Hot flashes, mood changes, sleep disturbances, loss of bone density, changes to metabolism…when most women think of the changes of menopause, not much positive comes to mind. It’s true that there are many physical and emotional symptoms that can go along with the hormonal changes, but the picture does not have to be discouraging. Much of the worry women experience when thinking about menopause may be due to a lack of information about this period in their lives.
The American College of Endocrinologists recently updated their management guidelines for menopause. While there are no big changes to the recommendations, the authors stress the importance of individualizing treatment based on a woman’s symptoms, history, and risk factors.
Menopause is diagnosed after women have stopped menstruating for 12 months. The average age for menopause for women in the U.S. is 51. However, many women experience a constellation of symptoms that we call perimenopause 10-13 years before the actual start of menopause. Perimenopause often includes
- changes to the menstrual cycle including more frequent, longer, or heavier menses, or sometimes less frequent.
- hot flashes and night sweats
- changes in mood, libido, and energy levels.
- changes in how the body processes glucose, and changes in the levels of insulin resistance.
After menopause, additional symptoms include decreases in bone density, and changes in vaginal tissue that can lead to dryness and discomfort.
While all that sounds a little grim, it’s important to note that not all women experience all symptoms, and many would describe the symptoms as mild. Some women find the lack of a period, and not having to worry about pregnancy to be liberating. Menopause can mark a time of freedom – not just from periods, but also from PMS, hormonal headaches, birth control and all the side effects it can cause. Many women find themselves with a new, more positive relationship with their bodies.
Hormone Replacement Therapy
Our understanding of the role of hormone replacement therapy (HRT) in managing menopausal symptoms has changed in the past 20 years. It used to be that almost all women were encouraged to take HRT. Studies showing an increase in heart attacks and stroke among women on HRT radically changed recommendations and very few women were given the option of hormone replacement. Now we are more willing to individualize therapy. Experts no longer say there is a strict contraindication to HRT, although it appears less likely to be harmful if introduced earlier. Many providers are reluctant to use HRT if a woman is 10 or more years past the onset of menopause or if they are over the age of 60. For women with an increased risk of having a blood clot, it appears that certain formulations of estrogen, such as those given through the skin in a patch or cream, rather than in pill form, are safer. There are certain formulations of progesterone that appear to be safer than others as well.
We can use estrogen in the form of suppositories to treat vaginal symptoms specifically. This method carries little if any risk of systemic symptoms.
Risks and Benefits of HRT
| Effects | Combined estrogen and progestin | Estrogen only |
| Hot flashes | Decreased | Decreased |
| Night sweats | Decreased | Decreased |
| Sexual function | Improved | Improved |
| Bone Density | Improved | Improved |
| Breast Cancer | Increased risk | Possibly decreased risk |
| Heart attack, stroke, blood clots | Increased risk | Increased risk |
| Colon Cancer | Possibly increased risk | 1/3 lower risk |
| Hip and vertebral fracture | 1/3 lower risk | 1/3 lower risk |
| Insulin resistance | Possibly improved | Possibly improved |
| HDL cholesterol | Possibly improved | Possibly improved |
It is important to note that bio-identical hormones, even those specially compounded, are not recommended. This includes phytoestrogens that are plant-based. They have not been shown to be safer, and in fact due to inconsistencies in formulation and dosing, may be less safe. Some places will offer bio-identical hormones specially made based on the results of a saliva test, claiming that these are specially tailored for each person. Saliva levels of hormones do not correlate with blood levels, so these hormone formulations are not based on individual levels of estrogen and progestin at all.
Alternatives to HRT
The good news is that there are good medication options for managing menopause and perimenopause without the use of hormones. Often, these medications target specific symptoms, such as mood changes or hot flashes. We can use medications from the anti-depressant, blood pressure, and even anti-seizure medication families to target troublesome symptoms.
One of the most powerful tools that we have for managing the symptoms of menopause is exercise. Everything from hot flashes to mood to bone density can be significantly improved with regular, weight-bearing, cardiovascular exercise such as brisk walking or jogging. Attention to nutrition can also be key in navigating these changes. Most women feel and do better with smaller more frequent meals that are low in inflammatory foods like processed carbohydrates, and higher in non- or minimally processed whole foods like fresh fruits and vegetables. Ironically, one natural answer to the changes in vaginal mucosa is intercourse- studies show that women who have intercourse more frequently have better vaginal lubrication. Of course, this recommendation doesn’t always line up with the changes in libido that some women experience.
Many people will also use therapies such as meditation, yoga, acupuncture, and some herbal remedies such as Black Cohosh and Vitamin E. Depending on the symptoms, some of these remedies may be helpful, although there isn’t much data one way or another to help guide women’s choices.
If there is one constant that most women experience, it’s that their bodies change. From puberty on, it seems as if every phase of life is accompanied by major physical changes. Menopause isn’t always discussed openly, and hasn’t been the focus of as much medical research as it warrants, but it is possible to move through this period of physical change without undue distress. Support is available and if you bring your concerns to your provider, we can discuss the available options in more detail.