Joyce Varughese, MD, answers seven questions we whisper to friends, Google at 2 a.m., or hesitate to ask our doctors.
The truth is that we need a lot more research to definitively know all of the symptoms hormone therapy treats and the health outcomes it leads to.
For many years, menopause hormone therapy (MHT)—also known as hormone replacement therapy (HRT)—was considered a medical gray zone. We whispered about it to our friends. We were warned about its link to cancer. It was debated in doctors’ offices. And women making their way through the menopause transition and navigating its many symptoms were left with more questions than answers: Why can’t I sleep like I used to? What can I do about these hot flashes and night sweats? Are these mood swings something I have to quietly endure?
Thankfully, we’re talking more—and more openly—about our symptoms and demanding solutions. Even better, experts have reexamined the research, and the conversation around the safety of MHT has evolved. Yet many women are still left sorting through mixed messages, outdated fears, and a flood of information online. Here, Joyce Varughese, MD, FACOG, medical director of the Center for Gynecologic Oncology at the Capital Health Surgical Group and clinical assistant professor at the Lewis Katz School of Medicine at Temple University, cuts through the noise and offers clear, evidence-based answers to some of the most common questions.
Q: If breast cancer runs in my family, is hormone therapy off the table?
A: The short answer is no, says Dr. Varughese. This surprises many of her patients, mostly due to the lingering impact of the Women’s Health Initiative (WHI), which found an increased risk of breast cancer in women over age 60 who were taking estrogen and a synthetic form of progesterone.
“When the WHI came out, all everyone heard was that hormone therapy increases the risk of breast cancer and didn’t get into the details of who these patients were,” says Dr. Varughese. In the years since the WHI, experts have continued to look at the data, and what has emerged is much more reassuring. For starters, the average age of the women in the WHI study was 63, at which point women are already at an increased risk of breast cancer. As for that 26 percent increased risk of breast cancer? Experts say that stat was not statistically significant. In fact, the risk amounts to one additional case of breast cancer for every thousand women treated with MHT per year, and no increase in the risk of dying of breast cancer.
If breast cancer runs in your family, Dr. Varughese recommends genetic counseling and potentially genetic testing. “We know there are genetic mutations that increase one’s risk of breast cancer, and there are others that don’t,” she says. “A lot of factors can increase the risk of breast cancer, including lifestyle, obesity, and alcohol use, among others. Genetic testing helps women and their doctors know if it’s truly genetic versus a family history due to lifestyle or environmental factors.”
If you don’t have a known mutation that increases your risk for breast cancer, Dr. Varughese says you may be a candidate for hormone therapy. In fact, even if you do have a genetic mutation that potentially increases your risk of breast cancer, hormone therapy may still be an option. “There’s a lot of nuance to this conversation, so it’s a good idea to have a discussion with your healthcare provider to make the best decision for you,” adds Dr. Varughese.
Q: Will MHT fix symptoms like sleep issues, midlife weight gain, and mood issues?
A: Some of the symptoms that MHT can help with are mood swings and vasomotor symptoms (hot flashes and night sweats), which in turn may improve sleep. It may also help with vaginal dryness and pain with intercourse, though many patients also need local vaginal estrogen in addition to systemic hormone therapy to see benefits. Because estrogen—or the lack thereof in menopause—impacts so many of the body’s organs, the thinking is that MHT may help prevent osteoporosis and heart disease and promote cognitive health, sexual health, and more. “The truth is that we need a lot more research to definitively know all of the symptoms hormone therapy treats and the health outcomes it leads to,” says Dr. Varughese. “We haven’t been able to do this research because people have been afraid of hormones for so long.”
Q: My sex drive is has changed dramatically. Can MHT boost my libido?
A: When we talk about hormone therapy, we’re usually talking about the combination of estrogen and progesterone, explains Dr. Varughese. In general, estrogen therapy works to supplement declining estrogen levels in the body. Pro-gesterone is always added to estrogen therapy if you still have a uterus, because progesterone protects the uterine lining (called the endometrium) from overgrowth, which reduces the risk of endometrial cancer. These hormones come in several forms, from pills and patches to gels, creams, and vaginal suppositories.
