What is menopause?
The medical definition is "the cessation of menstruation".
Women know it’s a LOT more than that.
Our definition: it’s the time in life when our ovaries are no longer producing the hormone estrogen that we’ve had for the majority of our lives.
Falling Estrogen Production
This can occur with aging and ovary atrophy or with surgical removal of the ovaries. Either way, as you experience a loss of estrogen production the result can be....tough. Things like hot flushes, night sweats, vaginal dryness, painful intercourse, brain fog and weight gain are very common with menopause.
Other conditions that we can’t feel but may also occur include decreased bone density, increased risk of heart disease, diabetes, and other chronic conditions that occur with weight gain.
We’ll look at your whole health picture.
The good news: there’s lots we can do about what we find!
Hormone Replacement Therapy (HRT)
Although the absolute risk for breast cancer has proved to be very small—in fact, not statistically significant after confounding factors were accounted for in research—inaccurate statements about the risks of HT were made in the media and the use of HT plummeted overnight.
This occurred despite the fact that that the Women’s Health Initiative (WHI) confirmed the benefits of HT in 1991 and subsequent studies brought into question if there really was a significant difference in breast cancer with these therapies.
Studies have instead shown that:
1. HT for menopausal symptoms is critical and effective for many women.
2. Young, healthy women within 10 years of menopause DO NOT have increased cardiovascular risk from HT.
3. Consistent data now show that HT prevents coronary disease in women <60 years at the onset of menopause, which reduces mortality, with the strongest data being for estrogen alone.
HRT can be safe and extraordinarily effective, even transformative, for women in menopause.
Is HRT right for me?
There are many factors that need to be taken into consideration with HRT. Your treatment needs to be customized for YOU based on your personal situation, symptoms, conditions, and goals for therapy.
Benefits: No matter what form you choose, include improvements in symptoms and concerns including hot flashes, night sweats, weight gain, brain fog, vaginal dryness, painful intercourse, pelvic floor atrophy (incontinence), mood swings, bone density, heart health, and more.
Risks: None, if you find an educated provider.
Who should not get HRT: Patients with a personal history of breast cancer, uterine or ovarian cancer.
Patients with blood clotting disorders: Need to be cleared by a hematologist.
1. If you have an intact uterus your provider will balance your estrogen with progesterone.
2. Progesterone can be very helpful with a variety of symptoms including poor sleep, irritability, brain fog, and uterine protection.
3. Testosterone can be added for additional benefits with energy, sleep, libido, brain fog, and bone density.
Here at Pelex, we have extensive experience and training in all forms of HRT!
What if I prefer natural options instead of HRT?
At Pelex we can and do recommend supplements and dietary/lifestyle interventions to help with many of the negative aspects experienced with menopause.
If you are interested in a non-HRT path to help with menopause we can help!
1. Oral estradiol pills
Pros - easy to take, often covered by insurance, safe
Cons - poorly absorbed, not customizable
2. *Transdermal via cream estradiol alone or with estriol (Biest)
Pros - customizable with compounding pharmacies, well-absorbed, safe, available in bioidentical forms
Cons - messy, restrictions with contact with others, insurance may ormay not cover
3. Transdermal via patch estradiol
Pros - easy to use, well-absorbed, safe, may be covered by insurance
Cons - not customizable, estradiol only
4. Oral troches (dissolvable tabs)
Pros - customizable, well-absorbed, safe, easy to use, bioidentical
Cons - not covered by insurance, take 10-20 minutes to dissolve
5. Bioidentical Pellets
Pros - easy to use (one procedure- then forget about it), bioidentical, safe, well-absorbed, customizable
Cons - can’t remove once placed, can be a shock with symptoms to a patient who has been in menopause a while, not covered by insurance, infection risk, expensive
Transdermal estrogen avoids the first pass through the liver that happens with oral medications. This decreases the amount of estrogen that is given because it is absorbed directly into the bloodstream. Transdermal estrogen has not been associated with thromboembolism risk or stroke and is considered safer for women with obesity.
We know that you may be concerned about potentially negative effects of hormone replacement therapy (HRT) due to the contradictory, confusing, and controversial information published in recent decades—especially about breast cancer.
The first thing most of our patients say when we talk about HRT is that they’re against it because it “causes breast cancer.”
Is that true?
It would be misleading to say yes because it’s not that simple. But as a matter of fact, it is true in part.
