Menopausal Hormone Therapy

A practical guide to the hormone menoverse

When it comes to menopause, I get more questions about hormone therapy than anything else. And I don’t think my experience is unique, because everywhere I turn the focus seems to be on hormones. And while there is good info to find from various sources, there is also a significant amount of misinformation. How does the average person distinguish between the two when they are often presented side by side as being equally valid? Hormone therapy is both overhyped as “the only" solution for menopause by some while being simultaneously castigated and the subject of much fear mongering by others.

To help people weed through this chaos I’m writing a guide to hormone therapy. Each week I’ll tackle one aspect of menopause hormone therapy, starting with some basics, and then building on that foundation every week. Once the basics are covered it will be much easier to address the cinematic universe (multiverse? menoverse?) of hormones, bleeding issues, and all the other nuances. As long as the questions keep coming, I will keep expanding this guide!

This guide will have its own section on The Vajenda homepage and the pinned post will be a table of contents, with links to all the posts (as they are published), so the content will be easier to find and refer back to when needed. Today’s post is a general introduction to the series and is the only one that will be available without a subscription.

The Preamble

Hormone therapy can help many people with certain symptoms and health concerns. And we will get to all of those reasons. The fact that hormone therapy is sometimes withheld from people who could benefit is unacceptable. A big part of what I do online and will continue to do in this guide is provide information so you can advocate with your own health care provider. Or, if you choose to use an online service for hormones, you will know when they are offering you science and when it is pseudoscience.

But equally concerning is the fact that hormones are being oversold in some circles in the exact same way they were in the 1960s and again in the 1980s and 90s. In the 1960s estrogen was about being sexy and hot to the male gaze and looking great in a tennis skirt. This message came courtesy of Dr. Robert Wilson in his best-selling book Feminine Forever, which was actually a Pharma false flag operation. Now that hormones could be formulated in such a way that they could be taken by mouth, replacing less accurate and more cumbersome injections, Pharma needed everyone to take them! The message was basically, Hormone for Hotness! Hormones were the literal fountain of youth and the key to being sexy in the eyes of men. Menopause became a disease, and the worst kind of disease, because according to Wilson, with menopause a woman was no appealing to the male gaze.

Over time, evidence started to emerge that estrogen protected bones and seemed to be heart healthy. And so we started recommending it for health. And it seemed as if we we recommended it to everyone. At the peak of prescribing in 2001 about 40% of women in America were taking estrogen for menopausal hormone therapy. I remember starting women who were in their seventies on estrogen. Conversations went something like this,

“There is a slight increased risk of breast cancer, but heart disease is the number one killer of women and estrogen is heart healthy, and so overall you have a greater chance of living longer if you take estrogen!”

While we thought we were doing the right thing, it was widely acknowledged that all the data about estrogen and heart health was observational. People with access to healthcare were obviously more likely to start estrogen and of course people with healthcare are more likely to have the medical care to live longer. They were also more likely to be financially secure, which is sadly another factor in health. This is why we must be so careful about observational studies and hormones.

The Women’s Health Initiative or WHI study was supposed to answer these questions about estrogen and heart health, and it is this study that led to panic about estrogen and the pendulum swinging from everyone should take estrogen in menopause, to barely anyone should.

And now the pendulum is swinging back, courtesy of re-evaluating the data from the WHI, looking at long-term follow up from the WHI, and many other studies. But unfortunately, some people are combining the messaging of the 1960s and the 1980s and telling women that they can be eternally hot and young as long as they have estrogen. If an alien visited earth and Googled menopause, the false messaging about estrogen is so pervasive, I would not fault them for thinking women literally shrivel up and die without hormone therapy. And it certainly doesn’t help when celebrities, people with genetics that favor photogenicity and who typically have significant wealth, but no actual education, background or expertise in hormone therapy, insert themselves into the conversation.

What you are going to get from this guide is a review of all the evidence, combined with expert opinion, and thirty plus years of prescribing hormones for menopause. I think it’s helpful that I’ve already been around the barn. I’ve been part of the hormone hype of the 80s and the 90s, so I can see the messaging for what it is. Unlike many people who seem to almost exclusively recommend hormones online, I prescribe both hormones and non hormonal therapies as well as talk to my patients about non pharmaceutical options. If your only tool is estrogen, you aren’t a menopause expert. That's actually a big red flag to consider when you are reviewing other content. If the messaging is all about estrogen, you should pause and perhaps seek another opinion.

