Taming Menopause

HRT can help—but it’s not without controversy.

Illustration by Chris McAllisterThirty years ago, menopausal women were the stuff of TV sitcoms, with the likes of Edith Bunker and her liberal cousin, Maude, suddenly in the same boat and getting no sympathy.

No more. These days, an increasing amount of medical attention is being devoted to menopause—or more specifically, perimenopause, the life stage when you experience the telltale symptoms. And that’s great news for women between the ages of 45 and 54.

In many ways, improved knowledge about nutrition, daily exercise and general good health has made it easier for women to cope with the changes that occur when their ovaries begin to shrink and hormone production decreases.

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“It’s a time when you should be saying, ‘Hey, wait a minute. I’m not ready to crumble and die,’” says Anthony J. Bazzan, co-director of Jefferson University Hospital’s Great Life Program, geared toward men and women “crossing into middle age.”

For women, hormone replacement therapy remains both a popular and controversial way to smooth the bumpier stretches of this crossing. To understand HRT, it helps to know a bit about how hormones function. Produced by the ovaries, progesterone is often the first to have an impact on emotions, as fluctuating levels disrupt its characteristically calming, feel-good effect on the body.

Estrogen, meanwhile, comes in at least three different varieties produced in parts of the body aside from the ovaries—like the adrenal glands, liver and kidneys. It’s also one of the major symptom-producing hormones. During menopause, the ovaries struggle to produce more of the hormone, causing irregular or unpredictable menstrual cycles.

Efforts to remedy the symptoms that accompany menopause—everything from night sweats and insomnia to hot flashes and depression—have been rife with complications and controversy. In fact, HRT’s rise and fall in acceptance seems to mirror menopause’s emotional roller coaster.

Recent lawsuits have called into question HRT’s efficacy and safety. But there have been positive developments, fueled in large part by actress Suzanne Somers and her promotion of natural, plant-derived bioidentical hormones. Somers’ February 2009 appearance on Oprah was one of the show’s most watched episodes.

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While some in the medical community are concerned that Somers is placing too much emphasis on hormones as an anti-aging elixir, others are thrilled that she’s touting bioidenticals. That’s mainly because a majority of them aren’t FDA approved, so they haven’t gained the acceptance of their synthetic or pharmaceutical-grade counterparts.

“Every time you see an article about bioidenticals, you always read how they’re not FDA approved,” says Ann McCloud Sneath, a nurse practitioner who uses them exclusively in her integrative women’s health practice in Wayne and West Chester. “Well, chemotherapy is not FDA approved, and that’s become the standard for cancer treatment.”
 

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While Sneath doesn’t actively promote bioidentical hormone replacement, she knows that women want choices. “They’re seeking me out because they’re not gliding through menopause,” she says. “They’re suffering from one of a hundred symptoms, and it’s affecting their daily lives and, of course, their families.”

Like other integrative medicine practitioners, Sneath is guided by the idea that a majority of women may be able to re-balance their hormones without drugs or HRT. Her patients undergo a physical with blood tests (to rule out thyroid problems). They also complete a questionnaire that gets them thinking about ways their medical history, diet and lifestyle determine their overall health.

If menopausal symptoms are moderate or severe, Sneath may introduce BHR—but only after considering the risk-to-benefit ratio.

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Though it is FDA approved, HRT shouldn’t be taken lightly. One major clinical trial points to the “critical window” for starting therapy. It showed that signs of brain fog disappeared when HRT was begun shortly after menopause. But other research has shown that it could actually hasten pre-existing memory problems—and the risk of dementia may increase when HRT is started later in life with women in their 60s or 70s.

And it’s now known that long-term use of two of the most popular synthetic hormones can produce dangerous side effects. Lawsuits have been filed against locally based Wyeth Pharmaceuticals (now part of Pfizer), linking Prempro and Premarin to ovarian and breast cancer.

In 2002, a study by the Women’s Health Initiative was halted when it was discovered that trial participants were having strokes or becoming ill with cancer. After all these years, the WHI trial still mystifies and appalls Anthony J. Bazzan, a nationally known expert on the use of integrative and hormonal therapies for the treatment of menopause, andropause (male menopause) and osteoporosis.

“One of the criteria for getting into the study was that you couldn’t have any [menopausal] symptoms,” he says. “And the women were also all over the age of 65—long past menopause.”

At the time of the WHI study, a “one size fits all” approach was typical in HRT treatments, says Bazzan. He turned to bioidentical hormones for his patients within a year of the trial. “I could never understand it,” he says. “They were using a man-made hormone made of something that doesn’t exist naturally in the female body—horse urine. And then they gave it to these older women in massive doses.”

Bazzan addresses the pros and cons of HRT in the 2008 book, The Great Life Makeover: A Couples’ Guide to Weight, Mood, and Sex, co-authored by Jefferson colleague Daniel A. Monti. Even today, he says, most hormone studies have some weakness in design or implication. But that doesn’t mean women need to be scared off from seeking help.

“Middle age can be a wonderful time,” he says. “The last thing you should have to worry about is your body falling apart.”

To learn more, visit menopause.org and acog.org.

 

“Five Things to Ask Your Doctor about HRT” on page 3 …
 

HRT: Five Things to Ask Your Doctor

1. How will my hormone levels be tested? Blood tests are generally used, but the right level varies.

2. What about osteoporosis. Is HRT appropriate? The use of estrogen in HRT is generally thought to protect bone mass, since the hormone helps in bone formation throughout life.

3. I have high blood cholesterol and a family history of liver and gallbladder disease. Is HRT safe for me? Using progestin or estrogen replacement hormones may increase the risk of heart disease, but their relationship to other diseases isn’t so clear-cut. How HRT enters the blood stream seems to have an impact on risk.

4. Should I be concerned about stroke and blood clots? Again, the delivery method is critical. Methods administered through the skin are thought to be safer for certain women.

5. What’s safer: progestin or bioidentical progesterone? Many experts agree that the risk factors associated with progestin prove that HRT isn’t “one size fits all.” Bioidenticals have come into favor partly because they can be custom-compounded to fit specific needs.
 

Why Hormone Replacement Therapy?

The FDA now recommends that women with moderate to severe menopausal symptoms try HRT, but only for the shortest time needed and on the lowest effective dose. Women typically start therapy for more than one of the following reasons:

1. To prevent or control high blood pressure and high cholesterol.
2. To preserve bone density and prevent fractures.
3. To improve memory or combat brain fog.
4. To prevent hot flashes or vaginal dryness.
5. To help with severe mood swings or depression.
6. As a remedy for night sweats and insomnia.
 

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