Postmenopausal Symptoms and Hormone Replacement Therapy

Dr. Tracey Banks is a board-certified obstetrician/gynecologist and the founder and president of Adriatica Women’s Health in McKinney, Texas. The all-female practice of four physicians, three midwives and three nurse practitioners just celebrated its 20th anniversary in the North Dallas area. But these days, Dr. Banks focuses most of her care on older women and less on delivering babies. She and her husband, Bruce Lewis, own the Right at Home office in Sherman, Texas. Below, Dr. Banks shares her professional insights on special concerns for older women’s health.

What are common symptoms of postmenopausal women?

The most common menopausal symptoms are hot flashes, night sweats and difficulty sleeping. A rare subset of women will have heart symptoms like palpitations and even chest pain. Women can also experience mood changes, mood swings and increased irritability. Typically, women grow out of these symptoms after a few years. Late-onset menopausal symptoms can include vaginal dryness and pain with intercourse. There may also be a decrease in bone density, which puts you at risk for osteopenia and osteoporosis. But there are also some women who just one day have their last period and experience no symptoms. Not everybody gets these menopausal symptoms. Not everybody goes through the worst of it.

As menopause progresses, the hot flashes and night sweats can continue, but eventually you grow out of these symptoms. You may start to see more stress incontinence. You may notice you’re more prone to vaginal infection or vaginal dryness or vulvar symptoms like itching or burning. This is due to decreasing estrogen levels that can cause the vagina to lose its elasticity and lubrication, making sex more difficult.

What are increased health risks for postmenopausal women?

Bone loss increases with women in postmenopause, which causes an increased risk of osteoporosis. This puts women at increased risk for fractures, particularly in the hips, and compression fractures in the spine that give that dowager’s hump.

If you look at history, women weren’t living to menopause until after the 1900s. Before that, women were dying in their 40s and 50s, so it’s only been in this last century that we’ve been spending up to a third of our lives postmenopausal. Unfortunately with medicine, women’s issues tend to be placed on the backburner, so it’s only been in the last 50 years that people have really been studying what happens to women in later life. That’s why there have been such varying views on treating older women with hormones because we are just now doing useful, meaningful studies to see what effect hormones have on a woman’s life.

Do you recommend hormone replacement therapy for postmenopausal women?

It is an individual decision. Twenty years ago, if you were going through menopause, I would have said, “Here are some hormones, the fountain of youth. Take them for the rest of your life.” At that point, we were referring to one study, the Nurse’s Health Study that surveyed a number of nurses about their health history. That study found that the women who were on hormones seemed to have a decreased risk for heart attacks and hip fractures and showed other health benefits. Then the Women’s Health Initiative study was released, which was a better study and tested women for both estrogen and progestin. After seven years of data collection, there was a significant increased risk of stroke, heart attack, blood clots and breast cancer in the study participants. So then the medical world did a one-eighty and took everybody off hormones.

Since then, we’ve learned there were some limitations to that study, so now we’re more middle of the road. Our current thinking is that you have to individualize hormone replacement. Not everyone needs hormones. We treat based on symptoms. We put women on the lowest dose for the shortest duration. So if you’re a person who’s having symptoms, we have a spectrum of things we can give you now. We have several dosages and several mechanisms of giving you hormones, so things are better because of that study.

What are treatment options for postmenopausal symptoms?

Basically, I tell people we have a spectrum. At the low end of the spectrum, we have herbal supplements. There are herbal supplements that have definitely been clinically shown to reduce hot flashes and night sweats, and those herbal supplements are black cohosh and Siberian rhubarb. These are plant supplements that we feel are safe, and they will help people who have mild to moderate hot flashes and night sweats.

At the middle of the spectrum, we have the antidepressant category. There is one in particular that is for hot flashes and night sweats, Brisdelle, but you can’t give it to treat depression. These antidepressants are good for people who don’t want to take hormones or can’t because hormones are contraindicated — like a woman with breast cancer or blood clots. The antidepressant Effexor can help, and there are some cardiac medications like Clonidine.

At the far end of the spectrum is hormone replacement therapy, which will get rid of your hot flashes and night sweats bar none. But it does come with some risks. If we put people on hormones, we want to get them off at the five-year mark, because after seven years there is increased risk of blood clots, stroke, heart attack and breast cancer.

The problem with the Women’s Health Initiative study was that the increased health risks were for women starting hormones later in life. But the women who began hormones in their 50s really didn’t see the increased risks. We’re still trying to sort all that out. I have women in their 60s who do not want me to take them off their hormones. I tried to wean them off at the five-year mark, but they wanted to stay on despite potential risk. I have them on a very low dose three times a week — not any of the doses that were included in the study. I counsel these women that there’s a potential risk of health complications with long-term use, but they feel like the benefits outweigh the risk.

What type of hormone replacement is best?

There are different delivery mechanisms for hormones — a pill, patch, shot, vaginal ring, gel or lotion. There are even pellets that can be implanted in your rear. I’m not a fan of the pellets, because if I give someone a medication and they have a reaction, I want to be able to stop that medication or remove it from their body. With pellets, you really can’t remove them, and you’re stuck with what it does for three to four months.

The effectiveness of a dosage of hormones is dependent on many things, including body mass. Nowadays, we recommend a topical dose over a pill, because with a pill, you have a first-pass effect where the medicine goes straight to your liver and can increase your bad cholesterol. If you wear a patch, there is a steadier stream of hormones that bypasses your liver.

If you have had a hysterectomy, you only need estrogen. If you have a uterus and take estrogen by itself, your chances of getting endometrial cancer increase. By taking progesterone with estrogen, that risk is no longer there. Taking testosterone in the form of pellets has been very popular in recent years. Testosterone is the hormone of well-being, and some women feel like Superwoman when they start taking it because it can increase energy levels and libido. In my experience when I see patients who have gotten testosterone elsewhere, the patients feel great when they first start to take it, but after a while, the body starts to build a tolerance to it. Inevitably, patients start chasing that first high by increasing the dose, and start to develop side effects like hair on the face, hair on the chest and/or balding. The problem is, we don’t know what effect testosterone has on a woman. There are some early studies that show that testosterone can increase a woman’s risk of heart disease to that of a man, so that’s an issue with it. Testosterone is also not approved by the Food and Drug Administration for use in women.

Which are better: synthetic hormones or bioidentical?

There remains a debate on this. Unfortunately, the people who tout compounded, bioidentical hormones say they are safer, but they are not. They have the same risk as synthetic hormones. The Food and Drug Administration just approved a bioidentical hormone combination in the last few months. But all your body sees is an estrogen molecule — your body doesn’t know if it came from a plant or if it was synthesized. So the bioidentical hormones still have the same risk as a synthetic hormone. Everybody needs to be aware of that.

Some people feel that bioidenticals are more physiologic or don’t have the same side effects. Compounded hormones can be fine, but you’ve got to make sure you get them from a reputable pharmacy. The problem with compounding medications is that there is no standardization, so I can get what I think is the same compounding drug from three different pharmacies, but if I were to analyze each of them, they would each show different percentages of what I think they’re made of. Also, compounding medications is often not covered through insurance.