Menopause. General Information.
MENOPAUSE
*Turn the thermostat down to reduce hot flashes
• Use the lowest-dose estrogen and progesterone therapy for the shortest time possible
• Try Remifemin for hot flashes ***
• Eat tofu or tempeh or drink soy shakes **
• Ask your doctor about Paxil (paroxetine) or Effexor (venlafaxine) for hot flashes
• Inquire about Neurontin (gabapentin) for hot flashes
• Apply olive oil topically for vaginal dryness
• Squeeze vitamin E out of a capsule as a sexual lubricant
• Experience slippery sex with Sylk
• Experiment with aloe vera gel
• Get a prescription for Estring (estradiol) ***
Decades ago, menopause used to be referred to in whispers as The Change. The mystery surrounding the event gave it a sinister aura. Now, though, more than 5 000 women enter menopause every day in the United States. ~21 That’s because the baby-boom generation is aging. We are not a bashful bunch, and female boomers have brought menopause out in the open. Women refer to hot flashes, somewhat jokingly, as power surges. But few women relish them. Most would like some way W ease this symptom, even it it is the consequence of a perfectly natural biological process.
We ought to begin with some explanation of menopause. Most people know this refers to the time when a woman’s ovaries stop making the hormones that support the ripening and release of eggs. It is a gradual process that may be spread out over years, perhaps even a decade, and is properly referred to as perimenopause. Menopause itself is technically just one point in time: the day when an entire year has passed since the end of a woman’s last menstrual cycle.722 The average age on this day is 51 years, but women may be as young as 40 or as old as 58 and still be within the normal range for menopause.
Just as the timing of this change in ovarian function differs from one woman to another, so do the timing and intensity of menopausal symptoms (yes, we should be calling them perimenopausal symptoms). Some women barely notice a hot flash or two. We’ve even spoken with women who had “cold flashes” rather than hot flashes. Others are distressed by intense heat waves that may plague them daily for years. Most fall between those extremes but would still welcome some respite from the sweating, the flushing, and the distracting feeling that they might spontaneously combust. (Not to worry—that has never happened!)
I hope you can recommend something for my wife, who feels like she is about to burst into flames. Her doctor suggested Premarin, but she refuses to take it because she is worried about the increased risk of breast cancer What other options are there?
If it is any comfort, this period of discomfort lasts about 4 years, on average. That means, though, that some women zip through it much more quickly, whereas others take longer, sometimes much longer, to get through to relief.
The Hormone Controversy
For years, women suffering from hot flashes and other menopausal discomforts were told that their doctors had the magic solution: Just take hormones to replace the ones their ovaries were no longer making. Hormone replacement therapy, or HRT, has had its ups and downs over the decades, beginning with Premarin’s approval in 1942. Since then, more than 30 billion doses of this h101MIOnt di Wled from pregnant mares’ urine have been dispensed.
When doctors discovered that women taking Premarin were at greater risk of developing cancer of the uterine lining, this prescription went out of vogue for a while. But then researchers found that adding progestin, a synthetic form of progesterone (usually prescribed under the brand name Provers), could reduce this risk. In the 1990s, Premarin became the most prescribed pill in history. Besides easing hot flashes,night sweats, and other menopausal problems, HRT was supposed to save women’s lives by reducing their risk of heart disease, colon cancer, osteoporosis, and other serious health
threats.
These days, though, the story has changed, and a lot of menopausal women are feeling confused and betrayed. For years, they were told that they were suffering from an estrogen deficiency syndrome. Replacing the hormones their bodies no longer made was supposed to ease menopausal symptoms. Women who resisted a prescription for HRT were sometimes treated as difficult cases. Some were told that though HRT might raise the risk of breast cancer, it was a much less significant concern than heart disease, which HRT might protect against.
After I was operated on for breast cancer, I was told that I could no longer take estrogen, because my tumor was ‘estrogen-dependent’ My primary physician actually had the gall to tell me: The benefits of estrogen far outweigh the threat of breast cancer, and besides, we can cure breast cancer’
Women have a right to be furious. The hormone hype that lasted for several decades represents one of the biggest scams in modern medicine. Millions of women were guinea pigs in an uncontrolled experiment. Physicians who pride therpselves on practicing “evidence-based medicine” prescribed drugs that were unsupported by data. Many women who expressed their fears to their physicians were told in no uncertain terms that the benefits of HRT outweighed the risks.
