I am experiencing intolerable hot flashes and night sweats since menopause, but am worried about the risks I’ve heard associated with hormones. Are they safe for me?
Many of my patients entering their menopausal years have questions regarding the treatment options for symptoms associated with this life transition. These symptoms are referred to as climacteric symptoms, and they may manifest as hot flashes, night sweats, mood swings, irritability, altered sleep patterns, vaginal dryness , and decreased libido to name a few. The lack of estrogen that is associated with decreased ovarian function during menopause is the primary cause. Traditional therapy has been to replace the lack of estrogen with medications, but many patients have fears regarding this option. A large proportion of concerns regarding Hormone Replacement Therapy came about due to a large clinical trial called the Women’s Health Initiative. The WHI began in 1991, and its primary focus was to study the potential beneficial effects of hormone replacement on cholesterol and cardiovascular health. A portion of the study was stopped early due to the surprising finding of small but statistically significant increased risks seen on coronary heart disease, stroke, venous thromboembolism (blood clots in veins), and breast cancer. These results originally caused a large stir in the medical community and changed the way many physicians approach the treatment of menopause. However, there were significant flaws with the study, including the fact that the average age of participants was 63, and patients were not eligible for the study if they had climacteric symptoms at the time of enrollment. Considering that the average age of menopause is 51, and that the reason patients consider hormone replacement is for the treatment of symptoms, this patient population was very different than women who traditionally begin hormone therapy. Looking at the data as a whole, the consensus among most physicians is that hormone replacement is an acceptable treatment option in many patients with climacteric symptoms, but that patients should take the lowest effective dose for the shortest amount of time.
I’ve heard that some women have to take 2 hormones, while others take just one. What is the difference?
Estrogen is the key hormone that is needed to treat climacteric symptoms. However, women who have not had a hysterectomy, and therefore still have an intact uterus, must take both Estrogen and Progesterone if they are being treated with hormone replacement. The reason for this is that estrogen alone causes changes in the inner lining of the uterus (the endometrium) that could potentially become a pre-cancerous condition called endometrial hyperplasia, or even endometrial cancer. Therefore, women with a uterus are also given progesterone to protect the endometrial lining from these potential harms.
Another key point about the WHI is that the portion of the study that was stopped early was the segment in which women still had a uterus, and therefore were required to take both estrogen and progesterone. For the women without a uterus that were given estrogen alone, the results from the study were very different (no increased risk of heart disease or breast cancer was seen).
Are there other effective options to treating menopausal symptoms aside from hormones?
For those women who are not eligible for hormone therapy, or wish to avoid any risks associated, there are non-hormonal options. These options include some anti-depressant medications, certain medicines used to treat hypertension or seizures, lifestyle modifications, weight loss, and over the counter herbal therapies. The data on efficacy of some of these options is quite variable. The take home message considering all of these options is that if you are experiencing intolerable symptoms of menopause, you need to have a conversation with your doctor to further discuss the risks and benefits of treatment options, and together formulate the best treatment plan for you.