It may well be that from a cold, hard biological perspective, menopause -- and for that matter, the somewhat controversial male counterpart, andropause -- are simply not supposed to happen. The median age of menopause onset in the United States is approximately 50. Until well into the Neolithic era -- as recently as 5,000 years ago or so -- the average lifespan was less than 40. Bluntly, virtually no one lived to experience menopause.
Average life expectancy among women in the US today -- somewhat higher than that of men -- is inching ever closer to 80. Menopause is thus an all but universal experience, and women spend only a little less than half their lives in the post-menopausal condition.
For a span of years up until the late 1990s, the prevailing view was that the marked decline in ovarian hormone (estrogen and progesterone) production that is the hallmark of menopause warranted replacement therapy. This perspective was likely fostered to some extent by the notion that the levels of estrogen and progesterone in women of so-called "child bearing" age were normal, and data from observational studies clearly and consistently suggesting a reduced risk of chronic diseases with hormone therapy (HT).
But the operative word there proved to be "observational." In observational trials, participants choose their own interventions, and researchers simply monitor to see what happens to whom. In such trials, women who chose HT had less premature death and chronic disease, cardiovascular disease in particular.
The liability of such studies is that people who choose A may differ in a whole variety of ways from people who choose B. In the case of HT, it may have been, for instance, that the more health-conscious, or highly educated, or affluent women were more likely to make use of replacement hormones.
That, in fact, is just what we learned in the late 1990s when the first major randomized trial of HT, the HERS study (Heart and Estrogen/progestin Replacement Study), was published. In a randomized trial, health-consciousness, education and affluence are all neutralized, because luck of the draw, not personal preference, determines who gets what treatment. In the HERS trial, overall mortality and chronic disease rates -- especially certain cancers -- were higher in the women using hormone replacement!
And then HT, already staggering from the blow delivered by the HERS data based on roughly 3,000 women, was laid low by results from the Women's Health Initiative (WHI) Study in which over 15,000 women received both estrogen and progesterone replacement, and roughly 11,000 women who had undergone hysterectomy received replacement estrogen only. In both cases, overall disease and death rates were slightly higher with hormone replacement than with placebo.
There were two major reactions to these trials. One was that hormone replacement therapy at menopause went from hero to villain in short order. Not only did the medical community do an about face, but spurred by alarming headlines that emphasized an increased risk of death, women, en masse, abandoned hormone therapy in fear. Speaking as a clinician, I can attest that for some years now, it has been challenging to talk a woman into HT even when it is clearly warranted.
The second major impact of these trials was to accentuate the distinction between observational and randomized intervention study data. The perception that took hold was that observational data could not be trusted, and data from randomized controlled trials were something akin to gospel.
But there has always been a very important limitation to even the largest and best-run clinical trials: they answer only the specific questions posed, and they provide answers for only people just like participants in the trial. The HT trials used only one kind of hormone replacement (the estrogen was Premarin, and the progesterone was Provera); they enrolled only women willing to be randomly assigned to hormones or placebo; and they enrolled women who were 10 years out from the onset of menopause on average.
These limitations are all addressed in a position statement on hormone replacement therapy just issued by the em>North American Menopause Society. Also clarified in this detailed and thorough report is the fact that even when HT was meaningfully associated with increased risks, those risks were generally very small. As an example, one of the biggest concerns about HT use for more than five years was increased breast cancer risk. The data suggest HT use for five years by 10,000 women would result in a net increase of eight breast cancers. This is by no means trivial, especially if you or someone you love is one of those eight. But it is a small absolute risk.
Among the more salient messages in the new position statement is that HT use right at menopause is very different from use following a 10-year delay. HT at menopause decisively improves quality of life measures, forestalls osteoporosis, and appears to reduce risks of cardiovascular disease and diabetes. Lost in the disappointment and drama of the HERS and WHI headlines was this: HT use at menopause is associated with a slight reduction in all-cause mortality.
Neither the North American Menopause Society, nor I, is advocating for routine use of HT at menopause. Rather, we agree that HT was never the panacea it seemed before the HERS and WHI trials, nor the poison it may have seemed after. As is true for almost all matters medical, there is potential here for both benefit, and harm, and thus the need for informed and individualized decisions.
Beware, in general, the drama of the medical headline that promises a breakthrough or warns of dire peril. The truth is far more often on middle ground.
