The Menopause Transition and Hormonal Therapies

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May 9, 2023

 The menopause transition is a challenging time filled with bothersome symptoms. It is also a period of time where women experience increasing cardiovascular risk and decreasing bone density.  We often forget that heart disease is the #1 killer of women.  The primary goal should be to manage symptoms so patients have a smooth transition, good quality of life and can focus on their overall health. 

By definition, menopause is 12 consecutive months without a period and the average age is 51-52.  Most symptoms begin during peri-menopause, which can begin up to 10 years prior.  

The Menopause Transition is a time for SHARED DECISON MAKING between you and your physician.  There are many choices to be made, and you may decide to do nothing, use complementary and alternative therapies, non-hormonal medications or hormonal therapies.  Today I will focus on the significance of menopause and issues about hormonal therapies. 

Some women have many symptoms, and some have none.  These symptoms can be significant and impact their personal and professional lives.  Hormone fluctuations are responsible for menstrual irregularities and mood changes.  Menstrual cycles can be longer, shorter, closer, further apart, heavier …  Mood changes include worsening PMS, irritability, anger and depression. 

A few other common symptoms are: 

• Hot flashes and night sweats, in up to 85% of women. 

• Dry eyes, skin, nails, hair vagina

• Brain fog, memory issues

• Headaches

• Hair changes – growing in new places and fading in others

• Acne

• Breast tenderness

• Palpitations

• Insomnia, fatigue

• Joint pain

• Bloating, weight gain

• Low libido and other sexual dysfunction, urinary symptoms, and many others.

Important factors to consider when making a joint decision with your doctor about treatment include:

• Contraception – fertility declines, but not to zero.  You can still become pregnant in your 40’s.

• Medical history – Estrogen should not be given when there is a history of blood clot, stroke, heart disease, liver disease, unexplained vaginal bleeding, a hormone sensitive cancer, or a hereditary disposition to blood clots.

• Oral contraceptives can be used unless there are the factors noted above (since OCPs contain estrogen) or a history of smoking in women over 35yo, uncontrolled high blood pressure or migraine with aura.

Hormone levels fluctuate throughout the menopause transition and are not a reliable way to diagnosis menopause. Treating symptoms and not numbers should be the primary goal.

Some women request and prefer compounded hormones, which are marketed as ‘bioidentical’ and ‘safer than other hormones’, but in fact they are not regulated or FDA-approved and have inconsistent quality and safety.  If patients choose compounded hormones, I make sure they’re aware of the quality and safety issues and explain that we have FDA-approved hormones that are identical to the estrogen and progesterone made by their ovaries, and these should be covered by their insurance plan. 

A 2002 report from the Women’s Health Initiative Study noted an increased risk of heart attacks, strokes, blood clots and breast cancer in the estrogen-progesterone arm.  Many had their hormone replacement stopped abruptly.  Subsequently, re-evaluation of the data led the North American Menopause Society (NAMS) to publish a special statement in 2012 reassuring providers regarding the safety of these hormones in certain groups.  Every five years since, NAMS has reaffirmed its statement. Hormone replacement therapy used in healthy women less than 60yo and within 10 years of menopause has benefits for cardiovascular health, bone density, diabetes and menopausal symptoms and also reduces all cause mortality.

Here are some hormone replacement guidelines that you can discuss with your physician, to adapt to your personal situation:

• Estrogen alone if you’ve had a hysterectomy

• Estrogen and progesterone if the uterus is still present – cyclic or continuous regimens

• Lowest effective dose to address symptoms and minimize risk

• Transdermal estradiol (applied to the skin) is preferred in patients with cardiovascular risk factors and those deciding to continue hormones past 60 years of age.  

• After age 60 or 65, hormones may be continued in some, but risks need to be discussed.

• Micronized progesterone (Prometrium) is preferred over synthetic progestins (Provera, Norethindrone).  Progesterone is less likely to cause clots, possibly better for mood, and has a lower or no risk of breast cancer.  It is sedating and may help with insomnia.  

Whatever decision is made, periodic evaluation of symptoms and medical history is imperative to adjust therapy if needed.