Patricia Yarberry Allen, M.D. is a Gynecologist, Director of the New York Menopause Center, Clinical Assistant Professor of Obstetrics and Gynecology at Weill Cornell Medical College, and Assistant Attending Obstetrician and Gynecologist at New York-Presbyterian Hospital. She is a board certified fellow of the American College of Obstetrics and Gynecology. Dr. Allen is also a member of the Faculty Advisory Board and the Women’s Health Director of The Weill Cornell Community Clinic (WCCC). Dr. Allen was the recipient of the 2014 American Medical Women’s Association Presidential Award.

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Dear Dr. Pat:

I am 45 and I have terrible menopausal symptoms, even though I had four light periods last year and four the year before. I had my tubes tied at 38, and I read somewhere that this might be a cause of earlier menopause. I saw my gynecologist, who is in my insurance plan, and she did a sonogram of my uterus and ovaries, checked my thyroid tests and an estrogen test, and told me that my sonogram was normal, that I still had estrogen, and that my thyroid was working fine. She then suggested that I take a generic form of Effexor for the night sweats, constant hot flashes, terrible sleep, fatigue, and . . . yes, bad temper. I am overweight by 40 pounds and I do have two or three drinks a night to help me relax and sleep. Other than that, I have never had any medical problems. I have no family history of any cancer, and everyone in my family has lived to a very old age.  I need to get these symptoms under control so that I can manage my job, my children, and my marriage.

I asked why I couldn’t start hormone therapy, and she told me that I was too young and that women who used hormones before they had gone a year without a period had problems with heavy bleeding, and she did not feel comfortable giving me a prescription at this time. She said that the big study that ended in 2002 on hormone therapy showed that women who took hormones had more breast cancer, cancer of the uterus, heart attacks, stroke, and blood clots. So she gave me a prescription for an anti-depressant, and 15 minutes later I was out of the office. I tried the medication for six weeks. I did not have any improvement in my symptoms, and I felt dull all the time, so I stopped it. All the gynecologists in my area work for the same big clinic, and no one else will see me there since I am a registered patient who already sees a gynecologist in that clinic. Is it true that I have to live like this until I go one year without a period?

Mary

Dr. Pat Responds:

Dear Mary:

The answers to your questions are complicated. First, patients do deserve to have an individual approach to treatment for unmanageable menopausal symptoms. Secondly, it is important that both doctors and patients remain informed about the findings and recommendations from the study that changed the way that menopause was managed.

The study that your doctor referred to in her evaluation of the safety of hormone therapy for you, known as the WHI (Women’s Health Initiative), was a major clinical trial of the risks and benefits of combined estrogen and progestin in healthy menopausal women. “An important objective of the trial was to examine the effect of estrogen plus progestin on the prevention of heart disease and hip fractures and any associated change in risk for breast and colon cancer. The study did not address the short-term risks and benefits of hormones for the treatment of menopausal symptoms.”

The WHI study, which was scheduled to run until 2005, was stopped after an average follow-up of 5.2 years, due to an increased risk of invasive breast cancer, increases in coronary heart disease, stroke, and pulmonary embolism in study participants on estrogen plus progestin, compared with women taking placebo pills. The study focused on women who were older than you (ages 50 to 79). These frightening results caused most women to stop hormone therapy the day that the news was delivered.

More than 100 studies have come from the data collected and evaluated by the research team at the WHI, based on the 81 percent of the women who were originally enrolled in the trial. The most recent study, published in JAMA (Journal of the American Medical Association) on October 2, released a comprehensive follow-up of the women and hormone therapy with a conclusion that “Menopausal hormone therapy has a complex pattern of risks and benefits. Findings from the intervention and extended post intervention follow-up of the WHI hormone therapy trials do not support use of this therapy for chronic disease prevention, although it is appropriate for symptom management in some women.”

It is important for you and the other women suffering from menopausal syndrome that the results are now broken down by age and time of onset of hormone therapy since menopause. Just a few days ago—October 17—the NIH issued a press release, “Women’s Health Initiative reaffirms use of short-term hormone replacement therapy for younger women,” that provided more information about this issue. “Investigators from the Women’s Health Initiative (WHI) Hormone Trials are reaffirming conclusions that hormone therapy is not recommended for the prevention of chronic disease, but may remain a reasonable option for the short-term management of menopausal symptoms for younger women. Investigators reached this conclusion after reviewing data from the trial and the extended post-trial follow up.”

The scientists who released this information are not recommending the use of systemic hormone therapy, but recognize that patients should be evaluated individually for the management of symptoms.

What does all of this mean for you?

• First, do your part. Change the risk factors that have been shown to increase both the symptoms and the diseases that you describe in your life. If you want to manage your symptoms, begin with weight loss and no alcohol. Alcohol alone causes disruption of sleep and an increase in both hot flushes and night sweats. A recent report in the September 2013 issue of Menopause  (The Journal of the North American Menopause Society) examined risk factors for hot flashes and night sweats and reported that “Heavier women, women who gained weight, current smokers, high risk drinkers . . .” were more likely to report significant hot flushes and night sweats.
• Begin an exercise program. Exercise has been shown to improve sleep among midlife women with vasomotor symptoms. Simple changes in activity, such as walking instead of driving, taking the stairs instead of the elevator, have been shown to improve sleep in midlife women who are suffering from vasomotor symptoms and sleep disturbance.
• Find a support group for weight loss if you cannot lose weight alone.  Habits of overeating and poor choices of foods will add pounds to your frame year after year.
• Your gynecologist is right that hormone therapy begun while a patient still has some menstrual periods may occasionally cause some heavier or unpredictable bleeding. This may be prevented with the use of the lowest estradiol (estrogen) patch and the use of progesterone daily during this time.  In your case, you report that your periods are light and have only occurred four times a year in the last two years, so you may not have this problem.  If you begin systemic hormone therapy, you will need to monitor your bleeding pattern carefully and inform your doctor if there is any change.
• Let your gynecologist know that you will do your part to change habits that increase both menopausal symptoms and disease risk. Then discuss with her the recent information about short-term use of systemic hormone therapy for women who are younger and closer to menopause. If she still refuses to prescribe hormone therapy, ask her for a referral to a gynecologist who has a special interest in the treatment of menopause for a second opinion.

I hope that this overview of hormone therapy is helpful.  Doctors once prescribed “hormone replacement therapy” to prevent chronic disease to millions of women, based on inadequate research to support this treatment.  As reported in the recent information from the WHI, ”Decisions about hormone therapy are not easy, but these findings provide an evidence base for finding a way forward,”

Doctors need to listen to the patient, review her personal risks and benefits from hormone treatment, and get the patient involved in self-care along with her medical care.