Thoughts on Understanding Menopause and Peri-Menopause

November 20, 2018



Having practiced medicine now for almost 20 years, I’ve seen the pendulum swing back and forth on teachings regarding the best way to treat symptoms during menopause.  I remember sitting in one of my women’s health classes in medical school being told every woman must be put on estrogen the moment she starts going through menopause.  Then, in 2002, when the first arm of the Women’s Health Initiative was released, women’s health providers became quite leery of “hormone therapy” because of the increased risk of breast cancer seen in one arm, the Estrogen-Progestin arm, of the trial.  Unfortunately, that fear and that sudden change of treatment practices left millions of women with life-altering symptoms and sub-optimal solutions.  Prescriptions for anti-depressants and anti-anxiety medications increased as so many women were taken off their mood-stabilizing hormones and were left with hot flashes, insomnia, and night sweats.  The understanding of the complexities of hormone therapy (HT) have evolved tremendously since then, and we now believe HT to be a safe and effective approach for many women under the guidance of a health care provider who remains committed to understanding the risks and benefits.  This article will not cover all the types of hormone therapies as this must be individualized for each person.   


The average age of menopause is 52, so most women will spend at least 1/3 of their lives in menopause.  Three quarters of women will experience hot flashes and night sweats which peak about 1 year after menopause, stay fairly bothersome for approximately 4 years and then often taper off in about 8 years.   The most effective treatment for these symptoms is systemic estrogen. 


While women share stories of some symptoms (hot flashes, night sweats and insomnia) with their friends and likely learn from each other, another set of symptoms is often not spoken of – the changes that occur in the vagina and within the urinary tract.  Approximately 30-50% of women will experience changes in the vagina and within the urinary tract such as incontinence, frequent bladder infections, pain with sexual activity, and a sensation of vaginal dryness.  These changes are chronic and progressive if untreated.  Treatments for vaginal and urinary symptoms include vaginal moisturizers, vaginal estrogen (which comes in several forms – a cream, a vaginal tablet, a vaginal ring), ospemifene (an oral pill), prasterone (a vaginal pre-hormone insert which is converted to estrogen and testosterone within the cells of vaginal tissues.  Women having any vaginal or urinary symptoms may wish to discuss all treatment options with their health care provider.


Non-hormonal treatments for hot flashes and night sweats include:

  • Paroxetine, a low dose anti-depressant

  • Off-label treatments – other serotonin anti-depressants, gabapentin, pregabalin and clonidine

  • Cognitive-behavioral therapy


Unique Benefits of Estrogen Therapy for Women in Early Menopause

  • Prevention of heart disease with standard dose hormone therapy. 

  • See my post from June 23rd re the benefits of hormone therapy


Possible Risks

  • Breast cancer:  In the Women’s Health Initiative's PremPro (CE/MPA, conjugated estrogen and medroxy-progesterone acetate) arm, the risk of breast cancer 0.42% per year with CE/MPA versus 0.34% per year with placebo.  Said another way, CE/MPA added an excess of 8 breast cancer cases per 10,000 women per year.  The relative safety is that 9,992 women will not have an increase in breast cancer risk 

  • Ovarian cancer:  A collection of observational studies (not randomized prospective trials) found that HT use for 5 years yielded one additional ovarian cancer case per 1000 users and one additional ovarian cancer death per 1700 users.  This trial included multiple forms of HT.

  • The risks with Prempro, which contains a synthetic non-bio-identical progestin, cannot be extrapolated to risks with other bio-identical progestins.


The authors of the article listed below state that the best way to make medical decisions is with “shared decision-making” which involves the following:

  1. Patients must have access to the best available medical evidence.

  2. Doctors must provide “sound counsel based on evidence-based medicine and their own clinical expertise, without bias.”

  3. Patients’ preferences must be elicited and honored.

Resource:  “Perspectives on counseling patients about menopausal hormone therapy:  strategies in a complex data environment.”  Menopause, Vol. 25, No. 8, 2018


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