When the National Institutes of Health announced a huge, long-term study of hormone replacement therapy, advocates of HRT were thrilled. They anticipated that the best available science would support their convictions that HRT had many health benefits, far beyond simply easing hot flashes. Thousands of women were recruited to the study and randomly assigned to take either Prempro or a look-alike placebo pill.
When the results of this study—called the Women’s Health Initiative (WHI)—were announced in 2002, many physicians were surprised and women were shocked to learn that instead of protecting women from heart disease and cardiovascular complications, HRT actually increased their risk. A few doctors had anticipated that the study might show an increased risk of breast cancer. As early as 1995, the Nurses’ Health Study, which followed more than 100,000 women, had confirmed that estrogen replacement therapy significantly increased the risk of breast cancer in postmenopausal women and demonstrated that progestin did not diminish that risk 723 If anything, the data suggested that adding progestin could increase the risk .721
Although there had been hints from previous research that estrogen, with or without progesterone, might increase a woman’s risk of breast cancer, such concerns were mostly downplayed. Opinion leaders reminded physicians that the leading cause of death in postmenopausal women is heart disease. (Breast cancer comes in second.) Some eminent gy- necologists opined that if breast cancer was a risk, it was a minimal one, associated only with long-term HRT use. Such cancers were thought to be “good” cancers in that they were “early” cancers, easily detected and treated and not associated with increased mortality.
Further results from the WHI gave the lie to that claim. The investigators found that women taking combined HRT (Prempro) were more likely to be diagnosed with breast cancer than those on placebo and were more likely to have invasive, more advanced cancers. They concluded, “These results suggest estrogen plus progestin may stimulate breast cancer growth and hinder breast cancer diagnosis.”115
As a result of these new findings, doctors may also be feeling betrayed. They too were sold a bill of goods that did not turn out to be as advertised. It is now clear to all that HRT is not a panacea for the miseries of menopause. But what remains unclear is exactly how women should cope with hot flashes, night sweats, sleep disruption, and vaginal dryness. Finding out that estrogen doesn’t really prevent heart disease still leaves women with plenty of options for reducing their risk of heart trouble. And there are other possible treatments for osteoporosis, another condition for which women were given long-term estrogen treatment. But what can be done for those annoying, sometimes debilitating hot flashes?
Alleviating Hot Flashes
Certain simple lifestyle adjustments might be all that some women need to make hot flashes tolerable. First, turn down the thermostat. This seems too simple to work, but many menopausal women are less uncomfortable when the temperature is cooler.726 Second, dress in layers that can be easily removed. ‘Ibis is simple common sense.Third, follow the Southern belles’ example and keep a fan and a nice coot (nonalcoholic) drink handy. Fourth, keep exercising. Or if you are not already walking, swimming, or dancing, start. It’s not a miracle, but women who exercise regularly seem to have fewer hot flashes or find them less bothersome. Besides, exercise eases depression and anxiety and is beneficial for the heart and the bones as well.
Hormone Replacement Therapy
When it comes to taming hot flashes, estrogen is undeniably the gold standard. Estrogen, either alone or in combination with progestin, clearly reduces the frequency and severity of hot flashes by about 75 percent.727 This is significantly better than placebo, although women with hot flashes are susceptible to the placebo benefit.
In most studies of HRT or herbal alternatives, women taking the placebo had nearly 60 percent fewer hot flashes per week at the end of the studies, on average, than at the beginning. 721 Women on HRT, either estrogen alone or estrogen together with progesterone, also seem to have less trouble with night sweats that awaken them and disturb their sleep. There’s little evidence that herbal treatments have much effect on menopausal sleep problems, which many women find extremely disdirbing.
If it weren’t for the WHI, doctors would still be prescribing Prempro (a combination of Premarin and Provers) to virtually every menopausal woman who would take it. And they would still be encouraging women to keep taking it long after menopausal symptoms faded away, as a general-purpose “health and beauty aid.”
