Ep #9: Menopause Treatment Part I: Hormone Therapy (June 4, 2019)

Dr Jessica Stefanski discusses your treatment options for menopause in this 2 part series. In Part I, she discusses: 

  • What happens to your hormones during menopause

  • What symptoms and health concerns are common after menopause

  • What the hormone treatment options are for menopausal symptoms

  • Bioidentical versus non-bioidentical hormones

  • What you absolutely need to know if you’re on thyroid medication 

Part II will address non-hormonal options for menopause like nutrition, botanical medicine and the best exercises after menopause. 

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**Episode Transcript**

Hi there, This is Dr Jessica Stefanski on the Let’s Talk Hormones! podcast. This is episode #9. This is part 1 of a 2 part series on treatment for menopause. Today we’re going to talk about menopause and hormone therapy. Today we’re going to discuss:

  • What happens to your hormones during menopause

  • What kinds of symptoms or health concerns are common after menopause

  • What the treatment options are for menopausal sxs

  • Bioidentical versus non-bioidentical hormones

  • What you absolutely need to know about HRT if you’re on thyroid medication 

What happens to your hormones after menopause?

During a woman’s reproductive years, the ovaries get a signal from the brain to release an egg every month. If this egg is fertilized and takes hold in the uterus, the woman becomes pregnant. If pregnancy does not occur, the lining of the uterus sloughs off and you have a period. 

Menopause occurs when the ovaries close up shop. They’ve essentially run out of eggs, and the production of estrogen and progesterone that accompany the monthly cycle are not needed. The periods stop, and you’re officially in menopause after 12 months of no periods. 

If you’ve had a uterine ablation or a type of hysterectomy where your uterus is gone but your ovaries are still present, it can be a little trickier to figure out when you’re in menopause, but by measuring your levels of estrogen, LH, FSH, and getting a good understanding of your symptoms we can usually get a good idea of what is going on. 

The hormonal profile shifts dramatically during menopause. As the ovaries shut down, estrogen and progesterone are not going to be produced at the level they were being produced prior to menopause. 

It seems that some women sail through menopause, not a hot flash or a symptom. 

What are the common symptoms and the health changes that can occur?

Irregular periods until menopause: I always say, expect the unexpected until they stop completely. That being said, if the bleeding has gotten heavy or doesn’t stop, please go in to get this checked out. 

  • Hot flashes or flushing which can be dramatic and debilitating

  • Night sweats

  • Sleep issues

  • Changes to your mood

  • Brain fog, memory loss. Cognitive changes are common. Greater risk of dementia, Alzheimer’s after menopause

  • Skin and hair changes

  • Bone loss

  • Lose muscle mass, weight gain around the middle

  • You become more insulin-resistant in menopause, potential for blood sugar problems, weight gain, pre-diabetes, diabetes

  • Increased risk of cardiovascular disease

  • Changes to the vagina and pelvic floor. When the vagina becomes very atrophied, this can make intercourse and Pap smears very painful or impossible. Changes to the pelvic floor put you at greater risk of prolapse. 

  • What are the key hormones to potentially replace during menopause?

Estrogen is the big gun, this is really the mainstay of menopausal hormone therapy. Help with hot flashes, supports brain health, skin and hair, maintain lean muscle mass, bone mass, supports vaginal health and pelvic floor health. Estrogen therapy is generally very safe. I personally use only bioidentical estrogen which is mainly estradiol and to a lesser extent estriol.  Let’s discuss what bioidentical means, because it has gotten a bad rap because people don’t understand what they’re talking about. It simply means that the structure of the estrogen molecule is the same as what your body makes itself. Makes sense right? Why would you want to use any other kind? Now let’s compare this with the drug Premarin. 

Premarin was a wildly popular drug in the past but thankfully is much less common now although there are still, amazingly, some people on this medication. Premarin is derived from the urine of pregnant mares. The problem with premarin is that it is not bioidentical to humans. It has a bunch of estrogens that are horse estrogens only and are unknown in humans. They are not identical in their structure to human estrogens. These are bioidentical for horses but not for humans. SO I want you to do something right now. I want you to go to the mirror and take a good long look. Are you a horse? Check closely. If you answered yes, then please do take Premarin. If you are not a horse, please don't take Premarin. 

