Hormones Galore – The Menopause Edition

Menopause is something that carries with it a multitude of questions and idiosyncrasies. That said, I am going to be focusing on some of the most common concerns hear about menopause, as well as address the most common questions that I receive in the office. I also asked my professional Facebook page members if they had any questions, and will answer those, too.

Part 1: The Basics

Menopause is defined as a year without menstrual periods. Obviously, for women who have had a hysterectomy, or who are on medication that inhibits menstruation, this definition is a little bit more difficult to use, but for the scope of this blog, that’s what we’re going to go with (as a side note, the FDA defines menopause in those individuals as “six months with an FSH above 40” or “six weeks after removal of the ovaries.”) From an endocrine standpoint, menopause is due to a progressive decline in overall ovarian egg volume. Unlike sperm, which are produced continuously, ovaries contain a set number of eggs, and with hormonal changes such as puberty, menstruation, childbirth, etc., that number begins to drop. As the number of eggs diminish, so do the number of follicles that help produce estrogen (see the previous blog on the menstrual cycle), until the point that the egg cohort is virtually exhausted, and no more follicles are made. No follicles = no periods.

Prior to the actual menopausal transition itself, many people experience multiple months, or even years of “menopausal symptoms.” These symptoms include hot flashes, night sweats, mood swings, sleep disturbances, low libido, weight gain, etc. Honestly, you wouldn’t be too far off to potentially attribute any feeling of overall malaise or just “feeling off” to those menopausal hormonal fluctuations. That said, I am not endorsing “blowing off” symptoms for women who are close to their menopausal transition, and saying “it is just hormones,” but if you do a full work-up and nothing comes back abnormal, menopause may be a culprit.

Overall, it is important to remember that menopause is not disease. I’m going to say that again, menopause is not a disease!!! It is a physiologic representation of aging, and in many cultures is actually lauded and highly anticipated. It is interesting to note that in such cultures, the overall rate of “menopausal medicine” is very low. It seems that there is a definite correlation between our cultural idea of aging and age-related transitions, and the need for medical intervention!

Part 2: Q&A

In this section, I’m going to answer some of the most common questions I hear from patients about menopause, as well as address the questions that I received from my professional Facebook page. As always, what I write is for information only, and is not a substitute for actual medical advice. You should always talk to a qualified healthcare professional about your menopausal concerns, and not just go off what you read on the Internet 😉

Q: How long is this going to last?

A: That’s a great question. Let’s look at a couple of graphics to help answer it

Source: Centre for Menstrual Cycle and Ovulation Research

This graphic describes the menopausal transition, or what is otherwise known as the “climacteric period.” As you can see, is not uncommon for some women to experience symptoms – usually things like occasional hot flashes, mood swings, and weight gain – up to eight years prior to the actual onset of menopause itself. About three years or so prior to a final period, a patient becomes perimenopausal, and menstrual irregularities become more common. When a patient stops having menses altogether, the menopause countdown commences. The year after the final menses, one can officially say they are menopausal.

This much more complicated graphic goes into the timeline after that final menses, with early menopause being defined as a time period of four years or less following actual menopause, and late menopause occurring after that until death.

Of the big question with menopause, of course, is how long are the symptoms going to last. The good news is that the vast majority of vasomotor symptoms are time limited, and the majority of people will “outgrow” those symptoms once they are in the late postmenopausal period. Unlike the vasomotor complaints, however, the symptoms of the genitourinary syndrome menopause (GSM) unfortunately do not go away with time, but progressively worsen.

Back to the original question. The answer to “how long is this going to last,” is variable. If we say an average of eight years of menopausal symptoms prior to the actual diagnosis of menopause, and then an average of five years following menopause of postmenopausal symptoms, we’re looking at an average of 13 years. I will also say that there is a very strong racial component to this as well, with people of Asian decent statistically having the shortest duration of bothersome menopausal symptoms (around years), and Black individuals having the longest (average of 10.4 years).

Q: My mother/grandmother/etc. went through menopause early. Am I going to, too?

A: Not necessarily. While roughly 50% to the variations in age at menopause are related to genetic variants, studies have had a hard time demonstrating one specific gene or set of genes that determine age of menopause. As such, hereditary indications such as the age of female relatives when they entered menopause are not good of an indicator as to when any individual woman will go through menopause herself.

Q: What can I do about my symptoms?

A: This is a very complex question. Obviously with any menopausal patient, the first thing to identify is the most bothersome symptom. For some this may be more along the lines of hot flashes/night sweats, for others could be low sex drive and pain with intercourse. Hormone therapy remains the gold standard of treatment for the majority of menopausal symptoms, and has the following FDA approved indications:

Vasomotor symptoms – the above mentioned hot flashes and night sweats

Prevention of bone loss – therapies for osteopenia and osteoporosis

Premature hypoestrogenism – Treatments for women with primary ovarian insufficiency, or who undergo iatrogenic menopause as a result of surgical removal of the ovaries or medication (such as chemotherapy).

Genitourinary symptoms – including vaginal dryness, vulvovaginal atrophy, recurrent urinary tract infections or recurrent vaginal infections, and painful intercourse. This grouping of symptoms is collectively known as the Genitourinary Syndrome of Menopause (GSM).

The past few decades have been monumental in shaping the way we view hormone therapy in the United States. The Woman’s Health Initiative (WHI) is probably the most well-known of the hormonal safety studies, and was instrumental in changing our perspective of hormone therapy as a whole. The data it produced was rather controversial, and ultimately was responsible for a general sense of mistrust about the safety of hormone therapy. Thankfully that position is beginning to shift, as more and more research about “safe” hormone therapies come light. If you want to know more about the WHI, I advise you to check out this link.

