Raise your virtual hand if you’ve ever heard that menopausal hormone therapy can cause cancer.

You’re not alone. There’s a reason you’ve heard this, even though it’s an outdated misconception. Here’s what happened…

Hormone therapy was first marketed for hot flashes, etc. in the early 1940s. Menopausal hormone therapy was traditionally used to treat perimenopausal and menopausal symptoms, like hot flashes, night sweats, disturbed sleep, vulvar and vaginally atrophy (now called Genitourinary Syndrome of Menopause), and dryness or pain with sexual activity.

During this same time, menopausal hormone therapy was also used to prevent disease, specifically, osteoporosis, heart attacks, aging skin, hair, and nails, for example.

But, in July 2002 something happened: the Women’s Health Initiative (WHI), a project funded by the NIH, announced the results of  an important clinical trial, and emphasized that all the benefits of hormone therapy were inadequate to compensate for the risks of the therapy.

This abrupt change in perception about menopausal hormone therapy, from mostly beneficial to mostly detrimental, spread like wildfire through both professional worlds and the worlds of women approaching menopause. The media attention was enormous and repeated hundreds of times.

Unfortunately, this information wasn’t quite accurate. The findings have now been largely discredited, especially for early menopausal women (i.e. women less than 60 years of age). For those women, hormones for perimenopause and menopause can be safe, and very helpful.

But, for too many years, we heard such a strong and emphatic, “No—menopausal hormones are dangerous drugs.” So much so that medical education systems stopped teaching any of the benefits of menopausal hormone therapy, and only taught that such therapy was risky and should not be used.

This situation persisted for approximately 15 years. And, as a result, two or more generations of physicians were trained with this (misinformed) information, and now that their patients are menopausal or need treatment for these symptoms or prevention of these disorders, these practitioners have no idea what treatments to provide. The medical education system still hasn’t caught up to this educational deficiency, and it may take many more years to do so.

So, if your doctor tells you that hormones for perimenopause or menopause are bad, you will know why, and you’re now armed with the information to push back, and get clarification specific to your situation. Feel free to point them to this memo from The North American Menopause Society, the American Society for Reproductive Medicine, and The Endocrine Society.

We are also taking new patients, so give us a call to talk about options for your body when it comes to perimenopause and menopause symptoms, or to prevent menopausal disorders. We promise you don’t have to exist in discomfort.

Note: If you’ve had breast cancer or are considered high risk, please talk to your physician about whether hormone replacement therapy would be an option for you.

DID YOU KNOW THAT MENOPAUSE CAN IMPACT YOUR MEMORY?

If your partner is going through menopause, here’s a brief guide for survival.

Menopause isn’t just a challenging time for the person going through it, but it can also be difficult for partners, friends, and children. Hormones are very real, and they have a very real-life impact on our bodies and our relationships.

Dr. James Simon, Medical Director and Founder of IntimMedicine Specialists in Washington, DC, shared his expertise with True Women’s Health on how to best survive menopause as a partner, and we’ve distilled that for you here.

(Note: Not all women have a uterus so not all women go through menopause, and not all people with a uterus are women, so we will be using gender-neutral language throughout this guide.)

Step One: Understand What’s Going On

The first step in understanding what’s going on with your partner is to know exactly what menopause is. Here is a quick guide to help you understand a bit more of what’s happening before, during, and after menopause:

1. Perimenopause—This means “around menopause” and refers to the time when someone with a uterus is making the transition to menopause, usually age 45-50.

What even is perimenopause? Perimenopause means "around menopause."

At this time:

    • Periods become more irregular and/or heavier.
    • Ovaries begin producing less estrogen, and as menopause becomes closer, the drop in estrogen increases, causing symptoms like hot flashes, night sweats, disturbed sleep, lower sex drive, weight gain, and mood swings.

 

It’s important to note that during perimenopause, pregnancy is still possible.

2. Menopause—This is the time when the last spontaneous menstrual period occurs. Once a full year has gone by without having a period, the date of that last period is the moment of menopause. This usually occurs, for most people, around the age of 50.

Your partner might experience the symptoms listed above, as well as other symptoms, like vaginal dryness, pain with sex, and decreased sexual desire.

3. Postmenopause—This is the time after your partner has gone through menopause. In other words, after an entire year without a period, postmenopause has officially begun. For some people, menopausal symptoms, such as those listed above, may become less frequent and less intense. However, sometimes those symptoms can last for many years after the menopause transition.

Step Two: Listen to Your Partner

It can feel really bad when your partner is tired and cranky, and it might even feel like you did something wrong. You might even feel rejected romantically and physically, and that lack of desire and touch can lead to something called skin hunger – where you crave touch, and begin to feel lonely without it. But your partner is also going through all of this. And it is nobody’s fault. You can’t support your partner and your relationship if you don’t really understand what’s going on. And sometimes, your partner won’t understand what’s going on either.

The easiest thing to do is to ask what your partner needs, and what would feel good. And when it comes to sex, it’s about thinking outside of what’s “normal” for you in your relationship.

Dr. Simon has done significant research on the impact of painful sex after menopause, and nearly two-thirds of people experienced painful sex after menopause, causing them to avoid sex and lose interest in sex. This shift in desire can have a large impact on relationships.

