What is Menopause?
Menopause is a period of time in a woman’s life that marks the end of her reproductive years. It’s diagnosed after you’ve gone 12 consecutive months without menstruating and typically occurs between your late 40s and early 50s. In the United States, the average age of menopause is 51 years old.1
During the years leading up to menopause, a period known as “perimenopause,” your ovaries gradually produce less progesterone and then estrogen. The drop in estrogen accelerates during the last 1 to 2 years of perimenopause. As you get closer to menopause, you stop menstruating and you may experience more menopause symptoms.
Symptoms of Menopause & Perimenopause
Common symptoms of menopause include:
- Vasomotor symptoms (VMS): Also called hot flashes or night sweats, this cardinal sign of menopause occurs as a result of changes in sex hormones.2 VMS are associated with reduced sleep quality, difficulty concentrating, irritability, anxiety, stress, and poor quality of life.3,4
- Sleep disturbances: Sleep disturbances are strongly associated with VMS as well as mood disturbances, memory problems, obesity, and a greater risk of cardiovascular disease.5
- Genitourinary symptoms: Signs of genitourinary syndrome of menopause (GSM) include changes to the labia, vagina, urethra, and bladder, which are associated with menopause-related estrogen deficiency.6 You may experience vaginal dryness or irritation, itching, pain with sexual activity, or urinary tract infections.
- Irregular periods: The hallmark of perimenopause. Irregular periods are caused by drops in your estrogen levels.
- Weight gain: The transition to menopause is often marked with an increase in body fat, which leads to lower lean body mass. Experts estimate that the average woman gains about 1.5 pounds per year during their transition.7 More bloating and low back can also be associated with weight gain.
- Thinning hair, bone, and dry skin: Changes in your hair and skin may be the results of the natural rise in androgen (testosterone) levels and declining estrogen levels.8 Bone loss is also common due to the reduced levels of estrogen.
- Chills: The hormone fluctuations during perimenopause and menopause disrupt the hypothalamus, the part of your brain that controls your body temperature. As a result, some women experience chills after hot flashes.
- Mood changes: With hormone levels fluctuating month to month you might feel “off” or not quite yourself. Anxiety, panic attacks, and depression are all too common as you move through perimenopause.
- Loss of libido and sexual interest: With declining hormones, there can be a decrease in libido and more difficulty with intercourse due to tissue changes.
What is Hormone Replacement Therapy?
Hormone replacement therapy (HRT) is a treatment for the relief of menopausal symptoms like hot flashes by supplementing women with the hormones lost during their transition. Conventional HRT comes in 2 main types:
- Estrogen only: Estrogen provides relief from most menopausal symptoms. Types of estrogen used include estradiol, estriol, or conjugated equine estrogen.9 This therapy is prescribed for women without a uterus.
- Estrogen plus progestin therapy: This type of HRT includes 2 components – estrogen and progestin – which mimic the natural hormones produced by your body. Progestin is added to protect women with a uterus to help reduce the risk of uterine cancer that can occur with estrogen alone.10
Estrogen therapy works in 2 ways to relieve your symptoms:
- Systemic estrogen therapy: Estrogen is released into your bloodstream via pills, gels, sprays, or skin patches. This allows the hormone to travel to where it’s needed.
- Local estrogen therapy: This method supplies estrogen directly to the vaginal tissue. This form may be useful for women who only have vaginal dryness. They’re available as a cream, ring, or tablet.
Administration of progestin is usually done by the oral route, though gels and intrauterine devices are also available. The method you choose will depend on your symptoms, lifestyle, and medical history.
The main benefit of HRT is relief from many menopausal symptoms, such as hot flashes and vaginal dryness. But HRT can also reduce your risk of certain conditions or diseases, such as:
- Colon cancer
- Joint pain
- Heart disease
The Controversy of Hormone Replacement Therapy
If you’ve heard of HRT before, you may have been told that it increases your risk of certain cancers or diseases.
But how much, if any, of the rumors are true?
HRT was introduced in the 1960s as a way for women to conserve their femininity in the face of estrogen loss.11 In the 1970s, researchers observed a connection between estrogen supplements and endometrial cancer, though it was later discovered that reducing the estrogen dosage and combining it with progesterone could reduce that risk.12
As scientists continued their research, they learned that HRT was not only effective at treating menopausal symptoms but that it could also prevent chronic diseases. But some experts raised concerns about the impact of progestin on the cardiovascular system, leading the FDA to require randomized clinical trials to confirm its benefit.