The Key Foundation for Menopause Care IS NOT Hormones

Yes, this is a guide for hormone therapy, but it’s important to be clear before we start, that many people live a very long, healthy, happy life without hormone therapy. If you can’t or don’t want to take hormones you may still find this guide helpful because you will learn what hormones can do and what is hype (it may surprise you), and that may help you feel less like you are missing out. Also, I will mention non hormonal therapy when there are viable alternatives.

Another important truth is the most important thing for a healthy menopause is the most important thing for health overall, adequate exercise, a healthy diet, and not smoking. In one study that followed women starting in the menopause transition (average age at enrollment was 46 years) for more than 10 years, only 1.7% of the participants were doing these three things consistently over that time span. Looking at just the exercise aspect, only 7.2% of people consistently met the goal over the length of that study. I’m not saying that it is easy to be consistent here, I spend a considerable amount of mental energy (as well as physical) trying to accomplish two of these goals (I’m not a smoker), because consistently eating a healthy diet and exercising is hard. Or it is in America anyway. Or at least it is for me.

Before we dive into the hormones, consider many of the symptoms and health concerns that people have in menopause, such as sleep issues, heart health, bone health, brain health and mental health…exercise is beneficial for all of these. So, whenever I discuss hormones in the office, I also always discuss the three pinnacles of menopause health: exercise, a healthy diet, and not smoking.

What is Menopausal Hormone Therapy? The Basics

Menopausal hormone therapy or MHT means prescribing a hormone, either estrogen or a progestogen (meaning progesterone or a synthetic hormone similar to progesterone) to treat symptoms of menopause or for osteoporosis prevention. It’s uncommon to give a progestogen without estrogen for MHT, but there are some situations where that may be considered, which we will definitely address in future posts. The goal of MHT is to get hormones into the bloodstream.

Some people also use menopausal hormone therapy to describe vaginal therapy, meaning estrogen or another hormone called DHEA (dehydroepiandrosterone) that is administered vaginally and stays in the vagina to treat vaginal symptoms. I don’t describe this vaginal therapy in this way, because the risks and benefits of MHT don’t apply to vaginal therapy. Many times people decide not to take vaginal hormone therapy because they are worried about the risks, but what is scaring them off is the risks of MHT.

I will do a post or two (or more depending on the questions) about vaginal therapy as part of this series, but for our purposes here (and how I think you should think about it) consider menopausal hormone therapy as systemic therapy, meaning entering the bloodstream, and vaginal hormone therapy as purely vaginal.

Who Needs a Progestogen?

If someone with a uterus is going to take estrogen, they also need a progestogen or a selective estrogen receptor modulator (SERM). Without one of these two medications, the estrogen will stimulate the lining of the uterus causing irregular bleeding and eventually cancer. The progestogen or SERM blocks the estrogen from having this effect on the uterus.

Almost always the point of the progestogen is to protect the uterus from estrogen, but there are a couple of exceptions. I know, always with the exceptions. If someone had a hysterectomy for endometriosis and there is concern that the estrogen might stimulate any endometriosis that has been left behind, we may recommend a progestogen to help prevent that from happening. The other situation is someone for whom sleep is still an issue, as progesterone can sometimes help with sleep. The nuances here will be addressed in later posts. There are also nuances to the different progestogens, and I will definitely address those as well.

For those who are interested in learning more about the use of a selective estrogen receptor modulator, I wrote about the MHT that contains it, Duavee, here.

Coming Up Next

The next post in this guide will be the reasons to start MHT. There are definitely things hormones can do, things they don’t, and a hazier in between “maybe” zone. Stay tuned to read more.

And as always, if you have questions, leave them below. I try to reply to the easier ones directly in the comments (obviously, nothing is individual medical advice), and those that are more complex, I tuck away to try to incorporate in future posts.

References

NAMS Position Statement. The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022;29:767-794.

Wang D, Jackson EA, Karvonen-Gutierrez CA, et. al. Healthy Lifestyle During the Midlife Is Prospectively Associated With Less Subclinical Carotid Atherosclerosis: The Study of Women’s

Health Across the Nation. J Am Heart Assoc. 2018;7:e010405. DOI: 10.1161/JAHA.118.010405.

Hersh AL, Stefanick ML, Stafford RS. National use of postmenopausal hormone therapy: annual trends and response to recent evidence. JAMA, 2004 Jan 7;291(1):47-53. doi: 10.1001/jama.291.1.47.