She’s So Hot!

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Illustration by Michael Burmesch

Hormone clock

Lisa, an effervescent 53-year-old woman confides “First I feel like I’m going to die. Then I get unspeakably hot and break out in a diffuse sweat dampening my clothes and ruining my make up.”    

Hot flash. That telltale sign of women losing hormones. Yet, I contend that reducing women’s experience of menopause to “some uncomfortable episodes of being too hot” dismisses the complexity of this transitional phase of life. First, hot flashes are not just an internal fire. The experience is more like a “neurotransmitter shower” that can be accompanied by feelings of panic, angst, or as in Lisa’s case, doom. Moreover, most women experience other sometimes debilitating symptoms: insomnia, memory challenges, weight gain, sexual dysfunction, urinary dysfunction, depression, anxiety, even panic attacks. With menopause, risk for several chronic diseases jump: atherosclerosis, type 2 diabetes, osteoporosis. even dementia. Is menopause natural? Of course. But nature doesn’t really care about our health and longevity once we can no longer propagate.  Still most women would like to live vibrant lives into old age. So, is hormone replacement therapy (HRT) the answer?

There are few other areas in medicine that have been fraught with as much prolonged controversy and misinformation as HRT. In the ‘90s, postmenopausal HRT was the standard of care. Then, an alarming press release in 2002 announced early results of the Women’s Health Initiative study (WHI) suggesting HRT increased risk of heart attacks, blood clots, strokes and scariest of all, breast cancer. The approach to menopause was turned on its head overnight, which in the end, in my opinion, was one of the biggest disservices ever done to women’s health.  

Risks in Perspective

While too complex to detail here, main issues with the WHI were that the study women tended to be 60 or over (10 years beyond menopause), and the hormones used were Conjugated Equine Estrogen (CEE-a blend of estrogens made from horse urine) with or without Provera—a synthetic progestin. Today, we typically use bio-identical hormones, (molecules that match our human hormones) which doubtlessly interact differently at a cellular level. Over the years, further analysis of the WHI showed opposing data: HRT has a helpful effect on cardiovascular and bone health, and generally reduces risk of death in younger women or those in the early postmenopausal period. 

To put the risk of breast cancer in perspective, it only occurred in woman that were receiving Provera in conjunction with CEE. Estrogen alone turned out to be protective. In those receiving Provera, breast cancer increased from about 3/1000 to about 4/1000 per year. This slight increase in breast cancer risk disappeared in subsequent analysis that looked only at women who received HRT closer to the time of menopause, but the new findings never got the headline “splash” of the initial results. Other observational studies have also shown no data proving that HRT causes breast cancer. Yet knowledge gaps persist among doctors, stemming from insufficient training on menopause-related issues and women remain fearful. 

Menopausal transition is a major midlife event, usually beginning between ages 45 and 55 and lasting about seven to ten years. I see so many women that start to experience difficult symptoms of anxiety, irritability and insomnia in their mid to late 40s and don’t understand what is happening to them. Often times a well-intended physician will offer an antidepressant, which might help, but doesn’t address the root cause (it is hormone not serotonin imbalance). There remains a dearth of research on HRT and while HRT is not right for every woman, it is safe to say it is significantly underutilized.

Once we had Lisa on her optimal bio-identical hormone regimen, she could not believe the difference. Her mood is stable, she is sleeping well and has only a rare hot flash. She feels like her old self again.