Rethinking the Use of Hormones to Ease Menopause Symptoms

Ever since the large government study called the Women’s Health Initiative found a number of risks associated with menopause hormones, millions of women who are in or near menopause have been weathering hot flashes and other symptoms on their own. But now, new research suggests that the benefits of short-term hormone treatment to control life-disrupting menopausal symptoms outweigh the risks — as long as the treatment is started at or near menopause.

There are also lots of products now available and different ways to use them that enhance the safety of hormone replacement. And there is even an app to help women and their doctors explore various options and choose the most suitable treatment.

For women without a history of cancer, blood clots or heart disease, most professional medical societies concerned with women’s health now recommend treatment for menopausal symptoms for up to five years using therapy that combines estrogen and progesterone and even longer for those who take estrogen alone.

Every day, about 6,000 women in the United States — more than two million women a year — enter menopause. At an average age of 51, they stop having their periods because their ovaries no longer produce enough estrogen to stimulate growth of the uterine lining that is shed each menstrual cycle.

For months before and up to a decade or more after menopause begins, many women have symptoms that can seriously diminish the quality of their lives by disrupting their productivity, sleep, moods and ability to enjoy sexual intercourse.

The most common symptom — hot flashes — can leave some women dripping with sweat for minutes at a time several times a day and especially during the night. Menopause-related vaginal dryness and atrophy can result in severe sexual discomfort, pain and bleeding with exercise, vaginal and urinary infections and incontinence.

Until the early 2000s, many women with menopausal symptoms took hormone replacement therapy — H.R.T. — to counter them. Even some who did not have disturbing symptoms used H.R.T. because observational studies indicated it lowered the risk of cardiovascular diseases, and popular books and articles suggested it delayed signs of aging.

Then in 2002, the results of the largest randomized clinical trial of hormone replacement, the Women’s Health Initiative (W.H.I.), created a kind of menopausal panic, prompting millions of middle-age women to stop or not start hormone treatments and doctors to not prescribe them.

The study found that, among the women treated with the hormones, there was an increased risk of heart attacks, strokes, blood clots and, most frightening of all to many women, a slightly higher risk of breast cancer among those randomized to take the leading H.R.T. regimen of conjugated equine estrogens (Premarin) and a synthetic progesterone (Provera) recommended for women who still had a uterus. (Those without a uterus, who were randomized to take conjugated estrogens alone, had no increase in breast cancer; in fact, they had a slight decrease over all.)

The hormone combination did protect against hip fractures and reduce the risk of colorectal cancer, but for the overwhelming majority of menopausal women, the risks of H.R.T. seemed — on the surface — to outweigh the benefits.

However, according to Dr. JoAnn E. Manson, an endocrinologist and one of the principal investigators for the W.H.I., “The W.H.I. findings have been seriously misunderstood and misinterpreted,” and millions of women for whom the benefits clearly outweigh the risks are needlessly being denied treatment. “The pendulum has swung too far,” she said.

The W.H.I. study actually had nothing to do with menopausal symptoms. Most of the 27,347 women entering the study were already in their 60s and 70s, already a decade or more past menopause. Rather, the study was designed to determine whether H.R.T. did, in fact, reduce the risk of heart disease, the leading killer of American women. Among these older women, it found no such effect.

In the years after the W.H.I. findings, many new analyses and studies have prompted experts to rethink the wisdom of avoiding hormone replacement, especially for women within a few years of menopause whose personal and family history do not place them at high risk of breast cancer.

Experts like Dr. Manson, professor of medicine at Harvard Medical School and Brigham & Women’s Hospital, maintain that the results of the W.H.I. study are not relevant to the more common use of H.R.T. for women in their 50s and for those experiencing earlier menopause as a result of medical treatments.

Dr. Howard N. Hodis, a preventive cardiologist at the University of Southern California, said the billion-dollar W.H.I. study made “a big mistake” by starting the hormones in older women, when cardiovascular damage may have already occurred. “The cardiovascular protection found in observational studies involved women who were younger and within a few years of menopause when they started taking H.R.T.,” he said.

In a Danish randomized controlled trial of 1,006 women entering menopause, among those given hormones for 10 years, “there was a reduction in cardiovascular disease and breast cancer — a clear benefit with nominal risk,” Dr. Hodis said. These benefits persisted after 16 years of follow-up, according to the study, which was published in 2012.

Dr. Hodis is especially disturbed about the reluctance to prescribe estrogens for menopausal women who have had a hysterectomy and don’t need progesterone to prevent endometrial cancer.

In an analysis in 2013 in the American Journal of Public Health, Dr. Philip M. Sarrel and his co-authors calculated that, based on reduced death rates among women taking only estrogen in the W.H.I. study, avoiding hormone replacement resulted in the premature deaths of 18,601 to 91,610 women in the decade after the study’s release.

To help women and their doctors assess H.R.T. options and select the best treatment for women 45 and older with menopausal symptoms, the North American Menopause Society has developed a mobile app, MenoPro, for iPhone/iPad and Android devices.

Risk factors for heart disease increase before menopause

Risk factors for heart disease, diabetes and stroke increase more quickly than expected in the years preceding menopause, according to new research, and the risk factors seem to be more prominent in black women.

Metabolic syndrome describes a constellation of risk of factors that contribute to cardiovascular disease, including a large waist, high triglyceride levels, high blood pressure and high blood sugar when fasting. It has been known that metabolic syndrome is more common in women post-menopause, but it wasn't clear when the symptoms start to kick in.

