For anyone who has suffered through the unbearable hot flashes, the sleep-wrecking night sweats, or the confounding mental fog at work, menopause can be a trying ordeal.
While some women appear to sail through this change in life, many others grit their teeth and endure it — sometimes without relief.
It doesn’t have to be that way. A new look at hormone replacement therapy offers hope for women in mid-life, while alternative therapies also have proven to work for those who can’t or don’t want to take hormones.
“It’s natural to have hot flashes, but there’s help out there,” says Dr. Tarek Bardawil, University of Miami Health System gynecologist. “There are many things to help alleviate the symptoms.”
Menopause is a biological process that signals the end of a woman’s menstrual cycle. It’s diagnosed after a year without periods. While it can happen naturally to women in their 40s, the average age of menopause in the U.S. is 51. The symptoms — hot flashes, disrupted sleep, mood swings, vaginal dryness, plummeting energy — can last for several years, a result of decreasing estrogen and progesterone, hormones that control menstruation.
While a few women go through menopause prematurely as a result of surgery, certain disorders or damage to the ovaries, menopause is considered a normal part of aging. It is marked by three stages: perimenopause, menopause, and post-menopause. Perimenopause begins as soon as the ovaries start producing less estrogen and can last several years. Most women begin to experience symptoms at this time. Menopause, when the ovaries stop releasing eggs altogether, is also accompanied by a plummeting of estrogen. Finally, postmenopause are the years after menopause, when symptoms tend to ease for most women, though health risks due to low-estrogen do increase.
For many years, hormone replacement therapy — a combination of estrogen and progestin to replace the dwindling hormones — was considered the gold-standard of treatment. Doctors believed it relieved the peskiest symptoms while also providing protection against heart problems and weakening bones. Then in the early 2000s, studies linked HRT to blood clots, stroke, cancers, even an increased risk of dementia. These findings scared women — and their gynecologists — off HRT, and use of this treatment method dropped by half in three years.
“Everyone was freaking out,” recalls Dr. Bardawil, who was just entering his profession then. “Women didn’t want anything to do with it.”
While those studies recognized HRT wasn’t the panacea that had once been touted, they failed to offer to differentiate between older and younger menopausal women. Thankfully recent research is doing just that. The latest study, published late last year in JAMA, followed more than 27,000 women giving them either a placebo or a combination of estrogen plus progestin or estrogen alone for five to seven years. At the end of the study, the death rates from any cause among the women receiving HRT was not significantly different than those taking the placebo.
Armed with new information, gynecologists, with the backing of the North American Menopause Society, are now once again recommending hormone replacement therapy, though the guidelines are more specific than before.
“We recommend hormone replace therapy not to protect patients [from heart disease, osteoporosis, and other aging issues] but to alleviate the symptoms,” Bardawil says. “We use supplemental hormones for the shortest period possible, in the lowest dose needed.”
What’s more, Bardawil and his colleagues recommend HRT for women in their first years of symptoms, usually in their early 50s. “I customize treatment,” Dr. Bardawil adds. “I go year by year and take note of what is happening. “
Of course, HRT isn’t for everyone. It isn’t recommended for women with, or at risk, of blood clots, heart or liver disease, heart attacks or stroke and certain cancers (breast, uterine, or endometrial). Bardawil also looks at a woman’s reaction to the menopausal symptoms.
“Is it affecting her lifestyle? Her moods? Is it mild or severe?” Dr. Bardawil asks.
For those who can’t undergo hormone replacement therapy or are simply wary of potential risks, there are alternatives, though Dr. Bardawil does not consider them as effective:
- SSRI (selective serotonin reuptake inhibitors) or SNRI (serotonin-norepinephrine reuptake inhibitors) antidepressants “are quite effective medically in decreasing hot flashes and also helping with mood changes and sleep,” Bardawil says. These include such well-known SSRI drugs as Citalopram (Celexa), Escitalopram (Lexapro), Fluoxetine (Prozac), Fluvoxamine (Luvox), Paroxetine (Paxil) and Sertraline (Zoloft). These are prescribed off-label by gynecologists. The only FDA-approved SSRI for hot flashes is paroxetine. Recommended SNRIs are Venlafaxine (Effexor) and Desvenlafaxine (Pristiq.) One more thing to keep in mind: SSRIs are not recommended for women on tamoxifen (for breast cancer), but a doctor can prescribe SNRIs.
- Gabapentin (Neurontin) appears to be effective in reducing hot flashes and sleep disturbances. Though approved to treat epileptic seizures, doctors also have prescribed it off-label for the treatment of headaches, shingles pain and other ailments.
- Acupuncture is believed to be 40 to 50 percent effective in treating hot flashes and even insomnia. Bardawil thinks there may be “a strong placebo effect” — a belief that treatment is working even when it’s truly a non-treatment — but nevertheless: “If a patient feels it’s helping, I would never tell her to stop.”
- Small lifestyle changes may also reduce symptoms. Many women lower the thermostat before going to bed or keep a bag of frozen veggies under the pillow. Others take up meditation, yoga and tai chi to improve sleep. They avoid alcohol. Some also keep a diary to monitor what triggers their hot flashes or mood swings. Is it stress? Coffee? A certain food?
As for “bio-identical hormones,” a “natural” remedy that purports to mimic a woman’s own hormones by using products from plant or animal sources instead of those synthesized in a lab, Bardawil recommends caution. There are no peer-review studies backing their efficacy or safety. “The doses are highly variable and these [compound] pharmacies are not controlled,” he warns. “There’s no data out there showing it’s safe and we’re worried about the harm.”
In the end, the best thing a woman can do to get through “the change of life” is to speak promptly and honestly with her gynecologist. “There’s no need to suffer through this alone,” Dr. Bardawil says.
In Their Words
Ana Veciana-Suarez, Guest Contributor
Ana is a regular contributor to the University of Miami Health System. She is a renowned journalist and author, who has worked at The Miami Herald, The Miami News and The Palm Beach Post. Visit her website at anavecianasuarez.com or follow @AnaVeciana on Twitter.