initiated within a few years of menopause.”
Hormone Therapy
I see women who are miserable with various menopausal symptoms. Hot flashes, night sweats, insomnia, mood swings, decreased libido, memory problems, and the list goes on. They are hesitant to start hormone therapy because of the potential risks. Starting medication is not something to take lightly. You should carefully consider any possible risks. But as the International Menopause Society has just stated in their updated guidelines, the risks are few for women who start close to menopause or before. If you just don’t want to take anything, I get it. (I have some suggestions to help you balance your hormones naturally without medication.)
The recent scientific studies support the premise that hormone therapy is safe, beneficial and may even be protective. And that is with conventional, synthetic hormones. There is additional data regarding Bio-identical Hormone Therapy. Bio-identical hormones are compounded with hormones that are the same structure as those made naturally in our bodies and seems to have even fewer risks associated. One big difference is that Bio-identical hormone therapy uses natural progesterone instead of a progestin, like Provera. Natural progesterone appears to have multiple beneficial effects including reduced anxiety and depression, improved sleep, and improved lipid profiles.
Dr. Kate Killoran is a board certified physician specializing in Gynecology. In recent years, Dr. Killoran retired from OB/GYN surgery to focus more on providing holistic well woman care and gynecology with integrative and lifestyle medicine. Learn more at drkatemd.com.