As a general rule, when we talk about hormone therapy, we’re talking about the pharmaceutical supplementation of estradiol, progesterone, and/or testosterone. These hormones can be used individually or in conjunction with each other, and have different indications for usage. While there are no hard and fast rules when it comes to the formulation of hormone used (pill, cream, injectable, etc.), there are some basic tenets that need to be followed to make sure that hormone therapy is given safely.

1: For people who have a uterus, any form of systemic estrogen therapy (i.e., pill, patch, cream, injection) needs to be accompanied by either a progesterone or a SERM (selective estrogen reuptake modulator) in order to decrease the chance of endometrial cancer. Local, vaginal estrogen formulations do not require progesterone or SERM therapy.

2: Hormone therapy should be initiated in women younger than 60, or within 10 years of the onset of menopause in order to reduce the overall risk for hormone therapy related adverse events.

3: If possible, FDA-approved formulations of hormone therapy should be used before compounded formulations due to concerns about over/under dosing, lack of safety information, and inadequate efficacy testing. This isn’t to say that there isn’t a place for compounded hormones – I routinely prescribe compounded testosterone because there currently isn’t an FDA-approved formulation of testosterone for women (the discussion of compounded therapies vs. conventional therapies is a whole blog topic on its own), but if an FDA approved formulation exists, it should be tried first.

I would like to take a detour for a second, and talk about testosterone in postmenopausal women. The International Society for the Study of Women’s Sexual Health, in conjunction with the International Society for Sexual Medicine released a position statement on the use of testosterone therapy in women in 2020. This statement, available here, describes the methods in which testosterone can be safely used to improve sexual functioning in postmenopausal women. The gist of the statement is that testosterone can be used to improve symptoms associated with hypoactive sexual desire disorder, but that it needs to be done safely, and testosterone level should be monitored to make sure a woman is not receiving too much testosterone.

Now some people are uncomfortable with the thought of hormone therapy, or may not be a candidate for hormone therapy. For these women, there are other treatments that may be effective to varying degrees. Nonhormonal medications such as Paroxetine or clonidine have been shown to reduce the incidences of vasomotor symptoms, and the newest medication released in the Women’s Health Sphere, Veozah, is a gamechanger when it comes to reduction of both severity and frequency of vasomotor symptoms. In addition to specific medication therapy, increasing dietary intake of calcium and vitamin D may be beneficial in reducing bone loss. For women with genitourinary symptoms, vaginal lubricants and moisturizers can be used both with, and prior to, sexual activity, and may make sex less uncomfortable. I cannot downplay the benefit of environmental and lifestyle changes as well. Menopause experts across the world recommend a healthy diet and adequate exercise, and emotional therapeutics such as cognitive behavioral therapy and hypnotherapy may decrease symptoms, too.

Q: Can you go through menopause because you had a hysterectomy?

A: This is a controversial question. The knee-jerk reaction is no, as a hysterectomy is simply the removal of the uterus, and as we mentioned above, menopause is an expression of ovarian function. That said, I have numerous patients who complain of menopausal symptoms following a hysterectomy, so there has to be some truth to that, right?

I’ve looked through the national library of medicine database, and honestly the data is really quite limited on this phenomenon. Now, I did find a study that looked at removal of the fallopian tubes at the time of hysterectomy, and the development of menopausal symptoms after that procedure. These studies did demonstrate an increased risk of menopausal symptoms within one year following surgery, and from an anatomical standpoint, this makes sense.

I’ve talked previously about the collateral uterine circulation, and how there are vessels that go from the uterus, through the tissue underneath the fallopian tube, to the ovary. Removal of that whole section of tissue (uterus and tube), therefore, would theoretically yield a decrease in ovarian blood flow, which in turn could cause decreased ovarian function. Obviously clinical medicine should never be based off of a single study…but at least there’s a potential explanation as to why some women develop menopausal symptoms following removal of their uterus.

Q: If I start hormone therapy, how long should I stay on it?

A: Honestly, there’s not a definitive answer to this question. Historically, the Beers Criteria was used to determine an “appropriate” length of hormone treatment for women, although recent clinical guidelines have stated that this method is outdated and shouldn’t be followed. The truth of the matter is that long-term hormone use, especially when done correctly, has a very low risk of side effects. That said, every patient needs to have an individualized approach to hormone therapy which includes discussing issues such as desire for length of treatment, benefits versus risks for treatment, as well as ways to discontinue treatment if desired.

I will say that in people with primary ovarian insufficiency (POI), it is recommended that they stay on hormone therapy at least until age 52, which is the median age of menopause in United States.

Q: Does menopause cause other health problems?

A: For most people, the answer to that question is “no.” Now with menopause comes age, and with age comes other health concerns, so you could make the assumption that menopause equals health concerns, but that is really just a causal relationship. We also know that the low-hormone state associated with menopause can increase the risk that a person develops certain health conditions, but once again, it’s not a direct cause. That said, people who go through premature menopause are at a higher than age-related risk for numerous health issues such as osteoporosis, heart disease, cognitive decline, and sexual dysfunction, hence the FDA indication for hormone therapy in women with premature hypoestrogenism.

Q: Is there a good resource for menopause online?

A: Yes! Menopause.org is the website for the North American Menopause Society, and they have a multitude of resources for both patients and providers. They also keep a list of both members of the society, as well as Certified Menopause Practitioners – providers who have undertaken additional training in menopausal medicine, and have passed a national certifying exam.

Well friends, I hope that answered some questions about menopause. As always, if you’d like to discuss your symptoms, including specific therapies and recommendations, please contact our office for a consultation. We’re here to help!