Menopause

Have You Experienced a Time in Your Life…

 …where you feel your heart is pounding so hard you are downright positive it is going to beat right out of your chest? Or maybe you are simply cooking dinner for your wonderful family and out of nowhere you feel so hot, sweaty, and angry you would swear your child decided to prank you by turning the thermostat up to 120 degrees in the house? Or maybe you are driving in your car picking the kids up from school and in the midst of their excited chatter talking about their day your anxiety is building to the point that your brain feels it might explode? Well, if you have experienced menopause already, then you may be able to relate. And, if you are currently going through it, then we hope to share some valuable information that will ease the discomfort that too often comes with menopause. 

We have had many women make statements such as: “I feel like I’m going crazy!”, “I don’t feel like myself!”, “You must think I sound like a crazy person with all these symptoms!”. Rest assured; you are not crazy. Every woman has a different experience with menopause and there is no “right way” to feel. Let’s start with the basics.

What is menopause?

From the time of puberty until menopause, a woman has two very important hormones circulating through her body that work in a cyclical manner. These hormones are called estrogen and progesterone. Menopause is defined as the time in which these two important hormones are no longer produced by the body in high enough amounts to stimulate a menstrual cycle.

We have all heard of low testosterone in men, which happens to the tune of about a 1% decrease per year starting around the age of 40. With menopause however, the change in hormones is much more pronounced. Over the course of a few months, circulating levels of estrogen and progesterone drop very rapidly and in many cases these levels become undetectable on lab work. This abrupt withdrawal of hormones (estrogen specifically) is responsible for the unpleasant symptoms associated with menopause.   

When does menopause usually start?

For most women, perimenopause (the start of menopause) and menopause start in the mid to late 40s and in many cases into the early 50s. It is not unheard of for a woman to show menopausal symptoms in her 30’s, but this tends to be the exception.

Interesting fact: The average age of menopause in North America is 51 years old.

How do you know if you are in menopause?

Menopause is typically diagnosed after a woman stops having periods for 12 months, but the process (and its lovely symptoms) can start years before this. If you are curious, menopause can be confirmed with simple lab work that is usually covered by insurance. Your doctor will look for circulating hormone levels (estrogen and progesterone) and will likely order levels of hormones called luteinizing hormone (LH) and follicle stimulating hormone (FSH).

Think of your LH and FSH as the signals from the brain to your ovaries asking for them to create estrogen and progesterone. The higher your FSH and LH, the louder your brain is asking for hormones. In the case of very high FSH and LH, your brain is essentially yelling at your ovaries for more hormones. If the conversation between brain and ovaries could be translated, it might go some thing like this: “Hey! Have you ovaries given up on me?” In which the resounding answer from the ovaries if they could talk would be “Yes as a matter of fact, we are all done!”

In terms of lab work, the classic menopausal pattern is as follows:

Estrogen and Progesterone = Low to undetectable

FSH and LH: elevated to very elevated

Key point to remember:

Menopause is not an illness! It is a completely normal part of aging. If you are a woman and you live long enough, you will experience menopause.

What are the symptoms of menopause?

Menopause is well known for its classic symptoms of hot flashes and mood swings, but the other symptoms women experience may surprise you. If you have already experienced menopause, then you might be able to relate to the following symptoms all too well:

• The list of menopausal symptoms is quite long and includes:  
• Difficulty sleeping 
• Heart palpitations 
• Joint pain 
• Night sweats 
• Mood changes/irritability 
• Breast tenderness
• Low or absent libido 
• Anxiety 
• Depression 
• Headaches 
• Weight gain or difficulty losing weight 
• Vaginal dryness  
   

For some women, they are able to breeze through menopause symptom-free, but the majority of women will experience some or all of the above symptoms to varying degrees.

So, What Can Be Done?

Options vary, but we have compiled a summary of common treatments offered to women during menopause:

#1: Do nothing

Remember, menopause is not a disease. Women have been going through menopause for thousands of years and while its effects can certainly be unpleasant, it is not inherently dangerous. There are certainly some risks that go along with the natural withdrawal of estrogen (which we will talk about) but doing nothing is a reasonable choice.

#2 Prescription Medications:

Antidepressants and anti-anxiety medications: 

Very often, these are the first medications prescribed by providers when women present with menopausal symptoms, even if depression or anxiety are not an obvious issue.While there is evidence that they can be helpful in reducing symptoms, they are not addressing the root of the problem. Furthermore, these medications can be difficult to wean off of and can have unpleasant side effects.