Libido is driven by testosterone, says Dr. Varughese, which means that going on estrogen and progesterone doesn’t usually increase sex drive. That said, it can improve vasomotor symptoms, sleep, and genitourinary syndrome of menopause (GSM), which includes vaginal dryness, all which may make us more interested in intimacy because “we’re not exhausted and sex isn’t painful,” adds Dr. Varughese.
Unfortunately, there are no FDA-approved testosterone product for women. This makes it important to see a clinician who really knows what they’re doing. “I would not recommend hormone therapy pellets of any type because these are not regulated,” says Dr. Varughese. “I’ve seen many women who were using testosterone pellets or in irreversible doses develop uterine cancer, even though they had no risk factors, because testosterone converts to estrogen. I’ve also had patients on testosterone develop male pattern baldness, facial hair, and even the growth of the clitoris, which is not reversible once it happens.”
Q: Does vaginal estrogen work differently from an estrogen patch or pill?
A: When you use an estrogen patch or pill, the hormone enters your bloodstream and circulates systemically. Vaginal estrogen is a lower dose than you get with systemic forms of estrogen, which is one reason why it stays local to that region. What’s more, the vulva and vagina are filled with estrogen receptors, which take up the estrogen before it has a chance to travel through the bloodstream.
Given this fact, it’s important to keep in mind that systemic and vaginal estrogen treat different symptoms. While systemic estrogen helps with symptoms like hot flashes and protects your bones over the long term, vaginal estrogen eases the symptoms of GSM, such as vaginal dryness, itching, or burning; pain during sex; urinary incontinence or urgency; frequent urinary tract infections (UTIs); and painful urination.
Many of Dr. Varughese’s patients think that because they aren’t sexually active, they don’t need vaginal estrogen. This is a myth she debunks often. “As estrogen drops, we lose lubrication and can experience dryness in the area, which can cause a general feeling of discomfort and also increase our likelihood of urinary tract infections (UTIs),” says Dr. Varughese. “Local vaginal estrogen can help with all of these symptoms.”
Q: Any advice on finding the best type of hormone therapy for me?
A: Start by having a conversation with your primary care physician or ob-gyn, says Dr. Varughese. These providers are trained in following evidence-based guidelines. In this age of misinformation, as well as general information overload, this is crucial.
Just as important: Use caution when it comes to people or companies trying to sell you something. Ask yourself, “Do they have an ulterior motive or a strong incentive to sell me this product?” Because the truth is that hormone therapy isn’t for everyone, says Dr. Varughese. “There should be people who say, ‘No, that’s not safe for you,’” she says. “And if someone is selling pellets, stay far, far away. There is a lot of good data about the dangers of hormone pellets.”
Q: What are the risks of hormone therapy that need to be on my radar?
A: Just as some women aren’t good candidates for birth control pills (like smokers), HRT can also pose risks for women who are at an increased risk of side effects. Dr. Varughese always asks patients about their personal and/or family history of blood clots, since hormone therapy can increase the risk of developing blood clots.
Your clinician may decide HRT isn’t right for you if you have a history of these conditions:
• Uterine or estrogen-positive breast cancers (in personal history, not family history)
• Heart attack, stroke, or a life-threatening blood clot
• Any hormone-induced blood clots while on birth
control pills
• HRT- or pregnancy-induced deep vein thrombosis
• Unexplained vaginal bleeding while taking HRT
It’s crucial to give your clinician an accurate, extensive medical history when discussing if hormone therapy is
right for you.
Q: Is it ever too early or too late to start MHT?
A: Is it ever too early? Yes, says Dr. Varughese. If you’re getting regular periods each month and all signs point to the fact that your body is still cycling, you’re likely making ample amounts of the hormones you need and don’t need hormone therapy. If your periods start getting a bit wonky or you start experiencing menopause symptoms, it’s something to start discussing with your doctor.
As for when it’s too late to start hormone therapy, we don’t know what that magic number is, says Dr. Varughese. “If you’re within five years of menopause, I have no qualms about starting hormones,” she says. “If it’s been more than 10 years, it’s more of a question, because those are the patients in the WHI who had increased health risks.” Because this is a gray area and more research is needed, it really comes down to shared decision-making with your clinician after you’ve talked through the risks and benefits.
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