The characteristics of the women who were willing to use HRT before the WHI results were available probably accounted for many of the benefits seen with HRT in earlier, observational studies. Women were told that HRT was good for their health, so those who chose to take it were more likely to be the health-conscious, careful eaters, regular exercisers, nonsmokers, and occasional drinkers. Their healthy behaviors, rather than the HRT per se, are now believed to be responsible for their lower rates of heart attack, stroke, and many other problems.
The WH I put the issue of HRT and heart attack prevention to Estrogen and Progesterone
Hormone replacement therapy reduces hot flashes significantly for most women. Women who still have a uterus need to take progesterone along with estrogen to protect themselves from endometrial cancer.
The risks of this therapy rise significantly at 5 years of use. For most women, intense hot flashes last less than 5 years. Ask for the lowest possible dose, and increase the dose only if that does not adequately relieve the hot flashes and night sweats. Hot flashes may return if HRT is stopped abruptly, so gradually tapering off it may be more successful. Transdermal estrogen (Climara, Estraderm) may be less likely to trigger nausea, but there haven’t been good headto-head comparisons.
Side effects: Breast tenderness, nausea, gallbladder problems, migraine headaches, intolerance to contact lenses, elevated blood sugar. If progesterone is given only 1 week a month, vaginal bleeding resembling a menstrual period is common.
Downside: HRT increases the risks of breast cancer and blood clots that could trigger heart attacks and strokes. These risks increase over time. HRT should be used only as long as it is needed for perimenopausal symptoms.
Cost: Approximately $40 to $75 per month for brand-name HRT; generic is available for $12 to $20 per month
the test with more than 16,000 postmenopausal women. Unfortunately, HRT did not pass. Women who had never undergone hysterectomy were randomized to Prempro or placebo, but the study was stopped early when it appeared that the women taking HRT were at greater risk than those on placebo .129 Although Prempro had been expected to protect women from heart attacks and strokes, the results showed that women taking this HRT were nearly 30 percent more likely to develop coronary heart disease and twice as likely to come down with a pulmonary embolism, a dangerous blood clot in the lung.730
None of this has much bearing, though, on the use of hormones to treat hot flashes. The risks are primarily for women who take Prempro or other forms of estrogen and progester-one for extended periods of time.The most recent recommendations, based on subanalyses of the WHI data, suggest that women just entering menopause (ages 50 to 54 in particular) may be more resistant to the dangers of estrogen and might even get some protection from heart attacks by taking it. 31 Short-term use (for a few months up to a couple of years) to get through the worst of the hot flashes doesn’t seem to pose an excessive risk for most women. Those who have previously had dangerous blood clots or breast cancer or who have a strong family history of breast cancer should probably avoid estrogen even in the short term, however.
O. 1 took hormones for 4 years and then discontinued them for a year. Now I have started again, at the urging of my doctor. While I was not taking hormones, I had hot flashes, night sweats, and vaginal dryness.
I stopped taking hormones because the progesterone component made me irritable and depressed. (I was taking Premarin and Provera.) My doctor put me on Estrace and Prometrium this time, but I still feel prickly and sad.
I’m convinced progesterone is the problem, so I wonder if I can take the estrogen alone. I recently read that estrogen has heart benefits.
A. The hormone controversy has heated up again. A study showed that women between the ages of 50 and 59 taking estrogen alone were not at increased risk of heart attacks (Archives of Internal Medicine, February 13, 2006►. These women had previously undergone hysterectomies, so they did not need progesterone.
Estrogen alone is not safe for a woman who still has her uterus since it increases the risk of endometrial cancer. Progestins like Provera protect against this kind of cancer. When added to estrogen, however, they may increase the risk of heart attacks and strokes and possibly breast cancer as well. For some women, progesterone lowers libido and leads to depression.
