Dr. Rebecca Brightman breaks down the basics of menopausal hormonal therapy so you can decide if it’s right for you
While hormones have been prescribed to women for over 50 years (hello, birth control pills!), there is still quite a lot of confusion when it comes to using them to treat the symptoms of menopause. Many women haven’t even heard of menopausal hormonal therapy (MHT), let alone spoken about it with their doctor. So we called up Dr. Rebecca Brightman, who specializes in menopausal medicine, to give us an overview. Even Dr. B admits, “I know this all sounds very confusing — it’s a language I learned to speak,” but she helped us to break it down to the basics.
KCM: Let’s start with the all important question: what exactly is menopausal hormonal therapy?
Dr. Rebecca Brightman: So hormone replacement therapy, or what we now call menopausal hormonal therapy (MHT) is a treatment that gives a woman back the hormones that were previously made by her ovaries. This is not the fountain of youth, but initially the FDA-approved hormone replacement for the treatment of menopausal symptoms like night sweats and hot flashes. We now know that it can also help to prevent bone loss. Many menopause experts look at hormone replacement as a way of treating the whole woman, because for many women it’s not just night sweats and hot flashes, but also poor quality sleep, brain fog, and a whole constellation of other symptoms that come with menopause. So MHT restores the hormone levels that have dropped and keeps them in a range that’s certainly not as high as somebody who is premenopausal, but one that will manage some of those side effects.
What hormones do women on menopausal hormonal therapy take?
MHT usually involves estrogen plus something called progestin, which is a class of drugs that protects the uterine lining. Progesterone is what’s made by the body post-ovulation to protect the uterine lining for a fertilized egg. So when women are not pregnant, progesterone levels drop, and period is induced. Since estrogen causes the uterine lining to grow, progestin is used in MHT to protect the uterine lining.
For many women, certain types of progestins can help with sleep. Many women may also feel a change in cognitive function during menopause. Studies have looked at women who feel brain fog going into menopause, and typically their cognitive levels return to where they were prior to menopause. Sleep is essential, both in terms of feeling better during the day, but also in terms of mood and cognition. So that progestin component of hormone replacement can be great for women who are suffering with sleep issues.
Are the hormones taken in a pill form?
In terms of delivery systems, traditionally it was always oral. There are pills that combine estrogen and progestin, or there are two separate pills that can be taken together. Over the last couple of decades, some transdermal systems of delivering estrogen have been developed, which include patches, gels, and sprays. In my practice, the patch is the most popular, and patches are usually changed once or twice a week. The majority of my patients use a patch and then take an oral progestin at night because it helps them with sleep.
There is also a new method called pellet therapy, where little pellets are placed under the skin with a syringe. I don’t offer pellet therapy in my office as it is not FDA approved, and there are a variety of FDA-approved hormone options available in a variety of doses which can be tailored to suit a woman’s needs.
Who is eligible for menopausal hormonal therapy?
Women who experience severe symptoms of menopause, women who may be prone to osteoarthritis, and women for whom it is definitely safe to be on hormone therapy.
Not everyone’s a candidate for hormone replacement. Someone who has undiagnosed uterine bleeding, estrogen-dependent cancer, or a history of clotting disorders will likely not be eligible. That said, it’s really case by case — there are some women with early endometrial cancer who can go on estrogen once they’ve been treated. I can’t stress enough how it has to be individualized.
How does MHT help combat bone loss?
Bones are in a constant state of what we call remodeling, where it is constantly being deposited and reabsorbed in the body. When women are younger they generally continue to build bone, but that starts to reverse as women enter perimenopause and menopause. Estrogen really helps prevent that. So for many women who opt to go on MHT, it’s an extra data point that I look at because women are much more prone to fractures and broken bones as they age. Of course, it’s not just estrogen alone that helps keep bones strong. It’s estrogen combined with exercise— particularly resistance training and light weight lifting.
When do women usually start on MHT, and how long is the average woman on MHT for?
