Menopause And Hormone Replacement Therapy
So, what are the real every day issues that still remain that concern today’s menopausal woman? As a doctor who has seen thousands of peri-menopausal women, I believe that it’s the quality of life issues that are most important to women right now.
These are the issues that women must grapple with every day and which greatly affect the enjoyment of their lives. Just because certain types of hormones have been found to be unacceptably dangerous for long term use, does not take away the need for and interest in, hormone replacement therapy.
Women are not so much interested in how they will feel in 20- or 30-years’ time, but rather want to be able to enjoy the still relatively young years, at least in today’s terms, that exist between the ages of 45 to 70. Today’s woman is smart and well educated and wants to know ALL her options. She knows that osteoporosis and heart disease have much more to do with diet and lifestyle, than they do with hormones. The reality is that if you have a poor diet, are overweight, have a fatty liver, smoke heavily, and do not exercise, then all the HRT in the world is no guarantee that you will be saved from cancer, fractures and heart attacks. A magic HRT pill to protect us from ageing would be great, I would take it! However, we are all too smart to be duped by the drug companies.
The real issues of the moment for perimenopausal women are:
- How do I feel and look today?
- How does my mind function?
- Can I have a good sexual and/or emotional relationship with my partner?
- How can I remain healthy for the next 20 years?
To help women achieve their goals and satisfy the above expectations, doctors have to think laterally, practice holistic medicine and have empathy with every individual woman. If this is not their area of interest, they can always refer to a doctor who is interested in this sub-specialty of medicine. Clinical trials are based upon large population studies, statistics, and a generalized deduction and recommendation. However, many women do not really relate to this academic world – it can be frightening and confusing for women trying to relate to the academic ivory tower.
Firstly, we must be honest with women – they deserve it! They depend upon us and we want to keep their trust.
Women would like to know that:
- Very few pharmacological treatments in medicine are perfect – most are a compromise between relief and possible side effects. We need to weigh up all the pros and cons. If we do take HRT it will have a protective effect upon our bones and usually improve our sex life, however if we use a potent oral form of HRT it may increase our risk of blood clots and strokes.
- There is a great difference between individual women – some women need HRT to enjoy their lives, while others feel well and function efficiently without HRT. We should not frighten all women off HRT – it remains a viable option.
- Nutritional medicine can work, especially for the prevention of long-term degenerative diseases; however, it cannot simulate the effect of real hormones in the way we feel. For example, homeopathic hormones do not work at all, and herbal hormones will not always be able to achieve the same effect of real hormones.
- There is a huge difference in the effect in the body induced by different types of hormones. Just like “oils aren’t oils, hormones aren’t hormones” – for example hormones taken orally, as in the Women’s Health Initiative (WHI) study, are absorbed from the gut and pass straight to the liver. The liver breaks the hormones down (metabolizes them) and only a certain amount gets past the liver into the general circulation – thus we must use higher doses of more potent hormones to gain a clinical result. This increases the work load of the liver and induces the liver enzymes to make more clotting factors – thus we become more at risk from blood clots. Also, because the progesterone that we use in oral HRT is usually synthetic, it takes longer to be broken down by the liver, and may accumulate in the body, causing more side effects. I have never thought that it was physiological (natural) to give hormones by mouth for this reason, unless we require oral contraception. It is much more physiological to give hormones in a way that bypasses the liver to get into the circulation and this can be done by administering hormones through the skin, which is called trans-dermal administration. This can be achieved using hormone creams and patches. Some doctors use lozenges (troches) that are designed to be placed between the upper gum and the cheek, so that their contained hormones are absorbed directly into the blood vessels under the lining of the cheek. This way we are meant to avoid swallowing the hormones and thus absorbing them from the gut and then through the liver. Some women tell me that it is difficult to avoid swallowing some of the lozenge, especially since they come in several hundred flavours!
I personally feel more comfortable prescribing trans-dermally absorbed hormones via the creams and/or patches, especially for long term use, or for women with risk factors for HRT. The beauty of the creams is that they can be tailor made for the individual woman, to contain the combination of natural hormones that she needs, as determined by her blood tests, medical examination and history. A doctor who prescribes hormone creams will use a compounding pharmacist who is specialized at mixing specific combinations of hormones. You cannot buy these creams under a brand name. The hormone patches can be purchased as a brand name on a prescription from a regular pharmacist. Many of the estrogens used in the WHI study came from Premarin, which is a mixture of horses (equine) estrogens and human estrogens. The human body makes 3 different types of estrogen – namely estradiol, estriol and estrone. We can administer any one or all of these human natural estrogens in the creams. The weakest and safest estrogen is called estriol, and this can be used for those women wanting to reduce estrogenic side effects and risks.
- Although there are some very favourable clinical trials evaluating the use of hormone creams for various hormonal problems, there are no very long-term studies available on their safety for use as HRT for the post-menopause.
- The use of any HRT is an individual choice and is not a medical necessity. We cannot give 100% guarantees of safety and generally speaking it is wise to find the lowest dose of HRT that will relieve unpleasant symptoms and improve well being. This can be compared to taking the oral contraceptive pill (OCP) – women know about the risks, as they are printed on the packet. However, millions of women choose to take the OCP, because its advantages often outweigh the disadvantages in the individual woman.
Communication is the key – treat women as intelligent human beings. Women need to take some responsibility in helping their doctor decide if they will use HRT. They can only do this if they know and understand all their options. Luckily one does not have to be a rocket scientist to work out the advantages of different types of HRT. Common sense and realistic expectations should be explored. It is always possible to prescribe HRT for a short period (under one year), choosing a trans-dermal application (patches or creams), just to see if it really makes a difference or not. Then one can weigh up the absolute risks, and make a personal decision for long term use.
Today’s menopausal woman has a much longer life span and totally different life expectations than women who lived 100 years ago. She does not want to:
- Age rapidly
- Stop being sexually alive
- Embrace old age mentally and physically at the tender age of 50
There is no doubt that hormones can help us feel and look younger and keep us sexually young. Just imagine if men ran out of their sex hormones at the tender age of 50 – well there would be a hormone shop in every suburb!
Yes “hormones make the world go round”, and controversial or not, they are not going to become taboo!
For more information women may phone 02 4655 4666 and ask for the book “Menopause – HRT and its Natural Alternatives” by Dr Sandra Cabot
Symptoms of hormone imbalances