Medical Opinions Vary on use of Hormone Therapy for Menopause

Posted on November 01, 2011

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Dr. Holly L. Thacker recommends that women see their women's health physician for hormone replacement therapy. She discusses the benefits of physician-prescribed hormone replacement therapy for many women and the dangers of compounding pharmacies without a physician’s care.

Menopause may have become synonymous with the idea of medical intervention.

It needn't be.

But with about 25 million women in the United States turning 50 in the next 10 years, most of the reports we read are about just that. Prescription hormones in particular -- and whether they are helpful or dangerous -- continue to be the subject of hot debate. Doctors are among those who disagree on the topic.

Fueling the controversy is the fact that it seems every female celebrity past 50 weighs in on how she handled the hormone issue, in books and interviews -- whether it's singer Naomi Judd or, famously, Suzanne Somers or, more recently, Rosie O'Donnell.

That's vastly different from the days when women never discussed the subject publicly. While such openness may be refreshing, doctors say it can muddy the issue, because the thing to remember is this:

Every woman is different. Some might need hormonal therapy to get through misery-inducing symptoms, like hot flashes. And many might not need anything. Or, they might just need to seriously change a few habits -- like reducing high levels of stress, getting more sleep and cutting down on refined carbs -- to get them through this passage (which is defined as beginning 12 months after the last menstrual cycle).

"The uproar is overwrought," says Dr. Holly Thacker, director of the Center for Specialized Women's Health at the Cleveland Clinic. "Too much or too little of any hormone in the body is not a good thing."

Some say it is "unnatural" to take hormones if you are in misery after your body stops making them. Thacker and author-physician Dr. Christiane Northrup -- though not of the same view on therapeutic approaches -- both point out, "It's also 'not natural' to live past menopause."

Thousands of years ago, women used to die in their early 40s, so they never had to go through it. For most of the 20th century, women did live decades past the onset of menopause, but they didn't have the "hormonal" interventions to do anything about it if they felt lousy with hot flashes. In 2002, years after hormone therapy began in the 1980s, a Women's Health Initiative, or WHI, study (since widely criticized for its methodology) suggested long-term users of hormone therapy were at greater risk of strokes, heart attacks and cancer.

So, the opinions of what to do vastly differ. And so do doctors' perspectives and advice on menopause and its related issues.

Dr. James Liu, department chairman of obstetrics and gynecology at University Hospitals' MacDonald Women's Hospital:

QUOTE: "Whether it is a bioidentical hormone or one made by a pharmaceutical company, the risks are the same for both."

Liu puts it this way: If a woman is without menopausal-hormonal symptoms -- which he says would be unusual -- then she won't need to do anything.

But, he says, symptoms that disrupt her life -- perhaps a lack of sleep from waking up because of hot flashes, or being unable to perform daily activities because she is sweating excessively -- might be sufficient reason for her to seek help.

If a woman is suffering these symptoms while still getting occasional periods, she can use a low dose of birth control pills, Liu says, because she might still need or want birth control protection.

Liu says some women shy away from hormonal therapy because they are concerned about side effects. "So they'll try to grin and bear it. The concern that always comes up is breast cancer, and if women have had personal [or family] experience of it, that fear gives them pause."

He says statistics show a 24 percent increase in breast cancer for women using progesterone-estrogen hormones during or after menopause.

For those women who are mainly troubled by the menopausal symptom of vaginal dryness, "a cream applied to the outside of the vagina, or a low dose of estrogen, can prevent further thinning of vaginal tissues, and there's a minimal problem with an increased breast cancer risk," Liu says.

Some women complain of low libido, and in some cases that can be related to lower amounts of estrogen or testosterone. Hormones can help in that case, Liu says, but he notes, "Partner problems tend to be the most likely issue for low libido. There's a big psychological component, and testosterone won't help with that."

For those women who can't or don't want to take hormone therapy, perhaps because they have had a history of blood clots or because they have an increased risk of breast cancer, Liu says doctors recommend a selective serotonin reuptake inhibitor, or SSRI, such as Lexapro or Zoloft. "That can reduce hot flashes by about 50 percent. But while it works for some folks, others get no relief at all."

Finally, there's been a big marketing push for bioidentical hormones, billed as more "natural" compared to the synthetically derived hormones often prescribed, and this has led to a huge misconception, Liu says. Somers has been a vocal proponent of bioidentical hormone therapy.

"The public perception is that if you use a bioidentical hormone, whether estrogen or testosterone, that it is safer than a pharmaceutical product.

"This is a biggie: The risks are the same for both."

Dr. Christiane Northrup, physician, author and speaker

QUOTE: "What we've collectively learned since 2002 when it comes to hormone therapy is that one size doesn't fit all -- we also learned that not all women need hormones [as therapy]. It is an art as much as a science."

When it comes to hormones and menopause, medical history now shows Northrup to have been prescient.

"What I wrote in the 1990s about the WHI study was that they were using the wrong hormones in the wrong dose on the wrong women, and in 2002 it became public that that was exactly what happened," she says. "And the wrong hormones turned out to be dangerous to some women."

The study was stopped early, in July 2002, when a study by researchers showed that women given hormonal therapy in the form of the pill PremPro -- a combination of Premarin (estrogen) and Provera (progesterone), had an increased risk of heart attack, stroke, breast cancer, Alzheimer's and dementia. The researchers also were criticized for using women in their study who were in their 60s and more than a decade post-menopause.

