Hormone replacement therapy got a bad rap but, with good medical advice, it can have benefits beyond dealing with menopause’s unpleasant symptoms
As women, we are no strangers to the cyclical ebbs and flows of our hormonal governance. As much as our reproductive rights are a gift and a privilege, they are not without their difficulties at every stage. This article explores the final hurrah — menopause.
Menopause is becoming a much talked about issue in the workplace. Studies support that more than 50% of women are significantly affected by their menopause in the workplace. Some go as high as 73%. One study showed the relationship between depression and anxiety in menopausal women and the severity of their menopausal symptoms.
A large percentage of women resign from their jobs during this period because they don’t have the support that they need. I was delighted to hear that Australia is forging the way with menopause leave for employees.
Menopause is the cessation of ovulation. It arrives, on average, at about the age of 51 but the range is 45 to 55. As you pass your 35th to 40th birthday, the decade preceding your menopause, your ovaries start to run out of viable eggs. As a result, your progesterone and then oestrogen levels start to decline. Before coming to a standstill, these levels can fluctuate immensely and erratically, potentially leaving you feeling a little mad, irritable or frustrated.
These changes can bring with them some turbulence and irregularity to your cycle too, and are often associated with heavier cycles and sometimes more pain. For some, this shift in balance can be subtle and short lived, and for others it can be a difficult time of adjustment.
Some women experience changes in mood, weight and energy and anxiety or sleep disruption. Later, this may begin to manifest as hot flushes, depression, irregular and erratic cycles, and cognitive changes such as poor memory and brain fog. You are officially over the menopause line when you are 12 months beyond your last period.
Many of our other hormones are affected in this changing period too and it’s important to have a picture of your well-being that includes other endocrine organs.
In contrast to some of this unpleasantness, women in their fifth decade can enjoy the accomplishments of a full life. Moving into menopause is often a time when the nest is emptying and your energies can shift away from maternal and domestic obligations to a little more self-care and enrichment.
With the wisdom and knowledge of a life well spent, this can be a time of growth, enjoyment and adventure.
Oestrogen not only contributes to keeping our urogenital organs healthy, but it also plays an important role in bone integrity, breast, skin, brain and cardiovascular health.
You have oestrogen, progesterone and testosterone receptors throughout your body and this is what makes the symptom profile of menopause so diverse.
What is tricky about this time (and all hormonally fluctuant times) is that there is no holy grail. Some women thrive in menopause and others wilt. Some women glow under the hormonal deluge of pregnancy and others experience weight gain, anxiety, depression and exhaustion.
Because this terrain is so unique to every woman, an individualised approach is asked for and a Western paradigm of medicine doesn’t always accommodate this. Pharmaceutical medicines don’t often allow for dose adjustments, but this is also what makes them accessible and affordable.
The women’s health initiative study in the 1990s was a landmark study looking at hundreds of thousands of women on hormones. We learned some valuable things from this study, but one of the outcomes that was manipulated by the press was that hormone replacement therapy (HRT) causes breast cancer.
When we look back on this study, we see that almost a third of the women in the study were significantly overweight, another third were obese and another third were former or current smokers. This alone introduces a whole host of other risk factors for cancer creation.
According to the absolute risk expressed in that study looking at a specific synthetic progestogen, the increased risk of breast cancer for women on HRT was only 2% more than the control group. Other studies show that women on HRT live longer and those with breast cancer have better outcomes.
The most important message for patients is not to approach hormone therapy with an air of fear, but rather to embrace all the knowledge that is out there and, with an informed practitioner, to make a decision that is right for you. Your decision is highly individual and will depend on current symptoms, past medical history, family history and your preference.
Current thinking is that oestrogen and progesterone replacement in the decade after your menopause protects your bones, your brain and your cardiovascular system in a significant way. The benefit after the age of 60 is uncertain. We also don’t have any large-scale studies looking at oestradiol and micronised progesterone.
The “safest” forms of the hormones are the ones that are molecularly the closest to the hormones our own bodies produce — body-identical hormones. Most of the newer oestrogen preparations out there are oestradiol, but not all “progesterone” formulations are body-identical.
Hormone therapy is valuable for its assistance with the symptoms of menopause, but also for the prevention of long-term health risks associated with the prolonged absence of these hormones, such as Alzheimer’s, osteoporosis and heart disease.
These risks are not measured by the presence of hot flushes, and so hormone replacement should not only be considered in those with hot flushes. If you have no symptoms, a bone density scan is a helpful indicator as to whether you should replace your hormones.
There are both genetic and environmental risk factors that one needs to consider before deciding on hormone therapy. Comorbidities such as hypertension, obesity or diabetes may discourage your healthcare provider from prescribing hormones, because all of these diseases increase your risk for a blood clot.
A history of blood clots, moderate to severe endometriosis, enlarging fibroids, gallbladder or liver disease, unexplained vaginal bleeding, atypical hyperplasia of breast tissue, or breast, endometrial or ovarian cancer histories might deter your doctor.
Giving oestrogen transdermally (through the skin) bypasses metabolism through your liver and reduces the risks of clotting associated with taking oral oestrogen. Taking micronised progesterone orally is the safest way to protect your uterine lining from becoming overstimulated by oestrogen.
These hormones need to be prescribed together to prevent the possibility of endometrial cancer, which is associated with unopposed oestrogen. You can think of progesterone and oestrogen as sunscreen and the sun. You need both.
Several studies have appraised the difference in effects of natural supplements versus placebos, and the placebos and supplements mostly fare similarly. This is not to say that they have no effect.
Using phyto-oestrogens such as soya can help blunt hot flushes. Evening primrose oil is known to relieve some of the symptoms of premenstrual syndrome and menopause. Vitex agnus-castus is a plant that supports the body to make progesterone and testosterone, and often helps with irritability.
There are also non-hormonal interventions that your doctor could prescribe. Some antidepressant drugs, such as venlafaxine, and clonidine, an alpha adrenoceptor agonist, can help to reduce flushes.
You can also wear light clothes and dress in layers, avoid hot drinks and keep your environment cool. Keeping your diet clean, eating whole foods (mostly plants) and avoiding animal products containing hormones and antibiotics also helps.
Exercise is the elixir of life, and you should integrate this into your social and everyday life. Weight training is important not just because we lose muscle mass (which affects our metabolism), but also because it helps to strengthen our skeletal system and improve our balance, independently reducing our fracture risk.
The most important message is you need your own individualised care programme. There are differing schools of thought in the medical community, and that’s okay. Connect with a practitioner who shares your well-being point of view.
Dr Skye Scott is a family GP and co-owner of Health with Heart. Follow @drskyescott or @health_w_heart on Instagram, go to Facebook for @HealthwithHeartDoctors, or visit www.healthwithheart.co.za