The Options for Managing Menopause

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Edvard Munch's famous work captures the menopause experience. Wikimedia Commons

For those women who have yet to experience the joys of menopause, a few remarks on what you might expect. Some women drench their sheets from sweat on a regular basis; others have difficulty controlling emotions; and then there are others who initiate divorce during the menopause years.

Oh, what the loss of those hormones can do. 

This hormonal change, which starts on average at 51, also is blamed for vaginal dryness, incontinence, insomnia, and fat gain. To quote actress Whoopi Goldberg: 

“It’s too hot! Nobody told me it’s going to last as long as it feels like it’s lasting. And sneezing is a new experience.” 

Menopause can last a long time. According to Stephanie Faubion, MD, medical director of The North American Menopause Society and director of the Center for Women's Health at the Mayo Clinic, it can last up to 10 years. “We now know that the mean duration of symptoms is seven to nine years,” and for a third of women, hot flashes can endure for up to a decade, she said.

At its worst, menopause can be debilitating. “It's true that some women literally stopped their periods and don't have any symptoms and just go on and nothing ever happens,” said Dr. Faubion. But that is not the norm.

Menopause is caused by reproductive senescence, meaning that a woman’s reproductive capability has aged out. Scientifically there are a range of theories as to why big mammals, like humans and whales, experience menopause. But, regardless of the reason, it marks a decrease in reproductive hormones like estrogen. 

In America, an estimated 2 million women will start menopause each year. “There are women that have significant mood disturbances and sleep disturbances and brain fog and can't think and can't function at work,” Dr. Faubion said.  Most women will have some symptoms -- and most, at least 75%, will be wetting those sheets, or at least feeling that intense heat, that is felt on a woman’s skin from the chest up

All of this translates to an economic toll for women and the health system. Menopause can mean clinical testing, more appointments, drugs and supplements, emergency department trips, and specialist visits. A 2017 study found that menopause costs women about $250, on average, per woman per year. Untreated, menopause can mean an estimated extra $700 in extra health care costs and visits. 

With a monetary cost to health care and employers, and a monetary, physical, and emotional cost to women, what treatments are there?   

For people looking to control their symptoms they have options: 

  1. Hormones

  2. Complimentary or alternative medicine 

  3. Lifestyle changes and behavioral modifications 

Picking the best treatment or treatments is a personal decision woman should discuss with their doctors. But how do the options stack up? 

Hormones

Replacing lost hormones with synthetic ones can help reverse the symptoms of menopause.

A big fan of hormone replacement therapy is Mary Jane Minkin, MD. “If somebody says, ‘I have these miserable hot flashes, I'm dying from these things. What is the most effective therapy for my miserable hot flashes?’ There's no question, it's going to be estrogen therapy,” she said. Estrogen therapy is part of HRT. Dr. Minkin is a clinical professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the Yale University School of Medicine, and has been in private practice in New Haven for more than 40 years. She also runs the website Madame Ovary.

Dr. Faubion is also in favor of HRT. She said that HRT can reduce symptoms by 90% to 95%. “The benefits typically outweigh the risks for women who are in their first few years after menopause and under the age of 60,” she said. 

But they aren’t small risks; one is blood clots. “With oral estrogens, the risk of a blood clot in the general population is about 1 in 1000, and in the people taking oral estrogen is about 2 in 1000,” said Dr. Minkin.

Another risk is cancer. A landmark study, the Women’s Health Initiative (WHI), found an increased risk of cancer for women taking hormone therapy, amounting to an extra 8 to 9 women out of 10,000, but both Dr. Minkin and Dr. Faubion said the risk was small. Dr. Minkin acknowledged the risk and said, “I think people need to make that assessment for themselves.” She also noted that there are different types and preparations of hormone therapy and that in the years since the WHI study there have been medical advancements in hormone therapy. 

“You can't lump all hormone therapy together,” said Dr. Faubion, “it's all different stuff. And it's all associated with different side effects and different risks.”

While HRT has risks, it also has benefits. Aside from alleviating symptoms like mood changes and hot flashes, HRT can protect against heart disease and osteoporosis. 

Estrogen, in its natural form, helps increase good cholesterol levels, and decrease the bad kind; it keeps blood vessels in shape so blood flows smoothly; and it rids the blood of so-called free radicals, which damage arteries and more.

Dr. Faubion considered the drop in women using HRT a shame. “We have created a massive problem,” she said. “It went from 40%, the most commonly prescribed drug bar none, to now where it's 4% to 6% of women are using it.” Research has shown that many women now have heart disease, outnumbering those who once received hormone replacement therapy.

Not everyone agrees with Dr. Minkin and Dr. Faubion. In 2019 The Lancet published a study showing that starting hormones at 50 would dramatically increase cancer risk. 

For women who had 5 years of estrogen (from ages 50 through 55 for instance) one in 50 would get breast cancer between 50 and 59. The researchers found the risk would double if hormones were used for 10 years. 

Complimentary or alternative medicine 

Part of the problem with complementary or alternative treatments is the lack of good data. Studies are often small, and because the FDA doesn’t regulate supplements as it does medicines, dosing can be imperfect. Dr. Minkin singled out flax and soy as two compounds with some research backing them. Both, she explained, had natural compounds that look a lot like estrogen.

A clinical review found that soy supplements might reduce hot flashes and vaginal dryness, but, the study authors were not particularly confident, saying the “suboptimal quality” of some of the studies required additional research. As for other supplements, like red clover, Dr. Minkin was less convinced. 

Although Dr. Faubion did concede there could be some science behind soy, she is generally skeptical. “None of them really work,” she said. “I think no one should be going out there and investing lots of money in an herb or a supplement that they think might help them.” 

That said, she added if herbal tea and meditation can help before bedtime, "then do it.” 

As for marijuana and its derivatives Dr. Minkin said that women who felt marijuana helped, were taking a reasonable amount and not driving impaired or otherwise misusing the drug, then it was a personal choice. “There's not a lot of data there,” she said, “But do people use it? Yeah, I've heard folks using it.” 

Some things like acupuncture or yoga might be helpful to reduce anxiety, which in turn, might relieve some symptoms but they are largely not backed by science and might be expensive. Dr. Minkin said losing weight and quitting smoking, both healthy choices in and of themselves, were worth the efforts. Losing weight will reduce the frequency of the flashes, said Dr. Minkin. A compendium of treatments put together by the NIH shows a few research studies that found exercise, medication or yoga, could be helpful. 

Both doctors also talked about a comfortable bedroom, suggesting women find ways to sleep in a cool, comfortable room. 

The bottom line: There is no magic pill that will reverse menopause without involving risks, but both physicians said a risk is no reason not to seek treatment. 

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