How do we take estrogen?There are several different forms. There is oral estrogen, there is a patch, Pellets that are inserted under the skin and last a couple of months. Vaginal estrogen which can be dosed in a ring, tablet, suppository, or a cream. Vaginal estrogen can be used in a very low dose to just treat vaginal atrophy or it can be dosed higher to get a whole body effect. Research shows that even people who have a history of female cancer can safely take a low dose of vaginal estrogen.There are benefits and drawbacks to each of these forms and this is something that you will have to discuss with your doctor to find the right form for you. But know that if one form doesn’t work out, you have other options. 

Estrogen has a stimulatory effect on the lining of the uterus, aka the endometrium. Estrogen can cause this lining to get too thick and cause you to bleed, almost like a period, this is dangerous and can put you at risk of endometrial cancer. If you ever experience vaginal bleeding after menopause, you really need to get this checked out. 

And this is a big reason why the next hormone progesterone is so important especially if you’re taking estrogen. Now I see a fair number of people with a hysterectomy who have been put on estrogen only. Now according to the conventional guidelines, this is perfectly acceptable. Personally I prefer that women take progesterone because in general I just don't like giving women unopposed estrogen and there is research showing that progesterone is protective for the breast tissue and may prevent breast cancer. 

Progesterone is the yin to estrogen's yang, again, if you have a uterus, you must take progesterone. Many of us are of the perspective that it can be protective for the breast as well. Progesterone converts to another hormone that affects the brain and can help with sleep and anxiety. There is a standardized pharmaceutical version of progesterone called Prometrium which I will sometimes use but it only comes in a limited number of dosages and it is made with peanut oil which some people cannot tolerate. Progesterone is very easy to make into compounded capsules or lozenges and this is typically the route I take because we can be more specific on the dosing and keep the peanut oil out. 

Provera aka medroxyprogesterone acetate is a progestin, not to be confused with progesterone although some doctors will call this progesterone. Provera has been shown to increases your risk of developing blood clots and increase breast cancer risk

So back in the day, the commonly given medication was Prempro which is a combination of Premarin and Provera. If you are on this medication, please get a different doctor because the doctor you have is not up on the science and is simply pushing what the pharmaceutical companies are telling them to. 

DHEA and Testosterone are the key androgens. The androgens are important for maintaining good body composition and lean muscle mass. They are important for brain function, memory and your ability to think clearly. They are also important for libido. 

DHEA is made primarily by the adrenal glands and if you have lived a life of stress, this tends to raise cortisol and lower DHEA. DHEA helps us maintain good cognition and is important for brain health, it helps support lean muscle mass and good body composition and supports healthy libido. It can convert into testosterone and to estrogen to some extent. Usually we give this orally in a capsule form at bedtime.  It can also be used to support vaginal health in the form of a cream or a suppository. 

Testosterone has similar effects as DHEA and in fact DHEA can convert to testosterone. For women it is often applied in a cream on the skin, better option though is vaginal, great absorption and avoids some issues that you might get with skin absorption. Another option is a pellet which is inserted every couple of months under the skin. The only problem that I have seen with the pellet is that once it’s in, it’s in and the doses can be quite high because they’re trying to give you enough of the hormone to last the whole 3 months, and what happens is that that you may need an additional medication called spironolactone to deal with the side-effects like acne, dark hair growth, deepening of the voice. Personally I don’t like to give so much of a hormone that I need to give a separate medication to deal with the side-effects. 

Where to start?

It’s important to get comprehensive lab work done before starting hormone therapy. You want a complete picture of where you are hormonally and also check things like blood count, liver and kidney function, blood glucose, insulin and markers of inflammation and risk of cardiovascular disease. Your symptom picture, your medical history and your personal preferences should all be taken into account when choosing the right type of hormone therapy for you. 

I like to start at a very conservative dosing and work up from there to find the optimal dose that relieves your symptoms and protects you from some of the health conditions that are more common after menopause. 

And a note about thyroid medication: Estrogen increases the levels of a protein in your blood that binds to thyroid hormone and makes it unable to be used. So if you’re hypothyroid and on thyroid medication, you may need to increase your medication if you start on estrogen therapy. 

Thanks so much for listening today and I hope you join me for part 2 of this series where I'll discuss non-hormonal options for menopause.