The first trial involved 2,736 postmenopausal women with coronary heart disease. After 4 years of follow-up, researchers couldn’t find any differences between the group that received HRT and the one that received a placebo. But in the experimental group, they found an increase in the number of coronary events, such as non-fatal heart attacks, after 1 year. This increase declined in the later years of the study.13
In 1998, a large randomized study called the Women’s Health Initiative (WHI) was started. Investigators of this study aimed to evaluate the effects of HRT on the most common causes of death and disability among postmenopausal women. In the women with an intact uterus who received a combination of conjugated equine estrogens and medroxyprogesterone acetate, there was an increased incidence of heart disease and breast cancer.14
The results of the WHI study suggested that the risks of HRT outweighed any potential benefits. Release of the data to the public created panic among HRT users. Despite subsequent studies finding no correlation between HRT and cardiovascular disease (some studies found that HRT use had a positive effect on certain age groups), the public’s perception of HRT remained negative.15
We now understand that HRT can be highly beneficial to many women. But the damage done by the WHI study was huge. It left many women experiencing postmenopausal symptoms without an effective treatment. One study reported that incidences of heart attack hospitalizations and stroke, rates of which were both falling prior to the data release, either stabilized or increased.16
Updates on Hormone Therapy Guidance From the North American Menopause Society
The North American Menopause Society (NAMS) is a non-profit organization dedicated to promoting the health and quality of life for women during and beyond menopause. On July 7th, 2022, NAMS released a statement outlining its stance on hormone therapy. The statement was created by an advisory panel of clinicians and research experts in the field of women’s health.
Here are some of key takeaways from the NAMS updated hormone therapy guidelines:
- Systemic hormone therapy can reduce the frequency of menopause symptoms, such as VMS and GSM, thereby improving menopause-specific quality of life in women. It may also help prevent bone loss and fracture.
- NAMS recommends risk stratification by age and time since menopause. If providing HRT to older women, physicians must be vigilant about risks and be aware of potential mitigation strategies, such as lowering the dose or choosing another progestogen.
- Treatment should be individualized to maximize a patient’s benefits and minimize her risks. Factors to consider include the dose, duration, regimen, route of administration, the timing of initiation, and the use of a progestogen. Periodic re-evaluations are recommended.
- The benefits of HRT outweigh the risks for healthy women younger than 60 or who are within 10 years of menopause onset. The benefit-risk ratio is less favorable for women who are over the age of 60 or initiate therapy more than 10 years from menopause onset.
- For GSM symptoms not relieved with non-HRT treatments, NAMS recommends low-dose vaginal estrogen therapy or other approved therapies like oral ospemifene — a hormonal therapy often used to treat vaginal dryness.
- More research is needed on the potential risks of longer HRT use. Results from observational studies suggest there could be a rare risk of breast cancer with long-term HRT.
- The decision to continue HRT remains a personal one for well-counseled women over the ages of 60 or 65.
- Transdermal routes of administration and lower doses of HRT may lower the risk of venous thromboembolism. But more data from randomized clinical trials are needed to confirm.
Overall, NAMS concluded that the “benefits of hormone therapy use generally outweigh risks for healthy women with bothersome menopause symptoms who are aged younger than 60 years or within 10 years of menopause onset.”
My Recommendations on Hormone Replacement Therapy for Women Going Through Menopause
Menopause is a challenging time for women both physically and emotionally. But it doesn’t have to be a dark period in your life. It’s a new phase of a woman’s life, and I believe it’s a time for celebration. A time for reinventing yourself, for stepping into the person you want to be.
Ask yourself these questions: What’s most important to you? How do you want to show up in your life in the next 5 years or 20 years?
Too many women see menopause as an end to the “good times.” There’s still much more of your life to live! They can even be the best years of your life.
If you’re considering HRT, take some time to learn about the various hormone options as well as any herbal support. For my clients who are symptomatic, I recommend bioidentical hormone replacement therapy (BHRT) over conventional HRT. The hormones used in BHRT are derived from plants rather than from the urine of pregnant horses.17 These natural hormones also have the exact same chemical and molecular structures as the hormones found in your body, which means they may be safer.18
There are many potential benefits of both BHRT and conventional HRT, including improvements in:
- Skin health
- Cardiovascular health
- Metabolic health
- Cognitive function
- Sense of well-being
- Lipid (cholesterol) profiles
- Maintenance of bone structure
Despite these benefits, I understand that not all women are interested in HRT after weighing all the pros and cons. HRT should also be used as a tool, a part of the path forward. It won’t solve all the problems associated with menopause. Certain lifestyle changes can also help you continue to look and feel well.
Feel Your Best During Menopause
If you want to look and feel your best during menopause, HRT may help you find the relief and balance you’re looking for. But every woman’s menopause experience is different, and there’s no one-size-fits-all approach in HRT.
As a women’s health expert, I am uniquely qualified to develop and guide you through menopause, with or without HRT.