Menopause and Estrogen Therapy

Living Well in Myanmar

The Challenges of Hormone Therapy for Menopause

This week I had a 49 year-old female patient in Yangon who in the last several weeks has suddenly become extremely anxious about completing daily tasks, having trouble with colleagues at work, finding it difficult to sleep, and having bouts of body temperature swings in which she suddenly felt extremely warm.  She wanted to know if she was going crazy.  Her menstrual cycle was unchanged, but could this be menopause?  If so, what could she do?

Menopause and its treatment has been a vexing issue for patients and doctors for more than 10 years now.   In the decades prior to the early 2000s it was widely accepted that once women reach menopause and start losing the hormone estrogen, it should be replaced with a daily pill in order to cure hot flashes, protect the heart and bones, and reduce mood swings.  Then in 2002 a large United States research study called the Women’s Health Initiative revealed that estrogen replacement therapy actually harmed women’s hearts, increased the risk of stroke, increased the chance of blood clots, and raised the risk of breast cancer by 24pc.  Readers of Living Well in Myanmar will remember that we recently wrote about heart disease as the number one killer of women.  The WHI study results were a bombshell and millions of women globally gave up hormone replacement therapy. 

However the story doesn’t end there.  Women and their physicians were still faced with the problem of how to treat the symptoms of menopause, which can be physically and psychologically traumatic.  Estrogen replacement is up to 90pc effective for those symptoms.  Researchers therefore re-evaluated the data (and continue to do so to this day).  It turned out most of the women in the WHI study were started on estrogen therapy about 10 years past their last menstrual cycle.  This doesn’t really reflect the timing at which most women look for symptom control, which is instead around the time of menopause onset. 

So perhaps the threatening data we’ve used to discourage hormone use doesn’t perfectly apply to the women who might benefit from it.  In addition, bits and pieces of new evidence have emerged in recent years that taking estrogen early (ie, just prior to the initiation of menopause) might provide some protection against heart attack and perhaps early cognitive decline.  This is the so-called ‘Timing Hypothesis’, proponents of which feel that at some point we will collect enough research to identify select groups of women for whom the early initiation of hormone therapy will provide a favorable risk/benefit profile when it comes to thinking about chronic disease. 

So what’s the right choice for my patient?  For the time being, because we have inconclusive research that doesn’t provide clear guidelines, the decision requires a good conversation between the individual woman and her doctor.  Starting hormone replacement therapy should be reserved for women who experience peri-menopausal symptoms that are suddenly debilitating enough to disrupt what was previously a generally fulfilling or productive life.  In the future we may also find that the dangers of estrogen therapy can be outweighed by benefits to certain women at high risk of osteoporosis or Alzheimer’s disease.  

It should be remembered that there are other treatment choices for uncomfortable menopause.  These include antidepressant medication, herbal supplements, and a series of lifestyle choices that are good for you anyway:  exercise regularly, maintain a healthy weight, and don’t smoke.  If hormones are selected, many practitioners follow a generalized approach in which we try to use the lowest dose of hormone possible and hopefully limit total treatment time to five years. 

Of course in Myanmar, for socioeconomic reasons, only a small fraction of women are even able to engage in this conversation.  Therefore it remains important for health workers at all levels to normalize the bodily and emotional impacts of hormone fluctuation.  We want to avoid misdiagnosing the symptoms of menopause as acute physical or psychiatric disease.  As we improve the primary care capacity and funding in Myanmar, hopefully we’ll also be able to include rational decision-making of pharmaceutical use for menopause.  © Christoph Gelsdorf 2013