It has been said that nothing in life is certain except
death and taxes. For women, menopause
can be added to that list. By definition, Menopause is when the ovaries have
exhausted their capacity and ability to make hormones. The result of this loss of function for 90%
of women is hot flashes, vaginal dryness, emotional ups and downs, moody
disposition, lack of focus, difficulty with memory, concentration, decreased
sex drive, and a lack of energy. Many
women simply say, “I am not myself”.
Hormones are a vital part of wellbeing and beneficially
affect a multitude of pathways in the body.
Imbalances can actually occur in various settings but the most dramatic
decline occurs with menopause. The low
estrogen and testosterone levels not only results in an uncomfortable
experience, but also bone loss. This
bone loss can lead to osteopenia and increased risk of bone fractures. Furthermore, it is well known that estrogen
increases HDL (good cholesterol) and decreases LDL (bad cholesterol). Estrogen also has been shown in many studies
to decrease atherosclerotic plagues (clogged arteries) and decrease the risk of
colon cancer. Before menopause, women have
a lower risk of heart disease than men.
After menopause women’s risk catches up with men. This suggests a beneficial effect of
hormones.
If Hormones are so good what is all
the controversy about?
In July of 2002 a study was published called the Women’s
Health Initiative (WHI). The study
results indicated an increased risk of Breast cancer in 8/10,000 women. In addition an increased risk of stroke or
heart attack in 7-8/10,000. Looking at
the adverse events together in short this study indicated that women taking
oral estrogen and progesterone (prempro) made from horse urine had an increased
risk of an adverse event of 0.3% each year of use of Hormonal therapy. A positive from the study was a finding of a
decreased risk of colon cancer by 30%.
These results initially were a jolt to the medical community
as prior studies showed a decrease risk of heart disease. Consequently countless women were told to
stop their hormones. It wasn’t long
though before these women came marching back to their doctor’s door demanding
relief from the symptoms of lack of hormones.
Further evaluation found 2 major flaws in the Women’s Health
Initiative (WHI) Study:
Flaw #1; All of the women in the WHI were given oral
estrogen. Furthermore synthetic oral
estrogen made from horse urine. Studies
have shown that transdermal estrogen through subcutaneous pellets, patches,
sprays or gels are safer and do not increase the risk of heart attack or stroke
as they do not increase clotting factors as oral estrogen does.
Flaw #2: The average age of the women in the study was
63! These are not the newly menopausal
women suffering from symptoms. The
question is whether the very small risk seen for breast cancer, heart attack or
strokes was secondary to the hormones OR the age of the patient.
Another very interesting point is that the all of the above
risks in the WHI study were based upon the women taking PREMPRO (estrogen and
progesterone from horse urine). In the
SAME study there was another arm. The
other arm of the study was with women taking Premarin (estrogen only from horse
urine). In this arm there was no increased
risk of heart attacks, strokes or breast cancer. In fact the risk of breast cancer in the
estrogen only arm trended down!
Good news! A study
released in 2012 called Kronos Early Estrogen Prevention Study (KEEPS) looking
at women between the ages of 42-58 found no increased risk of blood pressure,
breast cancer, heart attacks, strokes or blood clots.
The bottom line:
While more studies are needed to provide a definitive answer most women
suffering from the symptoms of menopause are likely safe in taking hormone
replacement therapy. Especially if taken for a short period of
time. In most women the vasomotor
symptoms resolve by 5-7 years after the start of menopause. It also does appear that using non oral forms
of estrogen may be beneficial. However
with every medical intervention care must be individualized and take into
account the individuals medical history.
Menopause is a natural aspect of
life. Why are we bothering with trying
to treat it?
Yes. It is very natural.
However, consider this. The
symptoms of menopause - hot flashes, loss of sex drive, decreased energy, loss
of concentration insomnia, and vaginal dryness - can start 8-10 years before
menopause actually starts. This time period before menopause is called
Peri-Menopause. So, in most women the symptoms of menopause will start 8-10
years BEFORE menopause actually starts and continues for 5-7 years AFTER
menopause starts. Quick math: That’s a potential 20 years! Busy women with active and healthy lives do
not want to live with these symptoms for 20 years.
Yes, Menopause is natural, but so is appendicitis, cancer or
diabetes. No one would ever suggest that these natural processes should not be
interrupted by modern medicine. Likewise
a women suffering from the symptoms of menopause deserves help. Women going
through menopause without significant symptoms do not need therapy. However for those with lifestyle disruptions,
therapy can be a quality of life saver.
Are there alternatives to hormone
therapy for menopausal symptoms?
Yes. There are many
alternatives to hormone therapy: Black cohosh,
Soy products, clonidine, and gabapentin are some commonly non FDA approved
mentions alternatives. For some women
these work well but for about 70% of women they don’t cut it.
There is only one FDA approved alternative to estrogen. A SSRI (typically used for depression) called
paroxetine was rebranded and approved as Breisdelle for the treatment of hot
flashes. It was shown to be more
effective than placebo in the control of hot flashes only.
What are bio identical hormones? Are they safer?
When most refer to Bio identical hormones they are
describing hormones derived from naturally occurring sources, such as yams and
soy that are identical in chemical structure as the hormones that are produced
naturally by our bodies. Simply using a
hormone chemically identical to natural hormones is not necessarily safer. However mounting evidence has shown that
using bio identical hormones subcutaneously, tailored to the hormonal needs of
the individual, and delivered based upon physiologic demand; can be safer that
traditional methods.
SottoPelle Bio identical Subcutaneous Pellet therapy is just
one way to help achieve this. SottoPelle Therapy® is an all-natural bio-identical
hormone replacement therapy administered with a pellet that allows for a
continual release - the key to improving brain and muscle function.
In the end, hormone therapy must be individualized depending
on the individual’s medical history, symptoms, risk factors and
priorities. Hormones are not poison and
for the most part results in life changing beneficial effects for women. Discussing options with a knowledgeable
physician equipped with the tools to provide relief is a must for all women
suffering with the symptoms of menopause.
In most cases achieving a proper hormone balance together with proper
nutrition and exercise is the key to aging gracefully.
Melvin Ashford, MD
Minnesota Women's Care
OBGYN and Pelvic Specialty Care Center
