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As women enter perimenopause and begin to transition into menopause, questions inevitably arise. How long can I expect these symptoms to last? Will vitamins or supplements help? Is menopausal hormone therapy (MHT) right for me?
While all these questions can be discussed with your doctor, the debate around MHT and when and what it should be prescribed for has become a topic of debate among some medical professionals. While the medical field supports the use of MHT for treatment of menopause symptoms, there are some doctors who are also proponents of it to help prevent conditions like cardiovascular disease, osteoporosis, and even dementia.
“As our population ages, we have more women living in menopause with many living well over 20 years after the menopausal transition,” says OB-GYN Ruth O. Arumala. “There is a demand to improve the quality of life of these women.”
The study that started the debate
Understanding the language behind MHT and the hormone replacement therapy (HRT) is an important place to begin. While the terms MHT and HRT are sometimes used interchangeably, many doctors draw a distinction between the two.
”Hormone replacement therapy and menopausal hormone therapy are not the same thing,” says Heidi Flagg, OB-GYN, Flow advisor, and founder and managing partner of Spring ObGyn. “Hormone replacement therapy is used very specifically in a woman who has experienced premature ovarian insufficiency. True HRT is twice the dose of standard menopausal hormone. MHT is used to treat women who experience the many symptoms of perimenopause or menopause and to prevent bone loss.”
MHT is typically prescribed to women who are experiencing menopause symptoms that are severe enough to be interrupting their daily life. This includes: hot flashes, vaginal dryness, night sweats, pain during intercourse, mood swings or mental health issues, brain fog or confusion, low bone density, or insomnia.
In the late 1990s MHT was the most commonly prescribed relief plan for women in the United States, with over 15 million taking treatment. But that number drastically dropped, and the latest data shows that roughly 29 percent of women with natural menopause or menopause that occurred without surgery, have used hormones to treat symptoms, according to the CDC. This is in large part due to The Women’s Health Initiative Study (WHI) published in 2002.
“The initial results of the study were alarming as they demonstrated that the use of hormone therapy in postmenopausal women increased the risk of heart disease, stroke, blood clot, breast cancer, and dementia,” said Dr. Arumala.
Further analysis of the results of the WHI years later, however, showed that in women ages 50 to 59 hormone replacement therapy had significantly fewer risks, and the 20 year follow up studies showed the women taking estrogen MHT alone had a statistically significant 22 percent decrease incidence of breast cancer, and a 40 percent reduction in breast cancer mortality, explains Dr. Flagg.
Age was also found to be a major factor. A later review emphasized that many of participants of the WHI were older, postmenopausal women. The reanalysis found that healthy women under 60 who underwent MHT had very little risk of severe side effects. Their findings revealed that women under 60 who participated in the trial had no elevated risk of heart disease, and that women who began MHT in their 40s and 50s had minimal risks for blood clots or stroke, two common conditions in older women.
The reanalysis also found that women over the age of 60 who began MHT did elevate their risks of heart disease after starting treatment, and that risk increased if they waited to start treatment until after the age of 70.
“A closer look at some of these long term studies show that things like lifestyle, alcohol intake, diet, obesity, stress are what lead to the increased risk of cancer, diabetes, and heart disease,” says Dr. Flagg.
What the latest research shows
Following the WHI study, new research was conducted to better understand just how severe the risks might be, and if there were any others.
The Million Women observational study, published in 2003 highlighted associated risks with VTE, a condition that occurs when a blood clot forms in a vein, and breast cancer. In 2019, research investigating MHT and the risk of developing VTE was published and found that an increased risk of VTE among patients, compared to those who did not take MHT, equivalent to extra nine cases per 10,000 people. This increased risk was seen with the use of oral hormone therapy, but not in transdermal therapy, such as an estrogen patch.
In 2020, a study with similar methods to the 2019 study was conducted. It looked into the link between breast cancer and MHT, and found that women who had never used MHT compared to those who took estrogen-only MHT treatments were associated with only slightly increased risks.
Combined estrogen–progesterone MHT treatments were linked to higher risks, but the increased risks of breast cancer declined after discontinuation of treatment. For women who used a combination of estrogen–progesterone MHT treatments in the last five years, their overall risk was increased by the equivalent of between nine and 36 extra cases per 10,000, but for women who had stopped five or more years ago, the overall increased risk was the equivalent of between 2 and 8 additional cases per 10,000 women.
In 2022, the North American Menopause Society (NAMS) advisory panel issued a statement regarding MHT and menopausal health in light of previous research. Dr. Staci Tanouye, MD FACOG, MD and board-certified OBGYN and August Advisor, says the statement in her opinion is the gold standard for menopausal health.
