We thought we’d found the fountain of youth. Less than a decade ago, it seemed hormone replacement therapy not only treated the bothersome symptoms of menopause, but protected women from illness and helped them stay young. “It prevents heart disease! Alzheimer’s! Wrinkling!” the scientific community told us. What woman wouldn’t want a part of that […]
We thought we’d found the fountain of youth.
Less than a decade ago, it seemed hormone replacement therapy not only treated the bothersome symptoms of menopause, but protected women from illness and helped them stay young. “It prevents heart disease! Alzheimer’s! Wrinkling!” the scientific community told us. What woman wouldn’t want a part of that magical treatment?
Then, in 2002, the fountain ran dry. A widely publicized clinical trial suggested the hazards of the therapy far outweighed the benefits. Women using hormones to protect themselves from heart disease were actually putting themselves at greater risk. Higher incidences of breast cancer, blood clots and strokes were also tied to the therapy. “Everybody sort of panicked,” says Dr. James Dolan, an obstetrician/gynecologist at Aurora West Allis Medical Center. Up to two-thirds of women promptly dropped the treatment, often without consulting their doctors. Practitioners were reluctant to prescribe it.
Today, many women remain confused about the treatment, now commonly called post-menopausal hormone therapy. Unfortunately, this often means patients who could benefit from the therapy – and some can – don’t get it. “I don’t think women have received the appropriate information on the updated studies. I don’t think they know what kind of research is going on currently. And I don’t think practitioners, by and large, are able to spend the time with patients to really give them a full understanding so they can make informed decisions,” says Dr. Patricia Dolhun, an OB/GYN and certified menopause practitioner with Madison Medical Affiliates in Milwaukee.
The fact is, hormone therapy does have risks, but it also has some clear benefits. And while it’s no longer recommended as a “fountain of youth” drug, it’s still the gold standard for treating menopausal symptoms. Ongoing research, revised guidelines and a closer examination of the 2002 study have allowed the medical community to be much more precise in its use of the therapy, isolating groups who stand to benefit as well as those for whom the treatment is a bad idea. In the end, the 2002 scare may have underscored a very basic truth of medicine: No one treatment is right for everybody.
Quality of Life
Approximately 75 percent of women in the United States will suffer from menopausal symptoms during their lifetime. This includes hot flashes, night sweats, sleep difficulties, memory problems and vaginal dryness. “Some women have to get up in the middle of the night, change their nightgowns, change their sheets. Some women have pain with intercourse. All of these things impact their quality of life,” explains Dolhun.
The average age of menopause – which technically occurs after a woman’s period has ceased for a full year – is 51 years in the United States, but symptoms may start years earlier (that stage is called perimenopause). Interestingly, women in Asian countries experience far fewer menopausal symptoms than those in the U.S. and Europe. The phenomenon could be genetic or dietary, or could have to do with our cultural ideas about aging, of which menopause is an unmistakable sign. “In America, a sign of aging is distressing. In Asia, a sign of aging is encouraging – it brings wisdom,” explains Dr. Julie Mitchell, an internist with Froedtert Hospital and the Medical College of Wisconsin.
Alternative treatments for menopausal symptoms include herbal supplements and off-label use of certain medications, yet post-menopausal hormone therapy is regarded as the most effective treatment, and by a wide margin. The new rule of thumb for hormone therapy is to take the lowest dose of the medication for the shortest period of time. The guideline is vague, Dolan acknowledges, and requires an ongoing conversation between doctor and patient.
Certain women are better candidates for hormone therapy – and some may even glean additional benefits from the medication. Those who may benefit the most are healthy perimenopausal and early post-menopausal women. “There may be a critical window of opportunity where these women – coming into menopause in their late 40s and into their 50s – are going to be benefited by hormone use,” notes Dolhun. Among these benefits are better bone health and a lower risk of osteoporosis-related fractures, as well as a lower risk of colorectal cancer. Data also suggests that estrogen therapy can decrease the risk of heart disease when it is taken in a woman’s early post-menopausal years.
Given the benefits, women with family histories of these diseases who have bothersome menopausal symptoms might want to consider hormone therapy. “If a woman is otherwise healthy at this time, there’s no reason why she can’t use hormones to treat symptoms,” says Dolhun. This is good news for the group that was probably most disadvantaged by the previous uproar over the therapy, when hormone use was stopped across the board.
That said, patients who already have a history of heart disease, breast cancer, blood clots or strokes are not good candidates for hormone therapy, regardless of their age. All of these conditions are serious risks associated with the therapy, and as a woman ages, her risk increases. “When you’re older, you just have a more likely chance of any of these things – clots, atherosclerosis or cancer,” explains Mitchell. The risk of hormone therapy causing heart disease, for example, doesn’t become significant until after the age of 60. Apart from specialized cases, Dolan believes the biggest risk to people is age. “If you’re a menopausal woman who is age 65 and beyond, hormone treatment really shouldn’t be considered,” he says.
