One of the most important things health care providers can do for patients is to educate them. Though most people have more access to information than ever before, it remains difficult for many people to differentiate rumor from fact. Menopause in particular has long been a subject of mystery and lore, as past generations didn’t often discuss details. Fortunately, much of the anxiety and fear that women experience in the years approaching “the change of life” can be corrected with some simple tutelage.
“Menopause is a phase”
Even the definition of menopause is often misunderstood. Technically, menopause is the point at which a woman has gone 12 consecutive months without a menstrual cycle. Up until that point, she is pre-menopausal, after that point she is post-menopausal and the years surrounding that date are often referred to as peri-menopausal. The average age of menopause in this country is 51.
“Menopause is a disease”
One of the greatest myths about menopause is the idea that it is a negative experience, or that all women must “suffer” through it. The truth is that this phase of life carries with it many advantages including no longer worrying about birth control or dealing with monthly menstrual cycles. Many women do not experience many symptoms at all including the hot flashes and vaginal dryness that are so ubiquitously attributed to this season of life.
“Menopause is all about estrogen”
In discussions of hormones related to menopause, estrogen is often the only consideration and while estradiol levels do decline during peri-menopause, there is typically only a 35% reduction, while during those same years there is a 75% reduction in progesterone levels. For this reason, many women see significant clinical benefit with progesterone supplementation alone.
“Hormone replacement is dangerous”
When hormones are employed, starting with progesterone only therapy can be a gentle and often effective treatment although there are many cases when estrogen is of absolute benefit. Unfortunately, the 2002 Women’s Health Initiative (WHI) findings of increased incidence of adverse cardiovascular events and breast cancer have caused many women to falsely believe that they must choose between the risk of heart attack and cancer and living with symptoms such as hot flashes, low libido, irritability and more. The WHI study was using oral conjugated equine estrogen and medroxyprogesterone acetate, which is not the same thing as progesterone. The general public, led by the medical community at large, does not typically differentiate between these hormones (conventional HRT) and therapies that employ bioidentical hormones (BHRT) such as estradiol and progesterone. When hormones are given in physiologic doses, and in correct ratios (i.e. estrogen therapy is never given alone) the risk profile is profoundly different. Knowledge is power and accurate expectations about menopause and the real risks and benefits of the many treatment options available will have profound impact not only on individual patients, but may help to correct the spread of misinformation. Of course, it is always recommended to evaluate salivary hormone levels before beginning any hormone replacement regimen in order to provide individualized, comprehensive care.
References:
WHI. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. Principal results from the women’s health initiative randomized controlled trial. JAMA. 2002;288(3):321-333.
Fitzpatrick LA, et al. Comparison of regimens containing oral micronized progesterone or medroxyprogesterone acetate on quality of life in postmenopausal women: a cross-sectional survey. J Womens Health Gend Based Med. 2000; 9: 381-387.
Holtorf K. The bio-identical hormone debate: are bio-identical hormones (estradiol, estriol, progesterone) safer or more efficacious than commonly used synthetic versions in hormone replacement therapy? Postgrad Med. 2009; 121: 1-13.
Fournier A, et al. Breast cancer risk in relation to different types of hormone replacement therapy in the E3N-EPIC cohort. Int J Cancer. 2005; 114: 448-54.
Murkes D, et al. Effects of percutaneous estradiol-oral progesterone versus oral conjugated equine estrogens-medroxyprogesterone acetate on breast cell proliferation and bcl-2 protein in healthy women. Fertil Steril. 2011; 95: 1188-91.
Bernstein P, Pohost G. Progesterone, progestins and the heart. Rev Cardiovasc Med. 2010; 11: 228-36.