Doctors have followed the practice of prescribing progestin along with postmenopausal estrogen for many years, since research determined that estrogen alone increased the risk of cancer of the lining of the uterus (the endometrium). Endometrial cancer is not an issue for women with no uterus, and in the WHI study, these women were randomized to Premarin (estrogen alone) or placebo. This works just fine for hot flashes. Don’t count on it to provide any cardiac benefits, though. Overall, women in the WHI study were not protected from heart attack or stroke by HRT whether they took Prempro or Premarin alone.32
Some critics of the WHI have objected to the use of Premarin or Prempro, and suggested that other forms of postmenopausal estrogen replacement therapy would be preferable. There aren’t studies to prove or disprove that idea. Epidemiologists at Group Health Cooperative, a big health maintenance organization in Washington, compared rates of heart attack and stroke among women taking Premarin and those taking another form of estrogen such as Estratab or Menest. They found a hint that the other forms of estrogen might be somewhat less likely to trigger a heart attack or stroke, but these data need to be confirmed.733
Bioidentical Hormones
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Q. I am a family physician. Back when we were prescribing HRT regularly, I used to offer women the option of plant-based estrogens instead of synthetic hormones. Since we learned the results of the Women’s Health Initiative (WHI), though, I’ve viewed all estrogens as carrying similar risk until proven otherwise.
There are practitioners who are saying that bioidentical hormones are safer. They encourage women to use them as an alternative for treating menopausal symptoms. Is there any research that shows that the risks are lower for plant-based HRT than for synthetic?
A. There is no comparable study of plant-based estrogens, and there is not likely to be one. The WHI was a very large and expensive study funded by the National Institutes of Health. Women were randomly assigned to receive Prempro or placebo. The results showed that postmenopausal hormones increased the risk of breast
cancer, heart attack, and stroke.
Women’s health expert Susan Love, MD, responded
to a question like yours: “I think that it is very unlikely that bioidentical hormones, as they’re called, will be any safer than Prempro.”
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The American College of Obstetricians and Gynecologists (ACOG) came out with a very strong caution about bioidentical hormones in 2005. Michele Curtis, MD, is associate professor of obstetrics and gynecology at Houston’s University of Texas Medical School. On behalf of ACOG she said. “There are a growing number of women who are seeking therapy with bioidentical hormones, but there is a lot of misinformation about the assertion that these are plant-derived and therefore more closely mimic the estrogen that is in a woman’s body….. These are hormones. They act just like estrogens that are 34 commer-
cially produced.,,7
The obstetricians and gynecologists of ACOG are concerned that plant-based hormones are unregulated and, as a result, women may not be informed about risks. In addition, lack of oversight may mean that it is hard to guarantee quality. Many of these products are made in small compounding pharmacies that act like micro–drug companies but escape the kind of regular FDA inspections one might expect a bigger manufacturer to undergo. When the FDA did check on samples from 12 compounding pharmacies, ACOG reports that “34 percent of them failed one or more standard quality teStS.!,131
Progesterone
Kau Nwmnwe intrigued by the possibility that a progesterone cream derived from plant sources can be applied to the skin to relieve hot flashes naturally. Although wild yam can be used as a raw material for the manufacture of progesterone-like compounds, the human body can’t convert wild yam to progesterone. A controlled study suggests that a cream containing wild yam extract is not much better at reducing hot flashes than a placebo.736 Other creams formulated to contain progesterone can provide a dose comparable to taking progesterone by mouth.”‘ Progesterone pills or long-lasting injections such. as Depo-Provera can ease hot flashes, but questions remain about the long-term safety of this hormone for postmenopausal women. 738
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0. A nasty divorce has left me feeling slightly depressed, despite the relief of being out of a bad marriage. At times my heart races and then I break out in a sweat. I don’t know if these episodes are just anxiety or if they are hot flashes, since I am menopausal.
I am reluctant to take estrogen because I’ve heard about negative effects. IV rather use a more natural approach. Would a progesterone cream be safe?
A. Many women experience hot flashes much as you have described them, with an accelerated heart rate, a vaguely anxious feeling, sweating, and feeling too warm. Progesterone cream may help reduce hot flashes. Women’s health expert Susan Love, MD, points out, however, that high levels of progesterone are not natural after menopause. She worries that potential side effects might arise with long-term progesterone use. In addition, progesterone has been linked to depression.