As if night sweats, mood swings, mid-section weight gain, low libido and vaginal dryness weren’t bad enough — menopause can also raise the risk of cardiovascular disease, autoimmune disorders and osteoporosis. Is hormone replacement therapy an option?
By Deborah Jeanne Sergeant
Ever since prescribing hormones for menopausal symptoms — known as hormone replacement therapy — was correlated with increased risk of blood clots, stroke and cancer, fewer doctors have offered hormone replacement as an option.
However, James Woods, OB-GYN with URMC, said that the real problem is a lack of understanding the biology behind menopause.
“You don’t need to fear menopause,” Woods said. “Your quality of life can be maintained with proper management. You just need people who understand this biology. You improve the overall health with the patient. We need specific things to be dealt with. Some women come in weeping or fearful. All they’ve been told is to ‘live with it; it’s just part of getting older.’ Or ‘It’s good news; you can’t get pregnant. Or ‘Hormones are bad; stay away from them.’”
He views menopause as not just one year without menses but a 10- to 20-year window where a woman transitions into the post-menopausal state. Each month from puberty until the early 40s, the ovaries produce high levels of estradiol at mid-cycle, when the woman’s body ovulates.
“That provides enormous positive effects,” Woods said.
Those include estradiol’s anti-inflammatory properties and its ability to boost dopamine and other “happy hormones.” But around age 40, when ovaries start to show some age, those positive effects begin to decline and by age 51 on average, women begin menopause. Since measuring estradiol levels isn’t part of a typical exam, it’s not obvious during that 10-year window that anything’s changing until other symptoms show up.
The old way of addressing menopause through hormones was high doses of estrogen-only therapy. However, estradiol is one type of estrogen. Just treating women with a dose one-tenth of what their ovaries would naturally produce offers benefits. Research from the National Institutes of Health show that estradiol helps protect bones and may improve cardiac function.
Woods said that the correlation between hormone therapy and breast cancer arose from a study with an oral product, Premarin with a synthetic, Provera, which resulted in fewer than one in 1,000 in the control group compared with the placebo group. But another part of the study using only Premarin showed a slight reduction of breast cancer.
“That has been maintained for 20 years,” Woods said. “Women carry a concept of ‘hormones cause breast cancer.’ It’s a statement that has to be broken down.”
These days, oral estrogen isn’t as commonly prescribed because more targeted delivery methods exist, like a patch or cream. Oral medication is filtered by the liver, which can raise the risk of blood clots.
Maintaining hormone levels can help reduce inflammation and promotes the body’s ability to support bone density. Woods explained that in younger women, the bones are in a constant state of building new cells and breaking down old cells. But an inflammatory response of the body disrupts that process so the bones become softer.
Hot flashes are more than a nuisance. Woods said that they can indicate a higher cardiovascular risk. The hypothalamus in the brain signals the body to develop at puberty.
“Right next to that group of two neurons is the heat center,” Woods said. “When you’re younger, you didn’t realize you have half a degree that your body temperature could fluctuate and it would send a signal that you’re hot. You lose that half a degree and it sends a signal to the brain that you’re hot.”
The body sweats as a response to get that heated blood near the surface of the skin to cool.
“It’s a cardiovascular risk,” Woods said. “If it’s not treated and stopped, those women will be at more risk of cardiovascular damage and death. It’s not just an inconvenience.”
Weight gain also affects many women between 45 and 65. Woods said that the lack of estradiol causes inflammation of the lining of the intestines and upsets gut bacteria. In turn, the body’s metabolism slows down so that it stores more fat, increasing risk of cardiovascular disease, diabetes and more.
Depression and anxiety can also increase the risk of cardiovascular disease. These mental health struggles can stem from health issues, as well as what Woods calls the “chronic stress window” of caring for aging parents, working full time at the busiest part of her career, and bearing the majority of household chores and child rearing responsibilities.
“At that stage many women realize life didn’t work out,” Woods said. “Domestic violence, divorce and kids who could be in trouble add to the stress.”
Woods said that compared with women of the same age who lack these stressors; their immune system is different from those subjected to chronic stress.
He said that the best time to begin hormone replacement is around 48, as the levels begin to dip and before inflammatory damage begins.
Woods also counsels about other, non-hormonal treatments that may help.
“The story about the risks of HRT have been confusing for both women and their medical providers over the last 20 years after the press around the Women’s Health Initiative study in the early 2000s leading to a generation of patients and clinicians terrified about HRT generally,” said physician Pebble Kranz, assistant professor of clinical family medicine and obstetrics and gynecology at University of Rochester and medical director of the Rochester Center for Sexual Wellness. “We now know that many of the findings from that study need to be evaluated in context and with more nuance.
“For most people younger than 65, HRT is not harmful and can be beneficial regarding heart, bone, sleep, mental and sexual health. Meanwhile, the current guidelines are that HRT should be used for bothersome symptoms of menopause — hot flashes, sleep disruption, vaginal symptoms and others — not for prevention of health issues of aging. As with so much in medicine, the benefits and risks of HRT should be an individualized conversation with a qualified healthcare provider,” Kranz said.
She wishes more providers would seek more up-to-date information about menopause care from organization such as The Menopause Society.
Samantha Sassone, doctorate of nursing practice, adult nurse practitioner and clinical director at Vitalize Medical & Aesthetics in Rochester specializes in HRT. She said that treating menopausal symptoms should be an individualized approach, starting with a physical and comprehensive blood work.
“Everyone is not on the same prescription,” she said. “We base it on their chief complaint, like more libido, or stopping the hot flashes or mood swings. We can tailor it to their specific needs.”
Patients receiving estradiol do so through pellets placed under the skin every four months. Sassone said they’re well tolerated and avoid the issues associated with patches and creams, such as the cream rubbing off on others or the patches falling off.
Patients receiving pellets must have a recent negative mammogram and PAP smear results and they receive follow-up appointments to keep tabs on their health.
Patients also receive follow-up appointments within six to eight weeks, including lab work and again in six months and thereafter annually.
Another of the ways Sassone treats menopausal symptoms is through peptide therapy, which mimics the pituitary gland to generate human growth hormone. This “whole body therapy” boosts mood, collagen production, muscle recovery, better sleep, libido and hair, skin and nail health.
“Each woman is different,” Sassone said. “Sometimes, it’s used for a couple of years to help them get through the symptoms. Some like the way they feel and it’s long-term.”