Let's talk about hormone therapy

For more than two decades, mixed messaging surrounding the use of hormone therapy has left many women uncertain about its safety and efficacy. Michele Helfgott, MD, PPG – Integrative Medicine, breaks down what we know now and how this treatment fits into menopause management today.
 

Perimenopause vs. menopause

Perimenopause is the transition phase leading up to menopause. During this time, women may experience regular or irregular periods, along with symptoms like hot flashes or night sweats. This transition can last for up to ten years, and we are noticing symptoms appearing earlier. More women are entering perimenopause in their thirties, whereas previously, it was more common for women to start in their forties.

Menopause is defined as the absence of menstrual cycles for 12 consecutive months. Menstrual cessation occurs due to a natural decline in the production of estrogen and progesterone. This distinction is essential for women who've had hysterectomies. When the uterus is removed but the ovaries remain intact (hysterectomy without oophorectomy), those women may no longer have periods. However, they will not start menopause hormonally or experience symptoms until the ovaries stop functioning.
 

What made everyone wary of hormone therapy

Fears around hormone therapy started with the Women's Health Initiative (WHI) study, designed to evaluate the risks and benefits of estrogen and progestin (synthetic progesterone) in healthy postmenopausal women. The trial initially planned to run for 8.5 years, but it ceased prematurely due to concerns of increased risks of breast cancer, high blood pressure, blood clots and various adverse effects. At the time, this became national news, and doctors began telling women to stop using hormones, no matter what kind they were. But in doing so, postmenopausal women saw a return of symptoms like hot flashes, night sweats, difficulty sleeping, mood swings, brain fog, fatigue and joint pain, all of which began impacting their ability to function. Because of this, the guidance shifted again, and the recommendation was to use only the lowest dose of hormones for the shortest amount of time, not to exceed 5 years.

A common misconception is that women think they "go through" menopause and then, eventually, their symptoms will stop. But that's typically not the case. The majority of women continue to experience symptoms into their sixties and seventies. The average age of menopause is 52, meaning that the five-year window does not, in most instances, meet women's long-term needs for symptom management.
 

Why was this problematic?

While the original WHI study included women of diverse racial and ethnic backgrounds aged 50-79, the initial analysis did not fully account for how their individual health factors might influence disease progression or treatment outcomes. Here's what follow-up research found about the women in the study: 

• 34% of participants had a body mass index indicative of obesity. Obesity is a known risk factor for heart disease, stroke and blood clots. 

• 50% of the subjects were either past or current smokers. Smoking significantly heightens the risk of cancer, heart disease, stroke, lung diseases, diabetes and chronic conditions.

• 36% of women were either treated for hypertension or had a blood pressure reading of ≥140/90 mmHg. High blood pressure over time can lead to heart disease, stroke and kidney disease.

• The average participant age was 63 years old, meaning most were 10 or more years past the onset of menopause. At this stage, estrogen levels have already significantly declined, making their risk for heart disease and stroke naturally higher.

In the context of WHI study, these existing health issues may have intensified the adverse results, leading hormone therapy to seem more dangerous than it potentially is for younger, healthier women who are nearer to the start of menopause. These factors do not automatically disqualify women living with these conditions from receiving hormone therapy, but it does contribute to their increased risk of complications and may require additional monitoring.
 

Why hormone types matter

In addition to participant demographics, the types of hormones used in the study raise more questions. Premarin®, conjugated estrogens derived from female horse urine, and Prempro®, a combination of conjugated estrogens and progestin (synthetic progesterone), are not bioidentical. This means they do not have the same chemical and molecular structure as the hormones present in the body. Because of that, the body has to change the configuration of the hormone receptor so that it can process the synthetic version, which can lead to different physiological effects. These formulations also may not be as bioavailable as their natural counterparts, which means the body might not absorb or utilize them as efficiently.
 

When hormone therapy makes sense

Deciding on hormone therapy always starts with a conversation. Before discussing hormone therapy, we examine how lifestyle habits may influence the symptoms they're having. Hormone imbalance may be a contributing factor, but menopause alone may not be the only cause. So we work on managing stress, sleep hygiene and eating a balanced diet.

