Thursday, January 18, 2018

Menopause happens: Start hormone replacement therapy, and for how long?


She could put up with the annoying hot flashes, even if they did wake her up three or four times a night. But when the panic attacks and unexplained crying started last December, Laurel Hall knew she needed help.

The normally positive, confident environmental engineer found herself overwhelmed at least once a week by sudden feelings of dread and sadness. "If it had just been the hot flashes, I may have toughed it out," said the Odessa woman, 56. "But when the panic attacks started, I was afraid it would hit when I was doing my job."

• • •

Hall found a specialist who explained that her symptoms were caused by normal hormonal changes associated with menopause — primarily a drop in estrogen and progesterone.

"It was so bad, I sat in his office and just cried like a blubbering baby and I was thinking, this is somebody else. This is not me," Hall remembers.

"It's shocking that a hormone imbalance can affect you so severely."

For most women, hormone production starts declining slowly in the 30s. It becomes more pronounced as women go through their 40s, and usually around age 50, menstrual periods stop. The schedule is of course more dramatic for women who have had a total hysterectomy.

Technically, menopause is said to begin one year after a woman's last period. For some, the hormonal change is so gradual that it's hardly noticeable, except for the absence of monthly periods. For others, symptoms range from mild to severe. The most common and bothersome are hot flashes, sleep disturbance, vaginal dryness and mood swings.

It's a natural part of life, but as the baby boom generation ages, we're hearing more than ever about menopause.

"So many women are affected," said Dr. Barry Verkauf, director of the new Menopause Center at the University of South Florida in Tampa.

"There's a huge population of women entering menopause now, compared to 20, 30 years ago when the big issue was infertility. Now it's menopause. So there's more of a need than ever for knowledge to deal with it," he said.


Doctors have treated menopausal symptoms with hormone replacement therapy since the 1950s. It has fallen in and out of favor over the years; at its peak popularity, doctors were touting its efficacy for preventing everything from cancer to heart disease to wrinkles.

HRT took a big hit in 2002 when the Women's Health Initiative, the largest government-sponsored clinical trial to evaluate hormone therapy for disease prevention, found disturbing results. The combination estrogen and progestin therapy given to women who still have a uterus was found to increase the risk of stroke, heart attack, blood clots and breast cancer.

The hormones are combined to prevent endometrial cancer, which is not an issue in women who have no uterus. Women who had a hysterectomy could take estrogen alone, and in this group, the study found an increased risk of stroke and blood clots.

The good news: Both groups had a reduced risk of bone fractures.

But since the initial data were released, additional research has returned more reassuring results. Taking estrogen alone did not increase breast cancer risk, but neither did it prevent heart disease, as so many women had been led to believe.

But beginning hormone therapy several years after menopause starts — rather than at the onset of symptoms — may increase the risk of dementia.

It's a lot to take in. The North American Menopause Society has the distilled the latest research in its 2012 position statement to help women and health providers make informed treatment decisions.

In general, the younger you are when you begin the therapy and the less time you're on it, the lower your risk.

"It's still a good therapy for women with intolerable symptoms, but it isn't without risk," said Dr. Margery Gass, the organization's executive director.

"The bottom line is, you have to ask, which risks are you willing to take?" For example, birth control pills carry a risk of blood clots, but they prevent pregnancy. "So, for some women, the benefit outweighs the risk," said Gass.


Laurel Hall, who is a patient of Dr. Verkauf's, asked about health risks before she started treatment. Because her heart disease risk is low, she has no family history of breast cancer, and she'd had a partial hysterectomy and would only need estrogen, she decided to give it a try.

"It was worth it for me," she said, "I was willing to roll the dice. That's how bad I felt."

Some doctors ask their patients to consider alternatives before going on hormone therapy.

"I'm a lot less quick to prescribe systemic estrogen like you get in a patch," said Dr. Anna Parsons, director of image-based gynecology at USF Health. "It isn't my first choice."

If hot flashes are the problem, Parsons may suggest the drug Neurontin (generic name gabapentin, used also for seizures and neuropathic pain), or the plant-based supplement black cohosh. For vaginal dryness, small amounts of an estrogen-based topical cream can alleviate the problem at a lower dose of hormone.

For interrupted sleep, low dose SSRI antidepressants such as Prozac sometimes are effective. For bone thinning, bisphosonates given for osteoporosis are an alternative, she said.

Finding alternatives is important because not all women can take estrogen. Liver disease, recent stroke, heart disease, a personal or family history of abnormal blood clots, and a history of breast and certain gynecological cancers all are conditions that disqualify a patient from HRT.

Most experts agree, if you decide to try hormone therapy, take the lowest dose that's effective, for the shortest amount of time possible.

"It takes very little estrogen to stop symptoms in most women," said Parsons. "And if a vaginal cream is prescribed, we recommend a tiny amount, only a pearl-sized amount, twice a week."


Current guidelines recommend limiting hormone use to two to five years, after which most symptoms naturally resolve themselves.

But for patients who still have symptoms, continuing therapy may be an option for women at low risk of the complications that become more common with age.

Parsons said women who maintain a healthy weight, exercise regularly and don't smoke are better candidates for continued hormone therapy.

These days, so many women are sedentary, overweight, diabetic and/or hypertensive that especially as they get into their 60s, "estrogen could be the factor that tips them over into serious trouble," she said.

What about staying on hormones as a sort of "fountain of youth''?

"There is no reliable, scientific data to support that," Parsons said. It's much better to protect yourself from the sun and not smoke if you want to improve your skin and prevent wrinkles. Take calcium and vitamin D and do weight-bearing exercise to strengthen your bones, and watch your nutrition to look good outside and inside.


Bioidentical hormones, plant-derived estrogen and progesterone that can be made by a compounding pharmacist or are manufactured like conventional drugs, are a popular alternative to prescription estrogen. They are also heavily marketed to fight natural signs of aging, including thinning hair, wrinkles and diminished sex drive.

"Some women think bioidenticals are safer than prescription hormones, but they aren't," said Dr. Madelyn Butler, an obstetrician-gynecologist with the Woman's Group in Tampa. "They are still estrogens. I'm fine if patients want to use them, but they carry the same risks."

Compounded hormones are not FDA regulated and so are not subject to the same oversight as prescription medications. Verkauf says you really have to trust the compounding pharmacist to consistently deliver a pure, high-quality product at the proper dose.

Some commercially produced, FDA-approved hormones are derived from plants and are considered bioidenticals, including Estrace, Climara patch and Vivelle Dot patch.

Laurel Hall was so eager to get relief from her symptoms that she put on a sample hormone patch before leaving the doctor's office. Within days the nighttime hot flashes stopped; within two weeks she felt like a new person.

"I wasn't depressed. I had more energy. My co-workers said I even looked different," she said. "It came down to quality of life for me."

But doctors stress that each woman must be evaluated individually, taking into account her menopausal symptoms, pre-existing conditions, heart disease and cancer risk, and her comfort level with taking additional risk.

"We used to put all women on hormones before the Women's Health Initiative study, just because it made them feel better," said Butler.

"Now we look at each woman individually. But know this: If you take hormones, you can't afford to miss a mammogram."

Irene Maher can be reached at [email protected]

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