At Dr. Monica Christmas’s clinic these days, she sees two kinds of menopausal patients. The first, she said, is suffering from the symptoms associated with this life phase, but is also wary of hormone therapy because she’s heard there are health risks associated with it.
The second kind of patient is almost the exact opposite: she may not have symptoms at all, but nonetheless is asking for hormones because she’s heard they will make her healthier.
“We seem to like these extremes,” said Dr. Christmas, the director of the Menopause Program and Center for Women’s Integrated Health at the University of Chicago.
Prescription data reflects a persistent anxiety around the health risks: In a study published in September, researchers found that only 5 percent of menopausal women used hormones in 2020 despite the fact that roughly 80 percent of women experience symptoms.
On the flip side, in the last few years, a growing number of social media influencers and celebrities, like Oprah Winfrey, have loudly endorsed hormone therapy, presenting it as a “magic elixir,” Dr. Christmas said.
“Now there’s this messaging that every woman who is menopausal should be on hormone therapy,” she said. But women need more clarity around what hormone therapy can and can’t do. “We’ve got to find our way back to the middle ground.”
What is menopausal hormone therapy?
Menopausal hormone therapy, or M.H.T., supplies some of the estrogen and progesterone lost in menopause. The Food and Drug Administration has approved dozens of types of therapies that have been shown to alleviate a narrow set of symptoms, including vasomotor symptoms — like hot flashes and night sweats — and genitourinary syndrome, which refers to painful sex, vaginal dryness and urinary tract infections. Hormone therapy can also be used to prevent postmenopausal bone loss.
There are two broad categories of hormone treatment: systemic, in which the hormones can affect the whole body, and local, which are applied just to the vagina. Systemic treatments contain either estrogen alone or a combination of estrogen and progestogen (a synthetic version of progesterone), and come in the form of a pill, patch, gel, cream, spray or vaginal ring. They tackle hot flashes and night sweats, and can prevent osteoporosis.
Systemic estrogen on its own can lead to the thickening of the uterine lining, which increases the risk of endometrial cancer, said Dr. Stephanie Faubion, director of the Mayo Clinic Center for Women’s Health and medical director of the Menopause Society. Women who have had their uterus removed can safely use estrogen alone but others need to take some form of progestogen as well to counter its effects.
Local treatments applied to the vagina are lower-dose estrogen, and are mainly intended to address symptoms like vaginal dryness and pain with sex.
M.H.T. isn’t approved to treat the dozens of other menopause symptoms, such as depression, anxiety, frozen shoulder, weight gain or hair loss, said Dr. Makeba Williams, a professor of obstetrics and gynecology at Washington University School of Medicine in St. Louis. But, the Menopause Society, which sets treatment guidelines, noted in its annual position statement that some patients who start hormone therapy do see small improvements in some of those symptoms too.
Earlier versions of F.D.A.- approved hormone therapy, which are still available today, contain what is called conjugated estrogen, derived from the urine of pregnant horses, while the products that are more commonly prescribed today (also approved by the F.D.A.) contain what is called bioidentical estrogen, which is derived from plant sources and has a more similar molecular structure to the hormones that the body creates. There are no quality studies comparing conjugated hormones head-to-head with bioidentical hormones, Dr. Faubion said, so we don’t yet have a detailed understanding of how their risks and benefits differ.
Who is it for?
According to the Menopause Society, hormone therapy provides more effective relief and carries fewer risks for a woman who is suffering from vasomotor symptoms or genitourinary syndrome and is younger than 60 or less than a decade from their last period, compared to one who begins it later in life.
Hormone therapy is not recommended for women with a history of stroke, heart attacks, blood clots, liver disease, unexplained vaginal bleeding or estrogen-sensitive cancers, like those of the breast or uterus, as it might make those conditions worse.
What do we now know about the risks and benefits of hormone therapy?
The landmark Women’s Health Initiative study, which was and still is the only long-term, large randomized trial of hormone therapy, was prematurely halted in 2002 because researchers found that the treatment elevated the risks for breast cancer and cardiovascular events. The study created widespread panic that led to women abandoning their treatments.
Since then, however, researchers have reanalyzed the data, and follow-up studies have found a more nuanced picture: Dose, delivery method and the age when therapy is initiated all make a big difference to the risks, Dr. Williams said. And, in many cases, the benefits — including an improved quality of life — can outweigh the risks, she added.
Among symptomatic women younger than 60, the reanalyzed W.H.I. data showed that out of every 10,000 women using hormone therapy (specifically conjugated estrogen and a progestogen pill), there were six additional cases of breast cancer, though not breast cancer-related deaths, and five additional cases of coronary heart disease and stroke.
Meanwhile, the hormone therapy significantly reduced the risks of fractures, all-cause mortality and diabetes. For women taking estrogen alone, studies have consistently found that hormone therapy reduced breast cancer and cardiovascular risks — a finding that is still not fully understood.
Untreated menopause symptoms have been linked to long-term chronic health conditions later in life, including neurodegenerative diseases, though it is still unclear if the symptoms cause the poor health or if they are markers of another underlying problem.
The Menopause Society warns that for women who begin hormone therapy after 60, the risks for breast cancer and cardiovascular events increase.
“If you read the package labeling, it’s going to say ‘this may give you breast cancer, this may give you a heart attack’ so there is that legacy of fear that still exists,” Dr. Williams said. But “we have to continue to educate about what are the real risks, the benefits, and for whom hormone therapy is appropriate and not.”