The hormone regimen to be used is another issue to consider. Women who have an intact uterus are treated with a combination of estrogen and progestin, because estrogen alone can cause uterine cancer. A woman who has had a hysterectomy may be treated with estrogen alone. The specific risks associated with each of these therapies may differ (for example, the risk of breast cancer is specifically associated with the use of estrogen-progestin).
It’s also important for doctors to get a sense of each woman’s preferences for therapy. “I assess what kinds of anxieties they might have about hormones and what kinds of hopes they have about how they might feel better,” says Mitchell. Some patients are more risk-averse than others; some simply don’t like the idea of taking hormones.
For women seeking alternatives, there are several options to consider. A number of medications are used off-label to treat hot flashes in particular, including the
antihypertensive medication clonidine and a seizure medicine called Neurontin. Antidepressants such as Prozac, Paxil and Effexor have also been shown to help with symptoms. Some women swear by black cohosh, an herbal supplement. Of course, all of these medications have potential side effects, so patients should discuss the pros and cons with their doctor.
Other women prefer to focus on lifestyle changes, such as dressing in layers, decreasing caffeine or alcohol intake, avoiding spicy foods or using cold packs in their pillows. Exercise or relaxation therapy helps some women manage symptoms. “Ninety percent of the time it goes away without you doing anything,” says Mitchell. “Depending on the severity, it can be a matter of, can you grin and bear it?”
Patients who do choose to try hormones will find treatment options have become much more sophisticated. “Women have a wide range of the types of hormones they can take and they have a wide range of ways to take them,” says Dolhun. Hormone therapy is available not only in tablet form, but also in patches and rings, gels or lotions that can be rubbed into the skin, or vaginal creams. Bio-identical estrogen – like the estrogen we produce naturally in our own bodies – is widely available.
After women decide to begin hormone therapy, they need to maintain a regular conversation with their doctor about how they are feeling and when it might be time to taper the dose. Long-term use of the combined therapy is associated with a slightly higher risk for breast cancer. Other risks, such as cardiovascular disease, clots and stroke, may also increase with extended use. These concerns need to be weighed against a patient’s wishes. “I have a couple of patients who say, ‘I can’t live without the hormones because I feel awful; I don’t care if I get breast cancer,’ ” says Mitchell.
In the end, it’s important that every woman have access to the optimum treatment for her symptoms, notes Dolhun. “Midlife is a time of change. Children that are growing, career stress, aging parents – women have a lot going on at this time,” she says. So it’s important they be able to function at their highest levels and feel their best. Too often, the medical community is lackadaisical about menopausal symptoms, she says. “My goal is not just, ‘You’re OK most of the time,’ but ‘How can we get you OK as many days of the month as is possible?’ I think this is what all women in transition at the time of menopause deserve.”
Caroline Goyette is Milwaukee Magazine’s monthly health columnist.
A roundup of the latest health wisdom
Slim men beat prostate cancer.
Maintaining a healthy body weight can reduce a man’s risk of dying from prostate cancer. A study in the Journal of Clinical Oncology found that heavy men with prostate cancer were more likely to die within five years compared to those in the lowest weight category. Diabetes was a key factor in deaths among prostate cancer patients. A healthy weight also reduces the chance of developing diabetes.
Socializing helps your brain.
A study following 147 pairs of male twins for nearly 30 years found that those with active social lives in their middle years were less likely to develop dementia. The report in Alzheimer’s & Dementia found that the following activities were more likely to reduce Alzheimer’s risk: hobbies, home and family activities, going to parties and playing cards. Activities that are both socially and mentally stimulating appear to be of greatest benefit.
Good news about ADHD teens and drugs.
Parents shouldn’t worry that teens taking stimulant medications for attention-deficit/hyperactivity disorder (ADHD) are more likely to use other drugs. According to the Archives of Pediatrics & Adolescent Medicine, teenage girls taking medications for ADHD are less likely to use alcohol, cigarettes or other drugs. In fact, they were about 75 percent less likely to use cigarettes or develop substance-abuse disorders. A previous study recorded similar results in adolescent boys. Untreated ADHD, however, has been shown to double the chances of long-term substance abuse and cigarette smoking.
Thyroid problem? Get checked for glaucoma.
Thyroid disorders may increase the risk of glaucoma, a serious eye condition that sometimes leads to blindness, notes the British Journal of Ophthalmology online. Glaucoma occurs when pressure within the eye increases, which can eventually damage optic nerves. Increased pressure is usually caused by excessive production or poor drainage of fluid inside the eye.
The mystery behind male breast cancer.
The Journal of the National Cancer Institute reports that men who develop a bone fracture after age 45 are more than twice as likely to develop breast cancer. On the other hand, women who suffer fractures are less likely to develop breast cancer. The report’s authors called the findings “unexpected.” It’s not known why fractures increase breast cancer risks for men, but hormones may play a role.
– Scott R. Weinberger