Researchers assessed data from 1,470 women taking part in the Atherosclerosis Risk in Communities cohort, a long-term national study that looks at the root and effects of artery hardening. The analysis covered changes in menopause status over 10 years.

Mark DeBoer, a pediatric endocrinologist at the University of Florida and one of the lead researchers on the study, said his previous research on metabolic syndrome in children showed differences across racial and ethnic backgrounds.

“Metabolic syndrome is [a] cluster that appears more often than you’d think,” he said. “African Americans were less likely to be diagnosed even though there is a higher rate of heart disease and diabetes.”

DeBoer and other researchers found that menopausal black women are at greater risk for cardiovascular disease and diabetes than their white counterparts.

Women across all backgrounds experienced a rapid surge in metabolic syndrome severity during the transition to menopause. However, black women experienced an increase in metabolic syndrome severity before the transition to menopause. Black women overall had higher rates of metabolic syndrome, especially with high blood pressure and high fasting blood sugar levels, compared to white women.

Nearly 45 percent of black women in the study had hypertension compared to 15 percent of white women. Almost 10 percent of black women had high glucose compared to 8 percent of white women. Black women had a slower rate of metabolic syndrome increase after menopause compared to white women, however.

Although nearly 14 percent of white women used hormone replacement therapy in contrast to almost 7 percent of black women, that didn't explain the racial differences. DeBoer observed that the women in the study had a much higher use of hormone replacement therapy than what is currently the norm.

JoAnn Pinkerton, an OBGYN and executive director of the North American Menopause Society, said she was struck by the rapid progression of metabolic syndrome during the transition to menopause, or perimenopause. Pinkerton noted that it is the most difficult phase of menopause, saying that women can gain five to 10 pounds per year in the time leading up to actual menopause, and fibroid tumor growth is possible due to changes in estrogen and progesterone.

“Women who approach the perimenopause need to be really careful about keeping their exercise going and decreasing their portion sizes,” she said.

Pinkerton said the medical field needs to start testing women earlier for metabolic syndrome. “Intervention for women at risk or who are developing metabolic syndrome should not wait until 50 or post-menopause,” she said. “We need to start looking at women in the 40s before they hit those hormonal fluctuations.”

“The most important thing is an awareness of changes at the time leading up to menopause that increase cardiovascular diseases,” said DeBoer. “This serves as a motivator [for] healthy lifestyle changes.”

The 4 different types of hot flashes women get during menopause... Which do YOU suffer?

Every woman goes through menopause.

But the symptoms that come with it like hot flashes vary greatly from person to person. When side effects strike, and how long they last, seem arbitrary and impossible to predict - some start early, some start late, some last two years, some last 15.

However, a new study has outlined four distinct categories that all women supposedly fit into based on their race, weight, and dietary habits.  The research by the University of Pittsburgh has been hailed as a breakthrough which could have a dramatic impact on the way menopausal symptoms - known as vasomotor symptoms - are treated. 

WHICH GROUP DO YOU FIT INTO?

1 FEW SYMPTOMS

Chinese women had a consistently low chance of debilitating symptoms throughout the menopause transition.

2 SYMPTOMS LAST LONGER

Black women, those with less education, heavy drinkers and those who reported depression or anxiety had a higher chance of symptoms all the way through the decade.

3 SYMPTOMS HIT EARLY

Early onset symptoms at the start of the transition period were most common among obese women, women with depression or anxiety, women in poor health, and women who start menopause later. 

4 SYMPTOMS HIT LATE

And late onset symptoms were most common in skinnier women, smokers and black women. Most women get vasomotor symptoms, and we used to think these symptoms lasted from three to five years, right around the time of the final menstrual period,' senior author Rebecca Thurston, professor of psychiatry at the University of Pittsburgh, said. 'We now know that these symptoms persist for far longer - typically seven to 10 years - and occur at different times for different women. 

This is strong evidence that we need to further investigate the underlying physiological causes of vasomotor symptoms and their link to potentially preventable health conditions. Menopause, when a woman stops menstruating, typically occurs at some point between the ages of 45 and 55.

The experience is linked to hot flashes and night sweats caused by sudden flushes of heat. These symptoms are the result of a decrease in estrogen and progesterone produced by the ovaries. Other symptoms include vaginal dryness, mood swings, and insomnia. 

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For the study, published in Menopause, the team followed 1,455 women enrolled in the Study of Women's Health Across the Nation (SWAN) who were yet to start menopause. None of them were on HRT and none of them had had a hysterectomy. Each year, the women described the vasomotor symptoms they had experienced. They also had annual clinical exams and blood tests.

After 15 years of testing, the researchers concluded certain factors led to different side effects.
Chinese women had a consistently low chance of debilitating symptoms throughout the menopause transition. Black women, those with less education, heavy drinkers and those who reported depression or anxiety had a much higher chance of severe symptoms all the way through the decade-long period.

Early onset symptoms at the start of the transition period were most common among obese women, women with depression or anxiety, women in poor health, and women who start menopause later.  And late onset symptoms were most common in skinnier women, smokers and black women. 

'It's fascinating that we can distinguish these unique patterns and then pinpoint specific characteristics associated with each of these trajectories,' says coauthor Maria M. Brooks, professor of epidemiology and associate professor of biostatistics. 

'When we see patterns like this, it indicates that there's something going on beyond hot flashes and night sweats being a passing nuisance. Depending on which category a woman falls into, there may be important implications regarding her health.' 

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