But we get it! You probably want to feel human again and sometimes we are willing to try anything. If you are on one of these medications and they are working for you, there is no shame in that. But there may be a better option for you.

Gabapentin:

Typically used for nerve pain and seizure prevention, gabapentin has also been used as an off-label drug to help improve menopausal symptoms, sometimes with good results. Gabapentin can help improve mood changes and anxiety and some women report improvement with heart palpitations. This medication can cause unpleasant side effects however and needs to be weaned off to prevent withdrawal. Again, is this a helpful medication? Sometimes. But it is not addressing the root of the issue.

#3 Hormone Replacement Therapy (HRT)

Another option for treatment and arguably the best way to combat menopausal symptoms is hormone replacement therapy (also known as HRT). This involves supplying the body with estrogen and progesterone to replace the hormones that were lost during menopause. There are both risks and benefits that come with HRT and not every woman is a good candidate for it. It will be important to have a conversation with your doctor about the pros and cons of HRT, but we will do our best to give you the most up to date information so you can arrive at your appointment well prepared.  Spoiler: We are big fans of hormone replacement therapy when it is done safely.

How is HRT Given?

As we said above, the goal of HRT is to supply your body with calculated levels of estrogen and progesterone to restore your hormones back to the normal range. As a general rule of thumb, the ideal window to be on HRT is either ten years from start of symptoms or until the age of 60, whichever comes first.  The best time to start HRT is early on in perimenopause, as you stand to benefit the most with the least amount of risk. In some cases though hormones can be safely given well past the age of 60.

Estrogen

Estrogen comes in multiple forms, but the most commonly prescribed forms are skin patches and creams. Patches allow for systemic absorption into the blood stream while the creams are typically applied locally for vaginal symptoms (this means they are only absorbed in the vaginal area). That said, there are higher dose estrogen creams that have substantial systemic absorption, and these usually come from compounding pharmacies. Some women opt for oral estrogen, although this has fallen out of style in recent years due to the increased risk of blood clots and high blood pressure with this formulation. 

Important to note: Estrogen is the component of HRT that helps the most with the long list of menopausal symptoms above.

Progesterone

Progesterone is most often given as a pill or capsule, but you may also find it in patches or compounded creams as well. There are multiple forms that can be prescribed, but we prefer the natural micronized progesterone prescribed in capsule form. “Micronized” is a fancy way to say that it has the same molecular structure as naturally produced progesterone. 

How does progesterone help?

While estrogen causes the uterine lining to grow, progesterone works to stabilize the lining of the uterus and protect it from abnormal growth that can lead to uterine cancer.

Progesterone can also be very helpful for insomnia, hot flashes, night sweats, and anxiety. Progesterone can make you slightly drowsy, so it is usually given at night-time.

Note: If you are on estrogen therapy and you still have your uterus (meaning you have not had a hysterectomy), it is non-negotiable to be on some form of progesterone to prevent uterine cancer.

For women who have had a hysterectomy (uterus removed) some clinicians feel that there is no benefit to taking progesterone as its benefits to do not extend past stabilizing the uterine lining. We tend to disagree with this, as many studies have shown progesterone therapy to be very safe and carry additional benefits to brain health, cardiovascular health, and mood. If you would like to bring some proof to your appointment, here are three research articles that will help support your case:

1: Progesterone in Peri- and Postmenopause: A Review

2: Lessons from KEEPS: the Kronos Early Estrogen Prevention Study

3: Progesterone Therapy, Endothelial Function and Cardiovascular Risk Factors: A 3-Month Randomized, Placebo-Controlled Trial in Healthy Early Postmenopausal Women

What is “Bio-identical HRT”?

Bio-identical HRT, sometimes called BHRT, refers to hormones that are structurally identical to the ones produced by our bodies. Most HRT these days is done with bio-identical hormones. If you are on “estradiol” or “micronized progesterone” then you are on bio-identical hormones. If your hormones consist of “norethindrone”, “progestins”, “medroxyprogesterone acetate”, or “conjugated estrogens”, then you are not on a bio-identical form of hormone.

What about hormone pellets?

Another method of hormone replacement therapy that has gained popularity in recent years is hormone pellets. These small pellets are implanted under the skin and slowly dissolve over time, supplying the body with estrogen and progesterone. These typically dissolve over a period of weeks to months and provide steady doses of hormones over that time period. This is a very low maintenance approach to HRT, as it does not require you to take medications every day. While this may appeal to many women, it does require surgical implantation under the skin, and it is usually not covered by insurance.

