“Give me my hormones or I’ll jump off a bridge,” a patient told me. “I will stalk you and hunt you down if you don’t write for my hormones,” another said. “I’d rather die from the side effects than live without hormones,” said another. “Life’s not worth living without them.”
These were daily exchanges in the years after the 2002 Women’s Health Initiative (WHI) study terrified women and their doctors that menopausal hormone replacement therapy—or HRT—increased the risk of blood clots, heart attacks, strokes, and breast cancer.
“Life’s not worth living without them.” This haunted me—a lot. When menopausal ovaries stop making estrogen and progesterone, replacing these hormones made sense. In my gynecology residency training, hormone replacement was touted as the “fountain of youth.” We learned that HRT maintained women’s bone, brain, and heart health. Without it, heart attack risk rose to that of same aged men after menopause. HRT was like giving insulin to a diabetic—replacing hormones the body could no longer make.
Then after the WHI media blitz, it was over. The case was closed on hormone replacement therapy and no further research was funded. Women stopped HRT cold turkey—and were MISERABLE. Some bargained for more hormones. Others went rogue, trying herbs and potions and supplements. For the next two decades, women suffered the effects of menopause: hot flashes and night sweats, insomnia, fatigue, loss of sex drive, painful intercourse, brain fog and memory loss, mood swings and worsening of depression, anxiety and ADHD symptoms, osteoporosis, joint and muscle pain and weakness, gastrointestinal symptoms, and massive changes in metabolism that led to weight gain, high cholesterol, insulin resistance, and diabetes.
“It’s the natural aging process,” said the party line. “Embrace it.”
I tried to buy it. What choice did I have? I knew WHI was flawed, but what could we do? WHI failed to account for risk factors like obesity, smoking, and family history (all of which increase the risk of blood clots, heart attacks, strokes, and breast cancer). The average age of women in the study was 63—meaning some were as old as 79 when starting hormones for the first time. They excluded women with hot flashes and night sweats in the study—yes, seriously. And they only studied oral routes of synthetic progesterone and conjugated equine estrogen (estrogen derived from horse mare urine). But what about non-oral routes and naturally occurring, bioidentical forms—hormones that are chemically identical to the ones made in the body?
I owed it to my patients to find alternatives to the cold-turkey-deal-with-it approach. I studied integrative medicine and became certified in numerous modalities so that when desperate patients needed to think outside the box or showed up with bottles of supplements and herbs, I could help them.
Twenty-three years later, menopause is having its moment. An Australian study found one in five women in the prime years of their careers quit their jobs due to symptoms of perimenopause and menopause. Oprah Winfrey and other celebrities started discussing the taboo topic and suddenly menopause is everywhere.
The pendulum has swung back to prescribing hormones, leaving patients and most doctors confused. It’s called Menopausal Hormone Therapy (MHT) now—not HRT. We know more about estrogen metabolism today, and that not all estrogens are equal. There are estrogen forms that are breast and uterine cancer-promoting (estrone and others) and forms that are cancer-preventing (estradiol, estriol and others). We know 50-70% of conjugated equine estrogen (CEE) is made from estrone. That explains a lot, I think. I prescribe bio-identical hormones today.
We know, too, that transdermal (patch or cream) estrogen bypasses the liver and does not increase production of blood clotting factors that cause blood clots, strokes, and heart attacks the way estrogen in pill form does. I prescribe transdermal estrogen today.
And we know the risk of breast cancer from HRT was blown out of proportion from the WHI study. That study (with oral CEE and synthetic progesterone—not transdermal, bio-identical hormones) found an increased breast cancer incidence of five out of a thousand women per year: an absolute risk of 0.08%; less than 0.1 percent.
There was no increase in breast cancer deaths in the women in WHI, but no one explained that either. Nor was it emphasized that one in eight women in the United States will get breast cancer, regardless. One in eight.
Nor was it stressed that even if we did still prescribe oral CEE (which we (or I) do not), the breast cancer risk would still be lower than that which is attributed to obesity and to alcohol use. The sobering facts are that 2-3 servings of alcohol per day increase breast cancer risk by 20%, and just one serving per day increases risk by 7-10% compared to non-drinkers. Obesity increases breast cancer risk by 20-40%. Why? Because alcohol and obesity cause good estrogens (estradiol and estriol) to be converted into bad estrogens, like estrone. We know this today.
The current standard of care supports use of transdermal, bioidentical estrogen even in women with a first degree relative (like a mother or sister) with breast cancer or with a personal history of a benign breast condition. You can read that again if you must. We know this today.
Today we also know there is a window of opportunity for starting hormones: within ten years of the onset of menopause and before the age of sixty. It’s not a hundred percent hard and fast, but it’s close. We now know that damage occurs to blood vessels in the period between the onset of menopause and the initiation of hormone therapy. So, the shorter the hiatus, the better. (This highlights the WHI flaw of starting older women on HRT.) There are exceptions to the age rule that must be discussed with your menopause-qualified provider.
You might be celebrating all the big, hot buzz about menopausal hormone therapy. Or maybe you’re not a candidate for hormones and are thinking, “but what about me?” There are non-hormonal pharmaceutical options that women (and many doctors) are largely unaware of, and there is a slew of blood work and health optimization that can turn your life around. Integrative medicine empowers us to realize we are in control of that metabolic pathway that converts bad estrogens to healthy ones and that dietary, herbal, mind-body, and other lifestyle approaches can specifically target that conversion. I teach this to patients today. When I’m counseling patients and lecturing to groups, today, I reflect upon the desperation my patients experienced two decades ago. I am thankful we have more to offer now, and I am hopeful that today’s buzz will lead to tomorrow’s research. Because we still have a very long way to go.
By Suzanne Bartlett Hackenmiller, MD, FACOG, ABoIM, dipABLM, MCP
Integrative Initiative 