Yellow Light Indications for Menopause Hormone Therapy
Weighing the Evidence
In our series exploring the hormone menoverse we’ve addressed the following reasons to take hormone therapy:
Primary ovarian insufficiency and premature menopause
These are what I call green light indications for hormone therapy (meaning estrogen or estrogen plus progestogen), and they are FDA-approved and/or there is excellent data to support their use for these reasons. In addition, there is universal agreement among menopause societies and getting multiple medical experts from around the world to agree to something is the equivalent of herding cats, so when it happens, it can only be because the data is solid!
But the menopause transition (the years leading up to menopause) and menopause itself (the final period and onwards) are associated with a variety of other symptoms and health concerns not listed in the approved indications. For example, joint pain, brain fog, depression, palpitations, and anxiety are common symptoms. Where do hormones fit in here? Also, the risk of dementia starts to increase with menopause. Can estrogen help?
Maybe sometimes. But it depends.
But before we begin, it is important to know that despite the fact that Internet hormone providers and celebrities have elevated estrogen to be some kind of get-out-of-menopause-jail-free card, that’s not how it works. There are many hormones that change with menopause, and sometimes it’s not just the estrogen. Remember, symptoms rarely correlate with hormone levels (and during the menopause transition, estrogen levels are often higher than normal!). And even if a decrease in estrogen is the trigger, that doesn’t always mean that pharmaceutical estrogen is the treatment. Consider lighting a match to start a fire; you don’t put out the fire by concentrating on the match. This is why we need studies because A) it’s complex and B) it’s ripe for abuse (because it is complex).
The Green Light/Yellow Light/Red Light System
This is my own design, but I think it works well. Let’s talk about what I mean by yellow light and red light.
Yellow light means there is some data to support the use of hormones, but are still questions or the data isn’t that great. There is often a spectrum here:
There is pretty good data: it just doesn’t cross the threshold for FDA approval/universal agreement.
The data is so-so: some studies suggest it could help some people. Ideally, we’d like more data, but we’re unlikely to get it anytime soon, so we’re going to make do with what we currently know.
Biologically it doesn’t seem like a bad idea, but we don’t have supporting data.
As you can see, I think of this on a chartreuse to orange spectrum, meaning there are stronger reasons (greenish-yellow) and less robust reasons (orange) with a solid yellow in between. I think of the yellow light reasons this way, it’s not wrong to try, but you need to be really vigilant and pay more attention to the risk benefit ratio as well as follow up to see if it’s helping. The lower the quality of evidence, the more mindful you need to be about the therapy and weighing the risks and benefits.
Many physicians feel comfortable prescribing hormones for people with severe hot flashes when there may be a higher risk of complications (with informed consent, of course) because, based on the data, there is likely to be a benefit. However, with a yellow light indication, the chance of benefit is less, so that must be considered. Also, it’s important to be very careful that these symptoms are indeed menopause-related and not caused by something else. We’ll discuss how we balance the potential benefits vs. the known risks for the yellow light indications in a future post.
The most important thing with these yellow light indications is balancing them against risk. The second most important is setting expectations, and in general, it is important not to continue to escalate doses if the therapy doesn’t appear to be helping. I advise everyone considering hormones for yellow light indications to write down their bothersome symptoms before they start and what they hope will improve, and what they consider a success. For most of these yellow-light reasons, I typically do a six-month trial. If there is no improvement in the desired symptom(s) at six months, then I recommend crossing that out as something hormones can help. Be mindful of the placebo effect, which often wanes at 6-9 months, so if symptoms return at 6-9 months on therapy, it is unlikely that you need a higher dose and more likely that the placebo effect is disappearing. We’ll address doses in another post.
There are also red light indications where the data shows hormones don’t work, or hormone therapy may work, but the risk-benefit ratio doesn’t favor hormones, or the therapy is completely unstudied and biologically just doesn’t make a lot of sense. We’ll cover the red lights–the reasons we don’t recommend hormone therapy–in the next post (otherwise, this post is going to be waaaaay too long).
Here are some of the more common yellow light reasons and a little bit of information about each one, going from more robust backing data to less robust backing data.