Menopause Treatment is Undergoing a Renovation

Menopause Miseducation

For decades, education on menopause—for both women and physicians—has been sorely lacking. This leaves women unprepared when midlife hormonal shifts start to wreak havoc on their bodies and moods.

“Women’s knowledge about their bodies, about their hormones, about how their bodies function have been reduced to baby-making capacity. There’s no real education when we teach young girls, teenagers, or grown women the impact that estrogen, progesterone, and yes, even testosterone, have on their bodies,” says Dr. Menn. While these hormones are important for reproduction, most people don’t know how they impact every cell (see “The Hormone Handbook” on page 62). “When our hormones go away and our estrogen levels decline, it’s not just hot flashes and vaginal dryness—it impacts all these other body systems. And we don’t teach women and girls much besides you’re going to get your period.”

In fact, the hot flashes and night sweats that most of us associate with menopause can actually be a bigger signal of other health impacts. “They’re the canary in the coal mine of what’s actually happening  in your body at a neurovascular and whole-body level,” says Dr. Menn. “Hot flashes and night sweats are directly associated with the markers of cardiovascular disease and bone loss. The worse your symptoms, the more severe, the earlier they come, the
more disruptive those hot flashes, there’s research showing direct association.”

These hormonal changes also have big impacts on the brain, as new research shows, and women should know that they’re not alone—and that it’s not just them that this change affects.  “New onset anxiety, depressive symptoms, insomnia, brain fog, cognitive changes, these things have impacts on women’s lives, on their relationships, on how they feel on a day-to-day basis,” says Dr. Menn. “The menopause transition is a period of vulnerability, but there’s things that you can do to make that transition easier and to improve your long-term health.”

The Helping Hormones

Due to the misinterpretation of the WHI, the acronym HRT became a bad word in health-care circles for decades. The use of HRT went down nearly 75 percent after the initial study, even though the treatment has been FDA-approved for decades, and continues to be the gold standard for treating menopause symptoms.

Today, experts like Dr. Munn prefer to use the term menopausal hormone therapy to reduce confusion and clear up old myths. “We’re not giving you replacement back to levels when you were younger,” she says. “Primarily, we think of it as estrogen therapy; and if you have a uterus, you have to take a progestogen.” The progestogen serves to ensure that the endometrial lining doesn’t continue to grow and cause problems like endometriosis or endometrial cancer. She also says testosterone will eventually be in the picture, but an FDA-approved option for women doesn’t yet exist.

The range of options for synthetic and bioidentical hormones for this purpose is far more expansive than what was used in the WHI study. There are patches, gels, sprays, and oral options that are all bioidentical, meaning they’re the same chemical structure as what your body used to produce. Vaginal estrogen, which can be applied via creams, suppositories, or a vaginal ring, also has been proven to improve genitourinary symptoms (like dryness, irritation, and frequent UTIs), all with very few side effects.

“[After WHI], estrogen became a dirty word. Everybody was fearful, and the FDA put a black-box label on any estrogen-containing products with the blanket warnings ‘may cause stroke, may cause breast cancer,’ when that’s not accurate for the label,” says Dr. Munn. “The saddest thing is that the label was put on vaginal estrogen, when it’s a local hormone therapy, not systemic.”

Not only has it been FDA-approved for decades, but it has been shown to reduce your risk for getting a UTI by 50 percent, one of the most common reasons an older woman gets admitted to the hospital. “When I tell you that vaginal estrogen saves lives, it literally can,” says Dr. Munn. “But for decades, no one was prescribing it.”

A Holistic Approach

While the myths surrounding the WHI continue to persist, increased menopause education and awareness of the positive side of hormone therapy options can begin to shift the tide. “WHI really did a disservice to women in this country undergoing the menopausal transition,” says Joyce Varughese, MD, the medical director of the Center for Gynecologic Oncology at Capital Health Surgical Group. “As a physician caring for patients with gynecologic cancers who sometimes end up in premature menopause because of their cancer treatments and would benefit from long-term HRT from a brain, bone, and heart health standpoint, it has been an uphill battle because patients are scared to take HRT. There are always risks to any treatment, and so treatment should be tailored in discussion with a physician.”

On a positive note, she has seen more and more women willing to speak about their menopausal symptoms and seek out care, rather than just “dealing” with it. The range of treatments available is broader than ever, even for cancer patients who may not be able to take systemic hormones.

As our understanding of menopause and HRT continues to evolve, women should feel empowered to take a more holistic approach to care and treatment, including asking directly about HRT or menopausal hormone therapy. Today, four major medical societies, including the American College of Obstetricians and Gynecologists, the American Association of Clinical Endocrinology, the Endocrine Society, and the North American Menopause Society, all recommend hormone therapy for menopausal symptoms—but despite the data, many physicians still struggle with understanding which patients are best suited for the treatment and avoid prescribing it altogether. Women may still need to initiate the conversation in many cases and should consider their overall health and conditions when assessing the impacts.

“The fear of breast cancer should not be the driving decision on whether you manage menopause with hormone therapy. We’re more than just our breasts, and I’m telling you as someone who is a long-term breast cancer survivor,” says Dr. Menn. “More women die of cardiovascular disease than they do of breast cancer, and estrogen alone has never been shown to increase your risk of breast cancer. That is the biggest driver of why doctors don’t prescribe [HRT]. They need to be re-educated on what the actual data says.”

If there’s one thing that women should know, it’s that menopause symptoms don’t have to be simply a “fact of life.” By arming yourself with the knowledge and vast treatment options available, women can have empowered conversations with their care providers, and navigate this life transition not as something to be suffered through, but as a time to create a new, and more humane, normal.