about Hormone Replacement Therapy for the Peri-menopausal Lesbians
Kate O'Hanlan, MD
Karen Casey, RN, MS, NP
L. Dibble, DNSc, RN
On July 9,
2002, the results of a 5 year study of the drug Prempro (combined Estrogen and
Progestin) in postmenopausal women were announced. The data safety monitoring
board decided that the risks of developing breast cancer outweighed the benefits.
Additional findings included a small but statistically significant increase in
heart attacks, pulmonary embolus, strokes, dementia and cognitive decline. Therefore,
we now have some understanding that this drug should not be automatically given
to women just because they are post-menopausal in hopes of preventing these same
diseases. This same data safety monitoring board did not stop the ongoing study
of Estrogen-only use in postmenopausal women (who had previously undergone hysterectomy)
because the drug did not show significant harm to these women.
So what does
this mean for peri-menopausal lesbians?
Hormone replacement therapy for the treatment
of significant menopausal symptoms continues to be appropriate. The study that
was reported last July did not address this issue but others have. Nothing relieves
hot flashes better than estrogen. It is also important to understand that the
risk for an individual woman should be identified based on years of hormone replacement
therapy use after the usual age of menopause (about 51 years of age) rather than
the age of the study participants who were ten years older.
let's talk about menopause. How do estrogen and progesterone affect different
organ systems and what role do they play pre, peri, and post- menopausally?
Basic Ovarian Function. During the reproductive
years, estrogen is produced in varying amounts on a continuous basis by the cells
surrounding the egg follicles in the ovary. Estrogen is released from the tissue
surrounding an egg in the ovary for the first two weeks of each month and progesterone
is secreted in the second half of a woman's cycle, and signals the uterus and
breasts to prepare for a potentially fertilized egg. If no pregnancy occurs, with
declining levels of both hormones around day 28 of the cycle, the lining of the
uterus sheds as a menstrual period.
Estrogen and progesterone have other
important functions as well. Estrogen supports the lining of the upper vagina
and maintains a lush wall of tissue to allow secretion of lubrication during sexual
excitement. Estrogen, along with testosterone, is responsible to some degree for
libido in women. It also supports the back wall of the bladder and urethra and
helps maintain strength and continence, preventing bladder infections. Estrogen
promotes bone maintenance by inhibiting calcium absorption from the bone. It also
induces mild but favorable changes in the cholesterol profile by increasing the
High Density Lipoproteins (HDL), the good cholesterol, and decreasing the Low
Density Lipoproteins (LDL), the "bad" cholesterol. It is also associated
with blood clots (especially in smokers) and is implicated in the higher rates
of gall stone formation among susceptible women.
Menopause Defined. Menopause
is clinically defined as the time after a woman's period has ceased for at least
12 months. Physiologically, it begins when the ovaries run out of eggs resulting
in very low levels of estrogen (20 pg/dl), and no more egg releases. The sudden
large drop of estrogen and/or progesterone can result in a variety of symptoms,
due to different patterns of hormone secretion slowing or stopping. The most common
patterns are 1) a gradual tapering off of both hormones which means less dramatic
symptoms, 2) an abrupt cessation of secretion of both hormones which is frequently
associated with hot flashes, insomnia, and sometimes changes in mood, and 3) the
confusing picture with loss of one hormone while the other continues which can
result in hot flashes while still getting regular periods or, on the other hand,
could mean a woman has irregular and occasional profuse periods. Other symptoms
may include palpitations, and psychological alterations in mood, such as irritability
and depression (which may be related to sleep loss due to nighttime hot flashes).
Symptoms that usually occur later in the menopause include vaginal dryness, painful
sexuality, and urinary incontinence, urgency or infections. The acute symptoms
usually go away or lessen in most women after one to five years; however, some
10% of women will continue to have hot flashes throughout their lives after menopause.
For some women these symptoms are mild and not bothersome, but for other women,
they can be distracting to intolerable, disrupting their lives and requiring treatment
for as long as they are present.
In addition to the physical changes
mentioned above, there are other changes which are not "felt" by a menopausal
woman, such as bone density loss, increased LDL cholesterol, and increased blood
clots. These are equally as important as the physical symptoms. Heart disease
almost never occurs as a surprise. It usually occurs after twenty or more years
of poor lifestyle, and/or elevated risk factors. About 45% of women die of heart
disease, which is largely preventable by lifestyle changes. When estrogen levels
drop, the cholesterol profile can worsen some, as it can also worsen due to natural
aging, lack of exercise, poor diet and obesity. Osteoporosis and Alzheimer's disease
are other concerns that women have as they age. Many women erroneously think that
hormones should be taken to prevent aging itself, although there is no clinical
evidence that this possible. Concerning osteoporosis, estrogen is only one of
five therapies that stop bone loss and is indicated for some women with very low
lifestyle - First line of protection for menopausal symptoms and other changes
are the first things to try in managing the symptoms of menopause and to prevent
osteoporosis and/or heart disease. With
the idea of a healthy lifestyle as the best way to prevent or initially treat
most conditions associated with aging and menopause, lesbians of every age
should be painstakingly counseled by every one of their health care providers
Exercise. 30-minute periods of exercise 4 times/
week and weight bearing exercises decrease the risk of heart disease, osteoporosis
and many cancers.
