Prevention & Recovery

Navigating menopause: Hormone therapy and other options

Navigating menopause: Hormone therapy and other options

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Prevention & Recovery

Navigating menopause: Hormone therapy and other options

The extreme nausea. The headaches. I was sure I was pregnant. The timing was right: I expected my period in just a few days. One pregnancy test and a negative result confirmed I wasn't, and sure enough, my period came. That was two years ago, but those symptoms and a few others have plagued me at the same time every month since.

My new PMS symptoms include insomnia, increased moodiness and anxiety. About a year ago, I started to experience pain during ovulation that lasted up to five days a cycle. A battery of tests (Pap smear, swabs for yeast and other infections, urine sample, blood work, as well as an ultrasound) revealed a uterine fibroid in addition to low iron and B12 levels. But otherwise, everything seemed normal.
So what was going on? Hormonal upheaval, that's what. I had always thought I'd be fretting about "the change" in my 50s. But in my mid-30s? I have an upcoming gynecological appointment I'm hoping will shed more light on my health. In the meantime, I contacted hormonal-health experts to help me understand what's going on and what may lie ahead.

Your 30s: PMS
"Hormonal changes can start in the 30s and 40s," says Dr. Jennifer Pearlman, attending staff physician at the Menopause Clinic at Mount Sinai Hospital in Toronto and medical director at PearlMD Rejuvenation. Symptoms, from sleep issues to mood swings, can be deceiving—it's not all night sweats and hot flashes.

No matter how young we feel in our 30s, hormonal changes through the menopause transition can be considered part of the reproductive aging process, she says. "Egg quality declines with aging," says Dr. Pearlman. "Ultimately, it's not the quantity of eggs that limits reproductive potential," she explains. "At menopause, the ovaries lose their potential to ovulate rather than the ovaries running out of eggs." We may also be creating less proges­terone, a hormone produced by the ovaries at ovulation that's intended to support an early pregnancy. Early in the menopause transition, progesterone levels fall, which can lead to symptoms for some women in their mid-30s. And in the case of increasing PMS symptoms, the decline in progesterone combined with a constant or increasing amount of estrogen creates a potent hormonal cocktail.

Other health issues that become common during this early transition include uterine fibroids and cysts on the ovaries and breasts.

Treatment: Reducing sugar and caffeine intake, getting adequate rest and exercising regularly can all help reduce symptoms of PMS, says Dr. Jennifer Blake, CEO of the Society of Obstetricians and Gynaecologists of Canada.
Progesterone therapy is an option for treating uterine fibroids and cysts on the ovaries and breasts. Dr. Pearlman prefers to prescribe bioidentical progesterone, taken orally or applied vaginally in the second half of the menstrual cycle, when progesterone levels are falling. (Bioidentical hormones are identical in molecular structure and function to what the body once produced.)

According to Health Canada, hormone replacement therapy has benefits and risks, regardless of origin. Hormone therapy must be carefully monitored for safety and efficacy, so be sure to keep your doctor apprised of your progress. Low-dose contraceptives may also be prescribed to level out the hormone fluctuations, says Dr. Blake.

Your 40s: Perimenopause
Most Canadian women experience menopause after the age of 45 (the average age is 51), so by the time a woman reaches her mid-40s, she's usually entering the first stages of perimenopause—the time leading to a woman's final menstrual period. How long a woman spends there varies, but it typically lasts two to three years, says Dr. Blake.

Weight gain is more common now, sleep and mood disturbances worsen and the menstrual cycle may shorten. Symptoms such as insomnia, rather than the broader developments of perimenopause, are what lead some women to seek help. During late perimenopause, periods can become irregular and hot flashes can occur.

Treatment: "In a younger woman who experiences premature ovarian loss or early menopause, birth control pills may be prescribed," says Dr. Blake. "It's a simple age-appropriate way to provide estrogen and progesterone." She adds that, in a woman over 45, the treatment would depend on her general health and whether she's still menstruating.

Dr. Pearlman says an intrauterine device (IUD) that releases hormones—but not estrogen—may be prescribed to control irregular menstrual bleeding. (Bonus: It also provides protection from unwanted pregnancy.) "Oral synthetic estrogen, used in oral contraceptives, may increase the risk of blood clots and stroke in older women. For symptoms of perimenopause, when contraception is not needed, progesterone alone may be an option."

Research has also suggested that low-dose antidepressants can be effective in the reduction of hot flashes, even when the woman does not suffer from depression, says Dr. Pearlman.

Your 50s: Menopause
Menopause occurs with the final menstrual period and is confirmed when a woman has missed her period for 12 consecutive months without any medical cause. Estrogen levels, once erratic during perimenopause, now dip to lower levels typical of the postmenopausal stage. Hot flashes, night sweats, a waning libido and short-term memory issues are the norm. Symptoms can occur years before, during and for several years following menopause.

Treatment: Treating menopause is not as simple as loading up on missing estrogen. A widely published Women's Health Initiative study reported in 2002 that menopausal women using a regimen of oral estrogen derived from pregnant horses and synthetic progestin therapy were at increased risk of breast cancer, clots and stroke. The use of menopause hormone therapy plummeted.

By 2012, however, 15 of the top medi-cal associations, including the Society
of Obstetricians and Gynaecologists of Canada, endorsed a statement observing the significant benefits of hormone therapies for menopausal and recently postmenopausal women, noting that hormone replacement therapy "is an acceptable option for the relatively young, up to age 59 or within 10 years of menopause, and healthy women who are bothered by moderate or severe menopausal symptoms."

How close to menopause a woman is when she takes estrogen (and, sometimes, progesterone, too) seems to be an important factor. If you're a good candidate for the treatment, the closer, the better.
If your symptoms are limited to "vaginal dryness or discomfort with intercourse, the preferred treatments are low doses of vaginal estrogen," says the 2012 statement.

Recent studies have shown that menopausal hormone therapies, when started early enough, have a preventive role in combating heart disease and osteoporosis.

When can you expect to be finally symptom-free? It varies from woman to woman. Some can expect symptoms to end soon after menopause is official;  others will have symptoms for years. Research published in JAMA Internal Medicine found that many women experienced night sweats and hot flashes 4 1/2 years after their last period.

The bottom line: Comb through your personal and family histories with your doctor to make informed choices about treatment. "The decision to prescribe hormone therapy is a highly individualized one based on the symptoms, risks, stage and preferences of a woman, and it should be made in consultation with a physician who is an expert in this area," says Dr. Pearlman.

Here are three things you need to know about your hormones during menopause.

This content is vetted by medical experts

This story was originally part of "Navigating Menopause" in the June 2015 issue.
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Navigating menopause: Hormone therapy and other options