If symptoms persist, I test their hormones. There are three ways to test hormones: blood, saliva or urine. While each test has its strengths, I prefer saliva testing because it measures bioavailable, free hormones, meaning they are not bound to protein in the blood. These hormones are closer to the hormone levels in the tissues, ready for the body to use.

On the other hand, a blood test typically measures total hormone levels, including free and bound. These results can be misleading in menopausal women because most reference ranges are based on what's normal for a premenopausal woman. Relying solely on bloodwork, a woman in menopause could fall within range even though her active hormone levels are too low to support her body's needs.

Once I receive the test results, I look at the whole picture. If a patient has made meaningful changes to their diet and lifestyle, and their test results are still indicating an imbalance, then I discuss their options for hormone therapy.
 

Options for menopause management

Hormone therapy is not a one-size-fits-all approach, and the type of treatment administered often depends on which hormones are out of balance and what symptoms are present. For example, night sweats are related to drops in progesterone, whereas decreases in estrogen more often cause vaginal dryness.

If we do decide hormone therapy is appropriate, we talk through the options available. Those typically include either estrogen or progesterone or a combination of the two in a patch, topical cream or oral pill form.

I usually avoid prescribing the pill because it is processed in the liver and has an increased risk of adverse side effects. Patches and creams are absorbed through the skin and are generally better tolerated. Topical progesterone is often more effective than oral forms when addressing symptoms like anxiety or heavy or irregular bleeding during perimenopause.

For patients with an intact uterus, I recommend pairing estrogen with progesterone to protect the endometrial lining and provide additional support for sleep, mood regulation and bone health.
 

Who shouldn’t use hormone therapy?

There are some instances where I won't prescribe hormones. If someone smokes or uses other nicotine products, they have to stop at least 6 months before starting hormone therapy.

The American College of OBGYN typically advises against hormone therapy for menopause symptoms in women who have had certain types of breast cancer. However, there are studies showing that some women who have had breast cancer can safely use a low-dose vaginal estrogen. Like many cases, it really depends on the type of cancer and the individual's other risk factors. For these individuals, it's best to explore nonhormonal treatment methods first.

Historically, women who were at an increased risk for blood clots or who had been diagnosed with clotting disorders were not candidates for hormone therapy. However, growing research indicates that transdermal routes of administration may be a safer alternative.

Other chronic conditions are not black and white; they depend on the patient's overall health and medical history.
 

Nonhormonal approaches

There are a variety of holistic approaches that can help ease menopause symptoms with or without hormone therapy.

Don't skip meals

• Prioritize a balanced diet that includes sufficient protein, complex carbs, vegetables at every meal, healthy fats and fiber.

• Eat more cruciferous vegetables (broccoli, cauliflower, Brussels sprouts) to help with metabolizing estrogen.

• Minimize alcohol, sweets and processed foods.

Prioritize self-care

• Set aside time to spend with yourself as well as with your significant other or friends.

• See a mental health counselor or therapist if needed.

• Reduce screen time in the evening and aim for 7-9 hours of restorative sleep each night.

• Be mindful of using products that contain xenoestrogens like phthalates and parabens.

• Engage in at least 30 minutes of moderate-intensity cardio daily.

Supplements and herbs

• Rhubarb root extract

• Black cohosh

• Dong quai

• Chaste tree berry

• Transitions™ (herbal blend)

Always speak with your primary care provider or gynecologist before starting new supplements, especially if you're managing other health conditions or taking medications.
 

Final thoughts

While we know that hormone therapy can be a helpful treatment option, it's still not for everyone. If someone is struggling with menopause symptoms and is unsure about hormone therapy, but they are a good candidate, I will suggest trying it. Starting hormones doesn't mean you have to continue if you don't like them. We can explore many of the alternative options to help women achieve the same benefits.

For more information or to schedule an appointment with a PPG Integrative Medicine provider, please call our office at 260-672-6590. To learn more about our services, please fill out a request form, and one of our care team members will contact you with more details.