There is no wisdom in menopause, only heat.
For many women there is also sleep disturbance brought on by a relentless cycle of waking in a drenching sweat, reigning fury on the sheets, then falling back asleep only to waken shivering as the perspiration evaporates while discarded pajamas silently torment from the corner of the bedroom.
And then there is dryness. Skin, hair, but especially vagina. It is like a desert storm, think shock and ow! not shock and awe.
Some women like to call their hot flashes power surges, but they leave me with no sense of strength. Maybe no one else sees the river of sweat on my top lip, appreciates the porcelain gripping nausea, or understands the gesture of grasping for something, anything, to fan my face, but I know and that is enough.
I don’t resent the aging, I resent the break in stride.
Hot flashes and other symptoms of menopause, such as vaginal dryness, are due to a drop in estrogen and progesterone. This can be a meandering descent over years or a precipitous crash. Women also have individual sensitivities to hormones so when and even if symptoms develop varies greatly. Some women are plagued for years before and after their periods stop and others don’t understand any of the fuss.
The biology of the hot flash has not been well elucidated. While this is due in part to society’s lack of interest in women of a certain age, they are also stunningly unpredictable and hence hard to study. Not knowing when they will strike adds to the imbalance.
Hot flashes are biologically complex. Science suggests they are a narrowing of the thermoregulatory zone, basically a wonky inner thermostat that renders one victim to environmental whims. The smallest change in temperature, even the essence of heat, can stoke the furnace. In a way it is like a fairy tale curse because I feel as if I have been transformed into a poikilotherm.
In the United States there are approximately 64 million women who are post menopausal and about 50% of them are suffering with symptoms, just like me. Many are also at risk for osteoporosis. We are constantly losing and building bone. Without estrogen the building mechanism for women can become perilously slow resulting in a net loss and an increased risk for fractures.
In the 1990s our approach to hormones for menopause could best be described as “A round of estrogen for all my friends!” Hormones, we were told, not only stopped hot flashes, reversed vaginal dryness, and protected bones, but might also prevent many diseases and even dementia. It was almost like the fountain of youth.
The Women’s Health Initiative or WHI was a large study designed to test the hypotheses that hormone replacement therapy could prevent chronic disease and then all of a sudden it was halted. We doctors were told this was due to an increased risk of breast cancer and heart attacks and so hormone prescriptions plummeted.
We offered non hormonal options, but dressing in layers often doesn’t cut it or isn’t possible. For example, when I’m in the operating room wearing a surgical gown and a lead apron it’s not as if I can take something off. Even out of the operating room I find it grating to be constantly obsessing about having the right clothing so I don’t feel like I am going to spontaneously combust.
Many women do not like the side effects or the idea of the non hormonal options for hot flashes, antidepressants and anti-seizure medications. And so the price of longevity for many appeared to be running the gauntlet of heat and sleep disturbance. This is no sprint, the average duration of hot flashes is four years, but some women can suffer for ten years.
A fresh look at the WHI data and how it was presented to the public paints a different safety picture, although I felt the burden of the harmful legacy when making my own decisions. Even though I believed the revised data that tells us estrogen is safe and effective therapy for hot flashes for women my age and is excellent preventative therapy for osteoporosis, a condition for which I am at risk, I waffled. My two medical fears, hormones and fractures, felt like Scylla and Charybdis. The indecision of standing still artificially felt like the safest ground.
And then my 85-year-old mother had another fracture and prolonged hospitalization. I’ve lost count of the number of fractures, but she has lost over six inches in height, is immobile, and has spent much of her last 10 years in extreme pain because of severe osteoporosis. Disease is often a lottery of both genetics and environment, but by the time I know my fate osteoporosis wise it will be too late for preventative therapy.
After reviewing all the literature the science told me I was only facing only one monster, osteoporosis, and so I took the plunge.
Overall, the data suggests no increased risk of death with hormones for women younger than 60 years who are within 10 years of menopause and there may even be a net benefit. There is an increased, though still very rare, risk of stoke and blood clots. The increased risk of breast cancer is 1 woman out of 1,000 per year. For perspective this is also the risk of breast cancer from drinking one glass of wine a day. There is a definitive decrease in osteoporosis and possibly a reduction in heart attacks. One analysis suggests in the 10 years after hormone therapy became tainted with risk between 18,000-91,000 women may have died prematurely because either they or their doctors feared estrogen.
I went with FDA approved pharmaceuticals eschewing so-called compounded “bioidentical” hormones“, a quasi-medical term of varying definitions. This is not medicine, it is marketing. Despite the claims of some self-styled anti-aging gurus and compounding pharmacies the raw hormones in these products are not one step away from ground up yams, they are synthesized in a lab. Also, the exact “bioidentical” estrogen the ovaries produce is why women who start their periods early or have later menopause are at increased risk of beast cancer.
There are also serious safety concerns with compounded hormones. Many women are duped into using transdermal progesterone cream, except progesterone is poorly absorbed though the skin. There are also concerns that compounded estrogen may have more hormone than advertised. This matters because high doses of estrogen that have not been studied may have unknown risks and women with a uterus who are exposed to either too much estrogen or an insufficient dose of progesterone or progestin (a hormone modified to function like progesterone) are at increased risk for cancer of the lining of the uterus (endometrial cancer). Accuracy matters.
A woman’s decision to start hormones should be based on bothersome symptoms, her risk of osteoporosis, her risk of breast cancer and any medical conditions that impact her risk of heart attack, stoke, and blood clots. The North American Menopause Society has a fantastic app (MenoPro) to help women get started. Assessing an individual risk benefit ratio will take a conversation with a medical professional, a blood pressure measurement, up to date breast cancer screening, and possibly a physical exam.
Anyone who claims hormone levels are needed to start or monitor therapy is way off base. Hormone levels offer an illusion of customization and safety and additional billing opportunities, but are impossible to interpret as values can fluctuate day to day. They are also not necessary as the dose of estrogen required to prevent osteoporosis is known and we treat the symptoms of menopause not levels.
Based on the revised data, my risk factors, and my previous experience with hormonal contraception I chose transdermal estradiol and an oral progesterone. Other women may make difference choices. Pharmaceutical grade estrogen comes in a patch, a pill, a cream, and a vaginal ring and they all have advantages and disadvantages. A progestin can be taken orally or transdermally and there is also a progestin containing IUD. Progesterone can only be taken orally, but there is some limited data to suggest it may be the safest option.
I am very grateful to the physicians and researchers who took the time to revisit the WHI data and to produce clear guidelines for me and other women like me to follow. Without their work I would probably be sweating away worrying that I was losing bone. Instead, I am sleeping soundly, which may not make me any wiser but is probably still very good for my brain.