Because the life-enhancing, fountain-of-youth effects of HRT that women love CAN be so transformative, it’s worth a detailed look of when it’s appropriate and when it’s not.
Why you need to know more about estrogen
Did you know the body produces 3 kinds of estrogen?
- E1 is estrone. This is the harmful form of exogenous estrogen; a common formulation that contains E1 is Premarin, which is less often prescribed now than it used to be because of our greater understanding of its risks.
- E2 is estradiol. This is very safe and is commonly prescribed for HRT.
- E3 is estriol. This estrogen is also safe and prescribed often in combination with estradiol.
So the answer to the question is this: estriol and estradiol are perfectly safe and there is some evidence out there that they can even be protective against breast cancer, heart disease and osteoporosis.
History of women's health research
A history of hormone therapy (HT) research
Where did all the controversy come from? It may interest you to know the facts about the twists and turns in our scientific understanding of approaches to hormone therapy over recent decades.
In the beginning, hormone therapy during the menopausal transition was appreciated for alleviating symptoms such as hot flashes, night sweats, poor sleep quality, brain fog, joint pain, and osteoporosis—in other words, really improving women’s quality of life.
Then it was noted that women who took hormone therapy had less heart disease, overall mortality, and Alzheimer's disease in observational trials. Because of this observation, many women were recommended to take hormones in order to prevent these diseases. However, there are risks associated with hormone therapy, including blood clots, strokes, and cancer.
Inclusion of Women in Research Studies
Around this time, the magnitude of differences in the biology between women and men with many diseases, including heart disease, was beginning to be recognized.
Until the 1980’s, women were routinely not allowed to participate in clinical research trials because of concerns that they might become pregnant and the research intervention could harm a pregnancy. So all of the early cardiovascular research was based on white men and results for men were assumed to be the same as for women.
It wasn’t until 1986 that the NIH issued recommendations that women should be included in all research studies. When this did not adequately result in better research for women, the NIH required that women be included in 1991.
Women's Health Initiative (WHI)
This led to the NIH funding the largest study and series of follow-up studies in women, called the Women’s Health Initiative (WHI) in 1991.
This study split women into two groups: those with a uterus and those without.
Estrogen stimulates the endometrial lining of the uterus to grow. Over time this growth can lead to precancer or cancer of the endometrium if there isn’t regular progesterone exposure (either from natural ovulation, cyclic progesterone, a progesterone IUD, or combined continuous progesterone with estrogen).
Because women who have had a hysterectomy don’t have a uterus, they also don’t have the endometrial lining that needs protection from unopposed estrogen.
Therefore they designed the WHI to give two different hormone therapy regimens based on whether or not a woman had a uterus. Women with a uterus received Prempro (Premarin and Medroxyprogesterone acetate) and those without received only Premarin.
The Timing Hypothesis
What we didn’t know is that when women start hormone therapy is critically important.
In this study, the vast majority of women had stopped having periods 10-20 years earlier. When women lose estrogen for a prolonged period of time, the plaques in the arteries stiffen. Estrogen can increase matrixmetalloproteinases (MMPs) which soften these plaques by dissolving parts of them. This makes plaques unstable, more likely to tear away from the wall, induce a blood clot, and block the artery.
Therefore, in retrospect, it’s not surprising that women who took Prempro did not have fewer heart attacks, but did have more strokes because estrogen does increase the risk of blood clots in some women, which can lead to strokes. In women over 60 years old, this process has been termed “early harm”.
In women who are younger, HRT can increase MMP but there aren’t substantial plaques present that the MMPs can soften and disrupt.
Risk of breast cancer
What about HT and Breast Cancer?
What was surprising about results from the Women’s Health Initiative (WHI) research was that the risk of breast cancer varied between the women receiving Prempro (estrogen and progesterone) compared to the women who only got Premarin (estrogen).
Combined estrogen and progesterone resulted in an increased risk for breast cancer while estrogen alone showed a possible decreased risk for breast cancer.
This was very surprising because it had been assumed that because breast cancer is associated with having estrogen receptors and causes cell proliferation, estrogen would be the bad actor in combination therapy. However, the WHI data suggest that progesterone may carry more risk for breast cancer rather than estrogen.
We now know that there are many profound differences between men and women and the cardiovascular system in both healthy physiology and when pathology occurs, such as different symptoms with heart attack, the role of estrogen, and the changes that occur when estrogen production stops.