Feeling lost and confused about hormones for menopause?
You are not alone.
In fact, recent studies have shown that most likely even your doctor is confused about hormones. The menopause phase of life begins for 1.3 million women annually in the U.S., yet most doctors don't know how to address it. Even amongst those training to become OB/GYN doctors, a 2023 survey found that less than a third of OB/GYN programs actually offer training in menopause therapies. And these are the doctors who are supposed to be specialists in women's health.
A 2019 survey done by the Mayo Clinic showed that of 177 respondents, only 6.8% of doctors reported feeling adequately prepared to manage women experiencing menopause. Pretty sad.
To make things more confusing, treatment options vary and include:
oral pills
transdermal patches
vaginal rings
vaginal topical gels
topical gels rubbed into skin on arms or trunk
Other options may include different amounts and types of hormones such as synthetic, animal derived, and the whole "Bio-identical hormones" concept; each offering different benefits and potential risks.
And that is just for hormonal treatments. There are also numerous non-hormonal treatments, with new ones entering the market on a regular basis.
What's a gal to do? And, why is there a knowledge gap?
Because menopause care rests at a complicated intersection between gynecology (women's health), endocrinology (hormones), cardiology (because menopause and hormones affect your heart health), orthopedics (due to bone health issues), psychiatry (due to mood changes), cosmetic dermatology (because hormones affect things like skin thickness, wrinkles, and hair thickness) and neurology (due to insomnia and 'brain fog').
The medical field has parsed up the human body into systems, with specialist for each, so when they overlap, well, 'uh- oh'. Your primary care doctor is supposed to manage all of these systems, but likely does not have any in-depth training in menopause. Some have no training at all. I know this because I AM a primary care doctor.
Also, medical treatments that overlap with anything "cosmetic" are awkward for doctors. Because, yes, some women want to take hormones to look younger or have thicker hair. (And that's okay with me as a prescriber). But most doctors only prescribe for medical reasons, and we don't have criteria, or feel comfortable, prescribing for cosmetic reasons. Plus, the FDA didn't clear hormone use for "looking better.” So technically, this is off-label use, so no guidelines there.
The recent history of hormone use. (Or, why was my mom prescribed hormones but my doctor says I should not take them?)
After initial use in the 1960s, hormone replacement therapy (HRT) for menopause was prescribed extensively in the 1990s, with nearly 15 million women in the U.S. taking an estrogen-based menopausal treatment, making it one of most commonly prescribed treatments in the country. Then, doctors were told that hormone replacement therapy was FDA approved to help prevent heart disease and bone loss. Physicians sometimes prescribed it for women just to lower her risk of heart disease, even if she had no symptoms and did not request HRT. That was considered the standard of care.
However, in 2002, a massive study was published called the Women's Health Initiative-and it showed-much to the shock of the medical world- that HRT increased the risk of breast cancer, heart disease, and stroke. SO much so that they stopped the study early for medical reasons. The researchers felt that it would be unethical to allow the study to continue without telling the study participants about the risks. Woah-prior to this study we were prescribing HRT to prevent heart disease, and now we find out HRT can increase the risk.
So, no surprise here: a study by the Women’s Health Initiative (WHI) concluded that the "benefits associated with HRT did not outweigh these risks."
After that, many women became worried and stopped their hormones. My own mom stopped her hormone treatment, and believe me, we all noticed (sorry Mom!) HRT prescriptions declined by almost 50% within six months of the study's publication.
For years after this, hormones in the medical profession were essentially demonized. I remember a breast specialist in our area who added a note to every patient letter (“Please do not increase breast cancer risk by putting this patient, or any patient on hormone replacement therapy.")
At that time, women almost had to beg for HRT.
So now what? And, what does that mean for me?
These days, the pendulum has swung back to some degree. Some new studies, and criticisms of the original WHI study, have muddied the waters on the risks and benefits of hormone use. The WHI study only included women in their 60's.
More recent analysis suggests that for women under 60 who HAVE menopause symptoms, HRT can offer "short term" benefits for hot flashes, night sweats, insomnia and other symptoms. So, currently HRT is FDA approved for "short term use to treat menopausal symptoms" It is currently for symptom relief only-no long term health benefits are claimed. Basically HRT is okay to help make a woman feel better.
Oh great; leaving women and their prescribers asking, “what does that mean? What is short term? Which symptoms qualify?”
The truth is, no one can tell you exactly what your risks are from taking (or not taking) hormones. But a knowledgeable doctor who takes the time to collect your health history and listens to you can come very close.
For most women, the numbers (??) describing the risks of taking or NOT taking hormones, are pretty small. Which ultimately leaves the ball in your court.
My thoughts are simple…
My patients are all "'grown-ass women" who are perfectly capable of making whatever choice works for them. There is NO one-size fits all solution.
I discuss risks, and outline a plan to minimize those risks, and then prescribe. In my experience, this collaborative model works well for most patients.
And… hormones are not actually that complicated, if-and-only-if your doctor has a clear understanding of hormones prior to the visit.
If your doctor hasn't explained hormones clearly, or is "skipping over" risks and benefits, or is vastly oversimplifying things, the problem is the doctor, not you.
Finally, be careful about listening to anyone, physician or not, who is trying to sell you something. I am not ever trying to sell my patients anything.
Sources
https://pubmed.ncbi.nlm.nih.gov/39331372/
https://jamanetwork.com/journals/jama/fullarticle/195120 (WHI)
https://pubmed.ncbi.nlm.nih.gov/15516400/