That is clearly where the truth about HT resides. Used thoughtfully, it will help some of the people some of the time. The new report can help inform the conversation you should have with your doctor to determine whether or not you are one of them.
-fin
Dr. David L. Katz; www.davidkatzmd.com
Follow David Katz, M.D. on Twitter: www.twitter.com/DrDavidKatz
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When is it "clearly warranted?" What does that mean? I am 50, have some sleep disturbance, have had a few hot flashes, and sometimes feel like I could easily kill the next person who gets in my way. My mother, who got HT as a matter of course in the 70's, fought a long hard battle with breast cancer: diagnosed at 53, died at 61. Soooo, my attitude has been I need to suck it up and deal with it. It's a natural process so quit whinning. Am I wrong? When is taking something to alleviate this natural event "clearly warranted"? Just curious. BTW - I do find that exercise helps a lot.
I have also added Chasteberry and have seen improvements as well and while I would not tell anyone to take Black Cohosh and Chasteberry without doing some research on them, taking both have done wonders for me.
Not everyone gets just the lovely "natural change of life".
Having said that, your stance is at least in the middle ground.
As you said the study that scared so many off HT was based on premarin. Why would any woman on earth want to use horse-urine based replacement. Another important issue, it seems to me, is that the women were not screened for lifestyles -- smoking, weight, exercise, nutrition, etc.
I have used HT for years and plan to use it for the long term. The quality of my life is 1000 times better.
It also makes absolutely no logic sense to me whatsoever for pre-menopausal women to be considered healthy without additional risk, yet when the hormones are replaced (especially with bio-identical hormones) to bring them back to pre-menopausal levels, suddenly those levels are no longer healthy.
And from age 46 to 48 I felt like a million bucks (and looked it, too) and thought the flashes were quite interesting in their own way.
Then I hit 50 and the fun stopped, but weight bumped 12 pounds, and at 51 I felt like I'd been hit by a truck and started needing a nap every afternoon. And I stopped lusting after my boyfriend (which was really weird, as he is gorgeous and we'd been chasing each other around for 4 years).
I went to my doctor for tests. He *could* have recommended HRT, but he didn't. He *did* recommend testerone shots (for missing libido) and thyroid medication.
The extra 12 pounds are starting to come off, my libido is back, and I only need a nap on days when I miss my workout. So, there are alternatives to at least some of the misery menopause brings.
And I don't miss my periods either. Good riddance!
Much better yet, see if you can find yourself a doctor who believes in bio-identical hormones. You may be able to find the information on Oprah's site. She did a show on the subject, which was repeated by popular demand. She featured female doctors who have been prescribing long-term bioidentical hormone replacement for years with incredible results.
Oprah interviewed various women who took no HT and whose lives and physical health were a mess. After these women started taking bioidentical hormones, their lives and health turned around dramatically.
Do you believe in taking an asprin or other medication for a headache? After all, isn't a headache a natural part of life. Do you believe in vitamins? Do you believe in other medical interventions?
If you do, why then would you think differently about replacing depleted hormones to vastly improve the quality of one's life?
5 days a month, my body wasn't my own, first day always vomiting, excruciating pain EVERYWHERE (even my toenails hurt), eternally grateful for ibuprofen becoming OTC (it's an anti-prostaglandin & stops cramps as well relieves pain).
10 years of hot flashes, as in sitting in air conditioning with 3 fans on me & still dripping sweat (literally) with no exertion on my part. Even more painful periods including one that lasted 13 weeks (no kidding), constant headaches, body aches & lack of sleep. One thing that's never mentioned, bladder spasms. Those were fun. Not just a little leakage when coughing, sneezing or laughing, but not making it to the bathroom. Plus, I was taking care of my bedbound (from Alzheimer's) mother AND grandmother for 7 1/2 of those 10 years. I was too tired to be cranky. Suicidal, yes, but not cranky.
Now, I ain't got no more hormones & I DON'T WANT ANY. Seriously, if I'd known how great being post-menopausal is, I'd have gone straight here from puberty & skipped all the in between. My body is my own every day of the month - finally.
I decided to let me body go through the natural physiological process nature intended it to do.
eat right, eat healthy, exercise and stay away from garbage food, sugar and fats and you should have no problems. the most I ever experienced was "hot flashes" maybe once or twice a day the first
2 years, then they disappeared.
don't need, take or use any pharmaceutical drugs, maybe an aspirin here and there for arthritis pain when it flares up.