It in part reads: “Hormone therapy remains the most effective treatment for vasomotor symptoms (VMS) and the genitourinary syndrome of menopause and has been shown to prevent bone loss and fracture. The risks of hormone therapy differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. Treatment should be individualized using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of the benefits and risks of continuing therapy.”
And while hormone therapy can carry risks, there are numerous documented benefits. In some cases, MHT can have a positive impact on cardiovascular health by improving lipid profiles and reducing the risk of heart disease, especially when initiated within a certain window of time after menopause.
MHT can help maintain or improve bone density, reducing the risk of osteoporosis and fractures, which can be a significant concern for postmenopausal women.
“MHT in the form of vaginal estrogen can be particularly beneficial for addressing vaginal dryness, atrophy, and discomfort, which can significantly affect sexual health and overall comfort,” said Dr. Haver.
What doctors are saying
The full scope of MHT and its side effects is nuanced. While research has shown that it is effective for the treatment of menopausal symptoms, some doctors still think that using it for treatment of other diseases not linked to menopause is one that should be avoided or at the very least thoroughly discussed with a healthcare provider.
“The formulation of MHT should be individualized as well and different forms of MHT also carry different risk profiles,” said Dr. Tanouye. “For anyone with contraindications to MHT like breast cancer, the risks will most likely outweigh the benefits. And for someone who doesn’t have any menopausal symptoms, the risks may outweigh the benefits.
These doctors also note that there are other options to MHT for treatment of these diseases that don’t carry the same risk factors. Cognitive-behavioral therapy has been shown to help women manage how much hot flashes bother them, while the selective serotonin reuptake inhibitor (SSRI) paroxetine is also prescribed for the relief of hot flashes. There is also a newly FDA-approved medication for hot flashes.
But for doctors, like menopause specialist and OB-GYN Mary Claire Haver, author of The Galveston Diet, her stance is that it can provide significant health benefits.
“The debate surrounding hormone replacement therapy for menopause symptoms is multifaceted and, to some extent, warranted,” she explained. “However, it’s essential to approach this topic with a balanced perspective. It’s crucial for healthcare providers to stay updated on the latest evidence-based practices and for patients to have open and informed discussions with their providers to make personalized decisions about menopausal hormone therapy.”
Creating your own toolkit to navigate menopause
The decision of whether the benefits of menopausal hormone therapy (MHT) outweigh the risks is highly individualized and depends on various factors, including a woman’s age, medical history, the nature and severity of her menopausal symptoms, and personal preferences. Dr. Haver says, “It’s crucial to approach menopause care as a comprehensive toolkit that includes multiple strategies to address women’s needs during this life stage.”
Here’s an overview of the components that she recommends to keep in mind.
1. Nutrition: Nutrition is a cornerstone of menopause care, says Dr. Haver. A balanced diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats can help manage weight, support bone health, and reduce the risk of chronic diseases. Nutritional guidance should also consider specific needs, such as calcium and vitamin D intake for bone health.
2. Exercise: Regular physical activity, including both aerobic and resistance training, can help manage weight, maintain muscle mass, improve cardiovascular health, and enhance overall well-being. Exercise can also help alleviate mood disturbances and improve sleep quality.
3. Stress Reduction: Stress reduction techniques, such as mindfulness, meditation, yoga, and deep breathing exercises, can help women manage the emotional and psychological aspects of menopause.
4. Sleep Optimization: Addressing sleep disturbances is crucial during menopause. Good sleep hygiene practices, relaxation techniques, and, in some cases, consultation with a sleep specialist can be beneficial.
5. Pharmacology: MHT is one of the pharmacological options available for managing menopause symptoms, but it’s just one part of the toolkit. The decision to use MHT should be made in consultation with a healthcare provider, considering individual factors and preferences. Non-hormonal options, such as selective serotonin reuptake inhibitors (SSRIs) or selective serotonin-norepinephrine reuptake inhibitors (SNRIs), may also be considered for symptom management.
6. Supplementation: Some women may benefit from dietary supplements, such as calcium and vitamin D, to support bone health. It’s essential to discuss supplement use with a healthcare provider to ensure appropriate dosing and safety.
7. Community and support: Building a support network and connecting with other women experiencing menopause can provide emotional support and valuable insights into managing this life transition. Online and in-person support groups and educational resources can be helpful.
“Ultimately, the decision to pursue MHT should be based on a careful consideration of the potential benefits and risks, weighing them against alternative options and taking into account individual circumstances and preferences,” said Dr. Haver. “This decision should be made in collaboration with a healthcare provider who can provide guidance and monitor the woman’s progress over time.”