Stop smoking! Smoking increases risk for heart diseases,
osteoporosis and cancers.
- Drink alcohol in moderation. While one alcoholic
beverage a day may be beneficial in preventing cardiac disease, more than one
alcoholic beverage daily will increase risk of cancers and osteoporosis.
Monitor and maintain an
optimal blood pressure, blood sugar and cholesterol very
- Maintain an
optimal weight (BMI<27, preferably under 25).
This will reduce risk of heart disease and stroke.
Eat well: A moderate
protein intake is associated with lower rates of osteoporosis. A low-fat, high-fiber,
predominantly vegetarian diet is the most protective for heart disease, cancer
and osteoporosis and facilitate weight managment. In addition, foods or a multivitamin
which include the following appear to offer proven health benefits; selenium,
Vitamin A, B, C, D and E.
- Get your Calcium!
Calcium intake (calcium carbonate
or citrate well-tolerated by most) from both dietary sources and supplements reduces
risk of osteoporosis, colon cancer and hypertension. Total intake from both sources
should be at least 1000 mg of elemental calcium for women with either endogenous
or exogenous estrogen, and 1500 mg for women who do not have or take estrogens.
Reduce Stress. Stress related to major life changes, such as menopause for some
women, has been linked to increased incidence of heart disease and cancer. Take
care of yourself always, but especially at these times to help reduce your stress.
Accessing a social network of family and/or friends, relaxation exercises, physical
exercise and adequate sleep are all examples of ways to deal with stress.
Treat Depression. Depression obviously impairs your quality of life from an emotional
perspective but it also affects your physical health and ability to treat/fight
physical ailments. If left untreated, depression can affect your heart and circulatory
system as well as your gastrointestinal system. There are many ways to treat depression
so if you think you're depressed, talk to your health care provider!!
Get enough sleep. People require different amounts of sleep at different times
but generally 7-9 hours of sleep a night is considered adequate for an adult.
While we're asleep we give our body essential time to
replenish itself physically and mentally. Women, however, often report problems
sleeping which has been shown to lead to moderately increased risks for heart
disease and accidents due to daytime sleepiness among other problems. If you are
unable to get enough sleep, try altering your sleep environment. If this doesn't
work, talk to your health care provider.
Dr. Kate, I tried all of those things and my hot flashes are terrible and my partner
keeps getting her sleep interrupted
Should I try herbs next?
can try estrogens which work predictably well or experiment with some of the many
regimens for helping the various bothersome symptoms that are available and safe,
and offer partial reduction of symptoms. Some patients report that vitamin E (alpha-tocopherol)
at 1,000-2,000 I. U. helps their flashes. Soy Bean Extracts, called isoflavones
(Promensil 40-80mg or any isoflavone with other name brands, 80 mg), or soy itself
in quantities up to 80 grams have relieved hot flashes for some. A trial of natural
progesterone, 100 mg daily, has benefited some women. A low-dose progesterone
cream can abate some hot flashes. Acupuncture and acupressure have relieved hot
flashes for many women. The following herbal formulas can be used only after consultation
with a practitioner knowledgeable about herbs and menopause: Two Immortals,
Zhi Bai Di Huang Wan, Osteoherbal, Zuo Ghi Wan and Er Zhi Wan. Specifically,
formulas conatining black cohosh, chasteberry, motherwort, skullcap, false unicorn,
licorice, and alfalfa to name a few.
Kate, I tried all of those things. My hot flashes and sleep are terrible and my
doctor mentioned some other drugs that might help with these symptoms?
Clonidine patches or oral tablets may be used but they have a side effect of low
blood pressure. Bellergal has been shown to reduce frequency of hot flashes as
well. Effexor is an antidepressant that can reduce hot flashes, and may be a great
choice especially if depression is present. Depression is a sometimes a temporary
response having a rapid drop in estrogen levels, but persistent or prolonged depression
may also be a result of insomnia or hormone loss. Troublesome insomnia can be
treated with any of the fast-acting, rapidly metabolized benzodiazepines (Ambien,
those didn't really help, now what?
try to soften the sudden decrease of hormones by using low doses of estrogen for
a short while, until symptoms do not recur. Most women will simply gradually stop
having periods and many develop hot flashes and sleep difficulties around the
age of 51. Some women will have irregular bleeding, sometimes flowing heavily
and require hormonal therapy to control the cycles. Some women develop hot flashes
while they are still having periods; they usually benefit from very small doses
of supplemental estrogens to ameliorate their hot flashes. Combination HRT is
probably safe for less than 5 years. Unopposed estrogen for women without a uterus
is still considered to be safe indefinitely.
