The transition through perimenopause and menopause is a significant life phase for many women, marked by a series of changes and potential challenges. Hormone replacement therapy can be an effective treatment for the symptoms related to menopause, though there are many misconceptions about the benefits and risks related to taking hormones that prevent many women from using this effective treatment.
The Essence of Female Sex Hormones
Our bodies undergo profound changes throughout life, significantly influenced by our sex hormones, estrogen, and progesterone. These hormones play pivotal roles from the onset of puberty, through the reproductive years, and into the post-menopausal phase (1,2). Each stage brings its own set of changes, with menopause marking a significant shift as the ovaries reduce sex hormone production, which can lead to various symptoms like hot flashes, mood swings, poor sleep, and decreased bone density.
Female Sex Hormone Fluctuation Across a 28 Day Cycle
What is Perimenopause?
Perimenopause by definition means “around menopause”, and marks the time when the ovaries gradually begin to produce less estrogen. Symptoms may include irregular periods, vasomotor symptoms like hot flashes and night sweats, mood changes, sleep problems, vaginal and bladder problems, UTI’s, changes in sexual function and desire, bone loss, and higher cholesterol (APO B) levels. Depending on the person, these symptoms can range from mild to severe. For many women, these symptoms can significantly impact their quality of life. HRT may be an effective treatment option for some of these symptoms.
What is Hormone Replacement Therapy
Menopausal hormone therapy (MHT) is the technical new term for hormone replacement therapy (HRT) though still referred to by most as HRT.
It involves the administration of estrogen and, depending on whether you have a uterus, progesterone to mitigate the risk of endometrial thickening.
Benefits of Hormone Replacement Therapy
Effective for Menopause Symptoms: HRT is the most effective treatment for vasomotor symptoms (hot flashes and night sweats). HRT can also be effective for genitourinary syndrome of menopause which includes genital symptoms (dryness, irritation, burning, pain with intercourse) and urinary symptoms (pain with urination, incontinence, urgency, recurrent UTIs) (3)
Improves Quality of Life: Reduction of symptoms can improve overall well-being during perimenopause and post-menopause.
Prevents Bone Loss and Breaks: HRT helps prevent bone loss, a condition known as osteoporosis/osteopenia, which can increase the risk of fractures. Hip fractures are linked to higher mortality in older adults (4)
The Controversy and Evolution of HRT
The conversation around hormone replacement therapy (HRT) is fraught with confusion, myths, and a history of controversy.
HRT was first approved as a form of estrogen called conjugated estrogens for the treatment of menopausal symptoms by the FDA in 1942.
About 30 years later in 1975, it was determined that there was an increase in endometrial cancer in those using estrogen alone, so providers started to include the use of a synthetic progesterone called medroxyprogesterone acetate (MPA) in women with a uterus to prevent uterine thickening, a known risk factor for endometrial cancer. By the early 2000s, about 15 million women were using hormone replacement therapy, many for reasons outside of menopausal symptoms - it was common to take HRT for the prevention of chronic diseases including cardiovascular disease and cognitive decline, though we did not have any randomized controlled trials to prove its efficaciousness or safety outside of menopausal symptoms (6,10).
In 2002, the Women’s Health Initiative set out to investigate the use of HRT for chronic health conditions, specifically cardiovascular disease. Ultimately, one of the study arms was stopped early due to the increase of breast cancer in persons taking conjugated estrogen and progestin without any benefit in cardiovascular outcomes. This led to a dramatic decrease in hormone replacement therapy for women (6).
Dr. Mary and Dr. Scheeler discuss the limitations of this study including the types and routes of hormone taken, the population used in the study, and the interpretation of the true risks. Ultimately, they argue, for certain populations, the reduction of HRT use could be a greater harm than benefit.
Choosing the Right HRT Approach
The decision to pursue HRT should be made with careful consideration of the form, dosage, and administration route, balancing benefits and risks. Transdermal applications of estrogen, for instance, offer advantages over oral estrogen by avoiding first-pass metabolism in the liver, thereby reducing certain risks associated with oral estrogen (7, 8).
Safety and Personalization at the Forefront
Initiating HRT before the age of 60 or within ten years of menopause can maximize benefits and minimize risks (11). Yet, it's not a one-size-fits-all solution. Personal health history, including cardiovascular disease, should guide the decision-making process.
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For Reference, Dr. Scheeler uses this diagram to explain the feedback loops in the hypothalamic, pituitary, gonadal axis:
Citations:
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