The prevailing belief in the 1990s was that all women needed hormones, Northrup says, and that has been shown to be incorrect. Further, she notes that the estrogen hormone in the form of Premarin was considered "the gold standard, and it shouldn't be. We know more about that now," she says, referring to its possibly negative health effects.

Northrup says the reasons many women feel awful during menopause are related to their lifestyles and level of stress: These are women who don't get enough sleep, or even moments of relaxation, so their bodies are flooded with stress hormones like cortisol and epinephrine. In other words, menopause is a time when the longtime unhealthy habits take their toll.

She says that Dr. Herbert Benson, famous for his groundbreaking research on the "relaxation response" and stress, has shown in recent studies that meditation, twice a day for 20 minutes, reduces hot flashes by 90 percent. (Some women say they've been helped by soy or black cohosh, but most studies have shown them to be ineffective.)

"It is the stress hormones that contribute to the problems women have during menopause, not so much the hormonal shifts," Northrup posits. There is synergy too: More stress creates higher estrogen levels, and a diet high in carbs and sugar -- typical for Americans --compounds the problem, adding to the extreme metabolic highs and lows.

"So first, I advise women to make the lifestyle changes your body is telling you to make," she says. "Get more sleep. Eat less sugar. Drink less alcohol. Exercise.

"If you want to keep ignoring these things, your body will react with the chronic inflammation that leads to heart disease and diabetes."

Such lifestyle-spawned diseases may be common, but they don't have to be, she says. She cautions that if a woman goes to a doctor and just walks out with a sheaf of prescriptions, "Then she is seeing the wrong doctor."

Not that Northrup is completely opposed to hormone therapy. "Some women might need hormones for severe hot flashes," she says, "but then, they can remake that decision every six months to a year."

Dr. Holly Thacker, director of Center for Specialized Women's Health at the Cleveland Clinic.

QUOTE: "Giving back a little more of the hormones that your body isn't making has benefits, and that is the important message."

"Women have to be informed about their choices," says Thacker. "As they live past a certain age where they no longer have the hormone levels they used to, you can't just tell them, 'You can't have any hormones!'

"Every day I see people who have suffered for five to seven years," she says, and adds that it just isn't necessary.

Yes, hormone therapy has its risks, but that doesn't mean it shouldn't be used by women who are having severely uncomfortable symptoms, Thacker says. "Everything has risks -- blood pressure medicine, even eating dinner. Nothing is risk-free."

Thacker is particularly concerned about the fear that women have about hormones produced by pharmaceutical firms. Some go to compounding pharmacies, thinking their risks of side effects will be lowered. At a compounding pharmacy, the pharmacist prepares medication a doctor prescribed for a patient's individual needs.

The U.S. Food and Drug Administration regulates standardized prescription medication.

"When women go pick up a prescription at a compounding pharmacy, they don't get the warning sheets that they have to get when they pick up an FDA-approved prescription, which includes any and all possible warnings," she says. "Sometimes those are excessive and can worry a patient, but they are required for general classes of medicines.

"Compounded bioidentical hormones still create the same potential risks [for example, for a blood clot] yet none are disclosed because they are compounded," says Thacker. "The erroneous assumption many women make is that compounded hormones are risk-free.

"I have also seen so many uterine cancers that could have been prevented, but weren't because women were rubbing in compounded estrogen that worked, but they were only using compounded topical progesterone. And that does not protect the uterus like oral progesterone does. Using unopposed estrogen [without progesterone] alone ups your risk of uterine cancer."

She adds, "People are dabbling in this field who shouldn't be. You can't just experiment with this."

She recommends women go to a doctor who is certified as a member of the North American Menopause Society, or NAMS. About 40 doctors in Ohio.

"When you go see a physician or health care provider, take a look at who is benefiting financially from what you do or don't do."

Also, Thacker says, "It's not fair to say to other women, 'Don't take anything, because I didn't take anything.' Don't blame or vilify them, or be for or against hormones.

"Every woman is different."

Dr. Thomas Frank, obstetrician and gynecologist, MetroHealth Medical Center.

QUOTE: "There's a misconception that everyone has to do something to get through menopause. Most people don't, and they shouldn't need to take anything hormonally."

Frank says a lot of women ask him about what they need to do about menopause, and he'll usually say, "Nothing."

"You only want to start taking something hormonally if you are terribly troubled by symptoms," he says. "The majority of women don't have terribly lasting or terribly severe symptoms."

Of course, those who don't have symptoms don't talk about menopause problems, so women tend to hear more of the horror stories.

The women who do suffer, he says, should know "that hormones aren't forever. You take them for a short period of time, in the lowest doses you can."

There is a slight "theoretical" advantage to taking hormones transdermally, meaning through a patch on the skin or through a cream, "because it [the hormone medication] doesn't go through the stomach and intestine, so it doesn't have to go through the liver. But it's not been shown to make a huge difference," he says.

In his practice, he has noted that for the vast majority of women, the symptoms of menopause will go away within three years, "but for most, within a year."

But he also recommends that holistic solutions be tried first, "before jumping on medication."

That means trying to get more hours of sleep (assuming it's not hot flashes waking you up), getting exercise and eating a healthier diet.

"I see women who tell me they are trying to get by on four or five hours of sleep," he says, because they are working, taking care of kids, and maybe caring for their parents, too.

Those women are not going to feel well, and it's probably because of major sleep deprivation, not menopause, he says.

What about women who are suffering from hormone issues, but can't take hormone medication because, for example, they have a risk of blood clots?