Ahhhh “menopause”. The cursed “m” word that women associate with all things miserable as they enter their midlife years (average age at menopause is 51 years). Hot flashes, vaginal dryness and painful intercourse, out of control mood swings, forgetfulness and bladder problems are just a few of the clinical manifestations of this transition. Often, the array of symptoms associated with the occurrence is so disarming because the only proven way of easing the transition is with a short course of hormone therapy. The questions, however, remains—are they safe to take? Data from the WHI and the HERS trials have led to changes in recommendations for postmenopausal hormone therapy. The approach outlined here is consistent with the Position statement of the North American Menopause Society.
Let us review the current recommendations for hormone therapy (HT) in order to ease your mind when the time comes.
Who is a good candidate for HT?
Symptoms of hot flashes and night sweats (vasomotor symptoms) occur most often in the late menopausal transition and in the early post menopause- which typically covers the late 40 to early 50 year range. Although there are alternative therapies for these symptoms such as black cohosh or soy/tofu products, none have been shown to be as effective as estrogen.
In as much, estrogen is a good, short-term option for most,women, with the exception of those with a history of coronary artery disease, breast cancer, stroke/ prior thromboembolic event—or conversely, those women who at a high risk of the aforementioned complications.
Patients also need to be mindful of the fact that the goal of HT is symptom management; it cannot alter or change the process of menopause. In other words, hormones cannot turn back the hands of time. In the past, short-term therapy was defined as less than five years. This definition is somewhat arbitrary as there is no general consensus about the duration of short-term versus long-term therapy. However, short-term therapy is now generally considered to be two to three years and not more than five years. Currently, hormone therapy, either estrogen alone or combined estrogen-progestin therapy should not be initiated for the primary prevention of heart disease or for osteoporosis.
Breast Cancer and HT
Although women with breast cancer often experience early menopause due to their treatment regime (radiation+/- chemotherapy), and may also suffer from vasomotor symptoms, estrogen therapy should not be prescribed.
In the Women’s Health Initiative (WHI), the risk of breast cancer with combined estrogen-progestin therapy did not increase until the fourth year. However, abnormal mammograms were more common in the HT group. HT is therefore not recommended for women with a personal history of breast cancer. Other established means of controlling symptoms or preventing osteoporosis should be utilized before considering estrogen therapy in these women. Finally, routine mammograms and breast exams are also essential, even if HT is used short-term.
The epithelial lining of the vagina and urethra are very sensitive to estrogen. It then reasonably easy to understand that estrogen deficiency can lead to thinning of this layer. This results in “vaginal atrophy” (atrophic vaginitis), causing symptoms of vaginal dryness, itching and often, painful intercourse. Both oral and vaginal estrogen preparations are effective for genitourinary atrophy symptoms, but vaginal estrogen is more potent. It can be administered locally (available as cream, tablets, or rings) and is an extremely effective therapy for genitourinary symptoms. It is an excellent option for nearly all postmenopausal women (with the exception of breast cancer patients) and can be administered long-term as systemic absorption, when appropriate doses are used, is negligible.
Osteoporosis and Dementia
Although it was previously recommended that estrogen be used as a first-line choice for prevention and treatment of osteoporosis, this is no longer the case. The current practice is to use other categories of medications such as the bisphosphonates or an aromatase inhibitor-raloxifene for our post-menopausal patients for the prevention of osteoporosis. Estrogen may also be given to selected women who cannot take a bisphosphonate or raloxifene. With regards to dementia, given the available WHI data, hormone therapy should not be initiated after age 65 years to prevent dementia. There is insufficient evidence to either support or refute that hormone therapy use in perimenopausal women is effective for the prevention of later dementia.
Hormone Therapy Administration
There has been much debate about the “best/ effective dose” for hormone therapy during the menopausal transition. Two major clinical trials provided data only on combined, continuous conjugated estrogens (0.625 mg) and medroxyprogesterone acetate (MPA 2.5 mg), a synthetic progestin. Estrogen preparations other than conjugated estrogens, and progestins other than MPA (such as natural micronized progesterone) should be discussed your doctor. Although there are reasons to believe that natural progesterone might be safer for the cardiovascular system, it is important to emphasize that it is not known if this preparation, or different regimens are safer for the breast or cardiovascular system. So even if you hear a celebrity in an infomercial attesting to the merits of “bio-identical HT”, you must think of these statements critically and talk to your physician about the medical evidence!
Let’s be honest with ourselves: menopause will come at some point to all women. It’s just that some of us will deal with the transition and the clinical manifestations better than others. If you are a woman who can manage without hormones-that’s great! But no-one needs to suffer unnecessarily with difficult symptoms in the short-term. Most postmenopausal women, with the exception of women with breast cancer or known cardiovascular disease, who have symptoms of vaginal atrophy and/or vasomotor instability are good candidates for estrogen therapy (for the shortest duration possible depending upon symptoms). So I suppose the answer to the Shakespearian reference in the title is a resounding yes…let it be!