I feel lucky and proud to be a woman. However, being a woman isn’t all peaches and cream. From an early age, we have to learn to deal with our monthly menstrual cycles. While being able to carry a child is a privilege, it is never easy and can involve pain, complications and a difficult healing process. The kicker is that we have to go through menopause 20-30 years later. I’m not saying men get off easy, but come on? And it’s not everyone who goes through the hot flashes, night sweats, vaginal dryness, and mood swings of menopause—just 50-84% of us that will (the lucky remainder get off scot free!).
From talking to my patients who have gone through menopausal vasomotor symptoms (aka hot flashes) I can only reach one simple conclusion: it’s miserable. So what about medical management of this condition? The go-to has historically been hormone replacement therapy (HRT). Some women continue this for life and feel similar to a patient I’ve had who said she would “rather be dead than wean off.”
But what are the risks of HRT? The Women’s Health Initiative (WHI) study, a large randomized control trial of healthy menopausal women ages 50-77 years, demonstrated a slightly increased risk of breast cancer, heart attack, stroke and blood clot with a decreased risk of fractures and colon cancer after on average 5 years of combined HRT. These complications sound terrifying but it is important to bear in mind that the chances of experiencing them are low. Still, it is terrifying to think you could, for instance, be the unlucky 1 patient in 83 who develops breast cancer while taking the hormones you are prescribed by your doctor.
It’s good to know there are alternatives to HRT. They include Paxil, gabapentin and clonidine. However the reality is that every medication comes with its own potential side effects and these medications are less effective at managing the hot flashes than HRT. Some of the side effects from these medications are annoying for sure (for Paxil, gabapentin and clonidine, they might include reduced sexual function, grogginess, and dry mouth, respectively), however the risks of hormones are much more severe if they occur, although more rare.
If you haven’t already concluded, the decision of HRT vs. alternative medications is a difficult one that should be made with ongoing conversations with your physician. For instance, you will need to consider the potential side effects of the treatments carefully, and if you want hormones to treat your hot flashes, you will want to make sure you don’t have any contraindications to hormones including prior history of breast cancer, heart attack, history of blood clot, prior stroke or active liver disease. Doctors will prescribe progesterone in addition to the usual estrogen regimen to help prevent endometrial cancer in patients who still have a uterus. Sadly, the risk for breast cancer was higher in the patients who were taking both estrogen and progesterone as opposed to the estrogen alone, thus drawing the conclusion that the risk of breast cancer might be due to the progesterone use. So if you go with hormones and start estrogen, you must start progesterone as well in order to prevent endometrial cancer BUT you are then increasing your risk of breast cancer. Talk about rock and hard place.
When to stop the hormones?
Hot flashes persist for, on average, 7-8 years into menopause. Hormone therapy can be continued until you and your physician decide it's time to stop. If you’ve made the decision to wean, go down slowly (emphasis on slow), and feel free to check in with your doctor about non-hormonal alternatives (i.e., Paxil, black cohosh, evening primrose oil, exercise, gabapentin, clonidine). Half of patients experience hot flashes due to withdrawal from the exogenous hormones, but don’t give up hope, it gets better!
Ask your provider if hormone replacement therapy (HRT) might be a good option for you.
By focusing on a heart-healthy lifestyle that includes exercising, improving nutrition, and reducing stress, you can manage your symptoms and maintain good health as you move beyond menopause and enter your golden years.
Emily N. Peterson, M.D., is a Swedish family medicine and obstetrics physician specializing in pregnancy and childbirth, pediatrics and primary care. Her goal is to empower patients with knowledge to promote healthy lifestyles and answer any health related questions and concerns that arise along the road of life.
Dr. Peterson practices at Swedish Edmonds Birth & Family Clinic.
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