A significant drop in estrogen
levels can cause symptoms in early menopause that are disruptive to women's lives,
therefore most women will want some form of short-term hormonal therapy. Hot flashes
can be debilitating and unrestful sleep can cause depression. But fortunately,
these symptoms will abate with the usually prescribed low doses of estrogen. After
the body gets used to the lower levels for a few years, the HRT can be discontinued
without return of symptoms for many women. It is thought that the symptoms go
away either because the body accommodates to lower levels of estrogen, or because
when discontinuing the replacement hormones, the drop is so much smaller than
the original plummet from the active ovarian secretion levels.
symptoms (hot flashes, night sweats, insomnia) amenable to hormone therapy should
be treated with the lowest effective dose for as long as they recur in a bothersome
manner. For some women, this may mean lifelong HRT so that they can feel normal.
should feel normal on the HRT, or the dose needs to be adjusted. The goal is to
keep you on the lowest dose of estrogen that abates your symptoms and makes you
feel normal. The major symptoms of too low estrogens are hot flashes and insomnia.
The major symptoms of too much estrogen are tender breasts, bloatiness and hot
flashes. While it is not useful to measure the level or estrogen in your body
when you are comfortable and feel normal, if you have symptoms but are on a dose
that seems right, it may become useful to check a blood level to see if you aren't
absorbing it well from your intestines. If hot flashes or insomnia persist, the
dose needs to be adjusted or your blood level checked. If you have tender breasts
on estrogens alone, the dose is too high and needs to be adjusted down. It is
not abnormal to experience tender breasts, and any of the other familiar PMS symptoms
while using the combination of estrogen and progesterone since it mimics the natural
cycle of these hormones in the menstrual cycle.
Kate, I'm having a hysterectomy at 40 and my doctor wants to give me estrogen.
What should I do?
It is not controversial to prescribe hormone therapy
to younger women (under age 51) entering the menopause, whose ovaries naturally
stopped or were surgically removed. In fact, if the ovaries are removed or shut
down for over ten years and low-dose hormones are taken to prevent hot flashes,
the breast cancer risk is still reduced by 50%. We do know, however, that the
breast and ovary cancer and gallstone risk is not elevated by hormone therapy
in women under age 51, the average age of menopause. Here is why: After removal,
estrogen levels drop dramatically. To prevent her from having hot flashes and
insomnia, she starts estrogen pills, which keep her blood levels higher than without
ovaries and but significantly lower than if she had functioning ovaries. This
much lower dose is just enough to make her feel normal. So the plan for her would
be to take the estrogen pill or patch until she turns 51 or so and then to go
off and see how she feels off estrogen, just like other women when their ovaries
naturally quit at age 51. It is important to note however that at 51 the clock
of estrogen use starts ticking. This is because from 51 on, the average woman's
estrogen level has fallen dramatically, causing hot flashes for some who will
want short-term hormones to ease the transition. If she takes estrogen after age
51, to keep a moderate level of estrogen and ease menopause symptoms, then her
estrogen levels will be higher than the average woman's level in this age group.
Research tells us that after 5 years of higher than the average woman's levels,
the risk of breast cancer etc. starts to increase. Research also tells us that
a woman who has her ovaries removed at age 30 and takes estrogens for 21 years
until age 51 has only a 6% chance of breast cancer, half of the regular risk of
12%. In sum, replacement doses are less than ovarian secretion doses, until menopause,
age 51, when the average woman's estrogen levels drop below replacement doses.
Dr. Kate, I want to stop my hormones. How do
I do this?
It is recommended that women take menopausal hormone regimens
for as long as they need them, discontinue using them when no benefit is appreciated
or predicted by research, and receive appropriate follow-up surveillance testing
once the hormones are discontinued. Most women will notice that their hot flashes
disappear after 2-5 years in menopause, either because they forget their hormones
for a few weeks or simply forego them for a few weeks and notice no difference.
They should stay off the HRT if the hormones make no noticeable difference. In
fact, all women on HRT after age 51 should try discontinuing their HRT every year
for a few weeks just to see if they still need their HRT. If their symptoms of
hot flashes or insomnia recur, restart the HRT. If none are noted, discontinue