Menopause can be a challenging transition, impacting not only a women’s quality of life, but her relationships, health goals, and career. Not to mention the day-to-day symptoms of hot flashes, night sweats, insomnia, and anxiety can be debilitating, with few options for relief.
Herbal therapies and nutraceuticals can certainly help lessen the severity of these symptoms. Still, for many women, they’re also taking into consideration the long-term impacts of the loss of estrogen on their cardiovascular health, bone health, and, most importantly, brain health.
Many women and clinicians alike are familiar with the option of hormone replacement therapy (HRT) - in more updated terminology, 'menopause hormone therapy' (MHT) - through and after menopause, but many don’t take advantage of their use due to decades-old research from the Women’s Health Initiative in 2002 stopping their study due to researchers finding that the combination of estrogen and progestin had an increased risk of breast cancer, heart attacks, stroke, and blood clots (1). Data shows the use of HRT following this study dropped by approximately 80% (2).
However, since then, numerous meta-analyses and long-term observational data have helped paint a more well-rounded realm of research to inform clinical care guidelines surrounding HRT. Now, we just have to work to raise educated awareness and break the stigmas.
A Summary of the Latest Hormone Replacement Therapy Data:
The 2002 WHI study flaws/misinterpretations were that primarily older women were at high risk from the use of hormones. The benefits of hormone therapy generally outweigh the risks for healthy women who are under 60 years old and were initiated within ten years from the onset of menopause.
In an 18-year follow-up study among ~28,000 post-menopausal women, all-cause mortality (aka death in general) and cause-specific mortality (aka death from cardiovascular disease, cancer, and other significant causes) was seen to be no different between the intervention group and the placebo group when HRT was used for a median of 5.6-7.2 years (3).
In the same study, the authors conclude that when HRT use is introduced early in menopause, women generally live longer than those who didn't take hormones. Furthermore, according to pooled stats of over 30 RCTs, women who started HRT before age 60 had a 39% lower risk of death than those who didn't take hormones.
Although total cancer mortality did not differ significantly between intervention and placebo groups, significant increases in breast cancer were seen in the treatment group using oral estrogen plus progestins (3,4). Findings for breast cancer point to an adverse effect from progestin (artificial progesterone) on the breast epithelium (3), but are linked to favourable effects on decreasing endometrial cancer with long-term use. Important things to consider: these studies only evaluate one dosage, one formulation of a hormone, and one route of administration (aka not transdermal estrogen and bioidentical progesterone); thus, results are not necessarily generalizable to all patients and hormone preparations.
The loss of estrogen through menopause has been linked to an increased risk of dementia and Alzheimer’s, explaining why women are at higher risk than men of developing it later in life (5). Brain imaging studies show a lower metabolic state in the brain has been observed through the menopause transition in women, likely relating to increased brain amyloid-beta deposition as compared to premenopausal women and age-matched men (6). Estrogen replacement therapy for young women transitioning through menopause (under 60 and within 5 years of menopause) is a promising option for preventing this hypometabolic brain state and reducing the risk of Alzheimer's (especially in those genetically predisposed). However, for women older than 60 or 5+ years after menopause, or for those presenting with signs of dementia already, HRT may actually increase the risks. Each cause should be looked at individually.
This leads to our next question…
What about Bioidentical Hormones
Increased breast cancer risks were seen in groups using oral hormones, with synthetic progestins. Since these studies, newer formations of hormones that were not widely used at the time of these studies, such as transdermal estrogen and micronized progesterone.
Transdermal estrogen shows superior benefits since it is applied across the skin and therefore surpasses the liver, minimizing negative impacts on liver function and the risk of blood clots and strokes. Furthermore, the most available literature so shows that when transdermal estrogen is used in combination with oral micronized progesterone, no increased risk of breast cancer has been observed thus far.
Where else is HRT beneficial?
Outside of menopause (loss of menses > 1 year) and perimenopause (a loss of or delay in menses > 7 days after age 45), premature ovarian insufficiency (POI) occurs when the loss of ovarian function and associated hormones declines prior to age 40.
These women experienced extended periods of their lifespan without the protective impacts of estrogen and progesterone, and as such, are at significantly greater risk of bone loss & osteoporosis, cognitive disorders, and premature mortality (largely associated with cardiovascular disease).
This group of women is often offered an oral contraceptive as a management tool; however, synthetic hormones do not equate to the same health benefits as physiological replacement of deficient hormones and as such, do not provide the same protection as HRT.
If you've been given 'the pill' to manage your premature ovarian insufficiency, I highly encourage you to revisit your options.
Contraindications to consider
While numerous health benefits may be seen for those interested in using MRT/HRT to manage menopause, personal medical history must always be considered.
The risks will likely outweigh the benefits in groups of women who have a personal history of breast, endometrial, as well as any hormone-receptive-positive cancer, including those with known BRCA or HER genetic family history.
This is why all use of hormone replacement must be considered on a case-by-case basis, with informed consent, so you know your risks.
In conclusion, women are more likely to suffer from hormone-related challenges through menopause (with many reporting negative impacts on their sleep, work performance, and relationships, and each case must be looked at individually) than be given the option of considering hormone replacement to manage their symptoms or lower their risks.
If you suspect you may be showing early signs of perimenopause, if you’re in the midst of menopause symptoms, or if you wish to discuss the use of BHRT, schedule your initial consult with Dr. Courtney Holmberg, ND, at 647 351 7282 today.
Manson JE et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials. JAMA. 2013 Oct 2;310(13):1353-68.
Manson JE, Kaunitz AM. Menopause Management--Getting Clinical Care Back on Track. N Engl J Med. 2016 Mar 3;374(9):803-6.
Manson JE, Aragaki AK, Rossouw JE, et al. Menopausal Hormone Therapy and Long-term All-Cause and Cause-Specific Mortality: The Women’s Health Initiative Randomized Trials. JAMA. 2017;318(10):927–938.
Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials. JAMA. 2013;310(13):1353-1368.
Scheyer O, Rahman A, Hristov H, Berkowitz C, Isaacson RS, Diaz Brinton R, Mosconi L. Female Sex and Alzheimer's Risk: The Menopause Connection. J Prev Alzheimers Dis. 2018;5(4):225-230. doi: 10.14283/jpad.2018.34.