The closer one is to one’s final period is the best time to start, although of course, that’s only something we know retrospectively. So within the first 10 years of their final period, or before the age of 60 is a rule of thumb. They used to say that women should only be on it for five years and that’s it, but I don’t have any hard, fast rules that I follow in my practice. Ten percent of women will have symptoms of menopause into their seventies. I have patients in my practice who are 80 on hormone replacement. I’m not terribly rigid. Sometimes people will come off of hormones because they need orthopedic surgery or something, and they decide they’re ok off of them. I certainly don’t pull people off of it at 65 routinely. It has to be individualized, and as long as your doctor is checking in with you at regular intervals and reassessing your health and giving you appropriate screenings, I don’t think there is a fixed number of years.
What are the potential dangers of menopausal hormonal therapy?
There may be an increased risk in cardiovascular disease, and sometimes we see an increase in uterine polyps. If a woman has had any unusual bleeding, she would need to be evaluated before she starts hormones. If one develops any unexpected bleeding on hormone replacement, she may have polyps or pre-cancer, or she could have uterine cancer. But it’s not to say these things wouldn’t have happened without hormones. I do see more benign uterine polyps in women on hormone replacement, but that’s a very small fraction.
We also have to realize that with age, women increase their risk of cardiovascular disease regardless. Some women may think hormone replacement is to blame for various health conditions that occur. I always make sure that a woman optimizes her healthcare prior to starting hormones. She must be up to date with screening exams i.e. mammograms, colon cancer screening, and pap smears, the timing, and frequency of which is individualized.
There’s always a risk that comes with taking hormones, including birth control. Hormone doses in birth control are so much greater. I spoke to a doctor who said that her patients are often scared off from using local estrogen creams because they see a boxed warning, but the hormones in a topical cream are the equivalent of what you would get with a single birth control pill. But we think about it differently, because contraception is a known entity, and serves a very important purpose for a lot of women. It’s socially accepted, and as a result, the risks are accepted. My belief is that if you have severe side effects of menopause and going on MHT can change the quality of your life, why not do it? I once had a woman who came to me and said, “I can deal with the menopause symptoms. What I can’t deal with is my hair loss.” Hormone replacement therapy is not the cure-all for hair loss, but for her, the changes that she was seeing in her skin and in her hair made the treatment worth it. The point is that overall wellbeing is so important. If the impact of a treatment is that it positively impacts how we physically feel about ourselves, and improves the quality of our lives, that’s important.
When it comes down to it, for 90 percent of women, the night sweats and hot flashes and menopausal symptoms will get better. Not everyone’s a candidate for hormone replacement, and there are some very good non-hormonal options available to women. The first rule of medicine is to do no harm. So I ask myself, do hormones cause harm? If I felt they did, I wouldn’t be giving them to my patients.
Are there any long-term side effects of MHT?
I mean, it’s better for one’s bones that’s for sure! I can’t say anything else with certainty. Some studies cite an increased risk of dementia, some studies cite an increased risk of ovarian cancer, but these are not the majority of studies. There are so many other factors at play with age, and we don’t always know what’s correlation and what’s causation. So you have to weigh the risks and the benefits and be reassessed annually.
Do a lot of women choose MHT as an option during menopause?
In my practice, probably more than the average GYN, because this is what I do. But the majority of women do not choose MHT. The discontinuation rate is high because it requires a very lengthy discussion with a patient, and I may give her some literature to read, and then she’s scared off by the warnings or scared about what she read online. That’s why I think it’s crucial to have a trusting relationship with your physician and feel like they’re giving you the best and most up-to-date information so you can make an informed decision.
I know this all sounds very confusing — it’s a language I learned to speak. Some doctors are not that comfortable with it. And I think it’s okay to say to a patient, I am not comfortable prescribing hormones, but go for a consultation with someone who practices menopausal medicine. The North American Menopause Society has a list of accredited NAMS certified menopause providers, which I am. That’s a great place to start to find somebody who is well versed in the area of menopausal medicine.
I think women need to be informed that their needs change with age. For example, if someone wants to have a baby, they’re going to go to somebody who specializes in delivering babies. By the same token, when someone is going through menopause and they feel that they need more information than they’re getting, perhaps they want to go to somebody who has a lot of experience treating women during the menopause transition.