What are the Benefits of HRT? 

1: Relief of menopausal symptoms

For most women, getting circulating levels of estrogen and progesterone back into the normal range brings fairly rapid relief of menopausal symptoms.

Within a few weeks most women notice:

• A decrease in hot flashes
• More stable mood
• Improved sleep
• Decreased anxiety

HRT is hands down the most effective treatment for menopausal symptoms and you will be hard pressed to find a medical professional who would disagree. 

2: Protection against Osteoporosis  

There is strong evidence that HRT is protective against osteoporosis, or the age-related weakening of bones. This is tremendously important given that the chance of dying from a fall-related fracture goes up significantly as we age. To avoid getting too technical, estrogen slows the rate at which bone is broken down. Put more simply, the more years you can spend with normal estrogen levels the better your bone health will be.

Not so fun fact: If you are age 80 or above and you suffer a hip fracture, your odds of dying in the next year are 1 in 5. This is a sobering statistic and makes the case for hormone replacement therapy that much stronger.

 3: Protection against dementia (though not for every woman)

This is an ongoing topic in the field of medicine, and we will hopefully learn more about this in the coming years. As it stands today, the evidence is as follows:

• In women who start HRT early in menopause, HRT has a protective effect against dementia. This means that when started in the late 40’s or early 50’s, HRT can reduce the risk of dementia.
• Conversely, when started later in life (typically 60 or over), research shows that HRT can increase the risk of dementia.

4: Protection against cardiovascular disease

Another important study on hormone replacement therapy revealed some very encouraging results regarding heart disease. The Nurses’ Health Study followed over 48,000 women and found that over a 10-year period, women who took HRT and had no prior history of heart disease had a 44% decreased risk of heart disease

These results have been seen repeatedly in the last 20 years in a variety of observational studies, with most studies showing a similar risk reduction in the 40-50% range. That’s a very big deal!

Important to note:

There has been a very consistent pattern in the research that shows:

The risk of a heart related event (heart attack) is slightly increased during the first year of HRT when there is a known history of heart disease. After the first year of HRT, this increased risk of a heart related event tends to disappear.

This increase in risk is because estrogen (especially in oral form) can be pro-inflammatory, cause unstable plaques, and cause platelet clumping, all of which are bad things in terms of heart disease.

The good news: This is less of an issue these days now that oral estrogen is not as widely used and is another reason that we recommend topical estrogen or skin patches as the route of delivery.

Starting HRT early in menopause is very important:

Looking at the data further, benefits to heart health are only gained when HRT is started early in menopause. When you think about it, this makes intuitive sense. Younger people tend to have less heart disease and starting estrogen is riskier in those with pre-existing heart disease.

The takeaway:

Start the estrogen early! If you start HRT before you have any heart disease, you stand to benefit. If you wait, these benefits may disappear and even turn into risk. As a general rule, if you are over 60, the benefits of estrogen in terms of heart health are really not there.   

What About the Risk of Breast Cancer? 

Breast Cancer:

You may have heard that there is an association with hormone replacement therapy and an increased risk of breast cancer. This dates back to a research study published in the early 2000s called the Women’s Health Initiative which revealed some seemingly shocking results.

The findings of this study showed that women who took HRT had about a 25% increase in rates of breast cancer. This was a very startling finding and essentially put a halt to doctors prescribing HRT, which at the time was very popular. When you take a closer look however, there were some serious issues with those results, and many believe these results were grossly overstated.

Women’s Health Initiative:

The most obvious issue with this study is that the bombshell conclusion they came to was based on results that did not reach statistical significance. What does this mean?  To say a study does not meet statistical significance is science language that says it is possible these results happened by pure chance. In general, results that do not reach statistical significance carry far less weight in the science community (or at least they should). 

Another issue in this study was the group of “healthy” women they enrolled to represent the general population. Collectively, this group had the following characteristics:

• Median age of 63 (remember, HRT should ideally be stopped at age 60 in most cases)
• 70% were overweight
•  34% were obese
• 36% were treated for high blood pressure
• Almost 50% of them were current or past cigarette smokers

Seems like a healthy population without any additional risk factors for cancer, right? Hardly. This makes it very difficult to draw any meaningful conclusions from these results and is part of the reason some clinicians disregard the results of the Women’s Health Initiative.

So, what is the true risk?