First, consider different ways to connect intimately. Perhaps penetrative sex isn’t a viable option right now. What about mutual masturbation? Or oral sex? What kind of touch sounds good to you and your partner? These conversations can be difficult if we aren’t used to having them, but communication is one of the most important aspects of sex.

There are treatments for painful sex, and that will be different for each person, but may include:

  • Vaginal lubricants or moisturizers
  • Vaginal estrogen
  • Vaginal dilators
  • Sex therapy
  • Pelvic floor physical therapy

 

Dr. Simon has found that nearly 60% of couples who went through post-menopause treatment for painful sex felt that their sex life (and their relationship) was significantly better than even before menopause!

Step Three: Count Sheep

Sleep is imperative for all humans, especially for those going through menopause. The constant night sweats cause more than disturbed sleep: weight gain, mood swings, and decreased sex drive are all results of a change in sleep habits.

If you’re in a relationship with someone who is currently experiencing these changes, then you probably know what I’m talking about. If you think it’s difficult for you, just imagine what your partner is going through. And, if you’re concerned about your partner, it’s okay to seek professional help individually or as a couple. Menopause can feel so isolating, especially when dealing with sleep deprivation.

If you see that your partner is isolating by setting up barriers, it will be especially important to work together to create a support plan with professional help. Mood swings, for example, may be related to PMS or heavy bleeding, and taking birth control can actually help lessen these symptoms. There are answers, but your partner may need that extra understanding and a gentle push from you to take the steps to get help.

Step Four: But, What Can I Do?

  • Take Initiative to Learn—There are so many books, articles, and podcasts  with good information on the topic of menopause. This is a great place to begin educating yourself. Asking your partner to do the emotional labor to educate you about menopause generally will be just as exhausting, and you want to help, not hinder. That doesn’t mean that you shouldn’t ask questions about what your partner is going through, how things feel, and what support would look like—questions like these can be really validating.Websites like menopause.org and isswsh.org have so much information that can help people navigate the struggles of menopause. You can also make an appointment with IntimMedicine—we often setup meetings with individuals and couples to better grasp how to handle menopause with a bit more ease. Having basic information before you talk with your partner will convey that you are really trying to understand what’s going on.
  • Have Compassion—This can be a difficult time for everyone, and hormones are fierce. Reminding yourself and one another that no one is at fault can be helpful. Take a beat before responding during heated conversations, and remember that, again, hormones are real and they actually alter the chemical state of the brain. If you’re feeling hurt, confused, or lonely, consider talking with a therapist or journaling about what you’re going through.
  • Use “I” Statements—When discussing your emotions around this whole menopause experience, try to use “I” statements. For example, saying “I feel _(hurt, rejected, sad, lonely)_ when I initiate intimacy with you and you turn away” is much better than saying, “You never want to have sex anymore.” Having an intentional conversation about your experiences of emotions can be really productive.

What’s Next?

Menopause isn’t easy for anyone involved. As a provider who specializes in caring for people who are at this stage of their life, this is Dr. Simon’s best advice: Understand what’s happening with your partner and know why it’s happening. This can help you navigate your way through the challenges of menopause—together. Now that you know more about menopause than perhaps you ever thought you would – use that information like a tool to work together with your partner to foster a healthy, compassionate relationship, even when things feel tough.

And if you and your partner are looking for hormone balancing or menopause treatment options, Dr. Simon and the IntimMedicine staff are ready to help.

Pink background with a mask sitting on top and letters spelling out "Don't Panic"

Back in April 2020, an article in the Journal of Women’s Health prompted me to think about the differences between men and women’s life and death responses to COVID-19. That article illustrated what we’ve heard in the news over, and over, and over again. Namely, that men tend to fare much worse than women if hospitalized with coronavirus (sars-cov-2) related diseases. Since then, we have come to know that, in this context, men are clearly the weaker sex. But even more data has emerged around the why, demonstrating that reproductive hormones are, in fact, an important part of women’s resistance to severe COVID-19 disease and can possibly even prevent death.

For most postmenopausal women, whether currently using menopausal hormone therapy or not, hormone therapy in early menopause (i.e., started in the first 10 years since their last menstrual period) is of significant benefit. Menopause specialists strive to determine the risk-benefit ratio for any woman before starting hormone therapy. It’s now clear that early menopausal women without absolute contraindications should seriously consider utilizing hormone therapy for disease prevention (i.e., heart attack and osteoporosis) and now to help prevent severe COVID-19 infections and even death.

Prevention of severe cases of COVID-19 may not be a good enough single reason to start hormone therapy, particularly as vaccinations are becoming more readily available. However, recent evidence documents that in women who start on hormone therapy for its basic, well-established benefits (treatment of hot flashes and night sweats, vaginal dryness and pain with sexual activity, prevention of osteoporosis etc. etc. etc.), may also benefit from the protection it provides against COVID-19 disease.

So, if you or someone you know wants a consultation to evaluate the benefit/risk ratio of postmenopausal hormone therapy, factoring in the potential benefits against severe COVID-19 infections, make an appointment to talk with us about all the options. All staff at IntimMedicine Specialists are fully vaccinated and we maintain careful CDC precautions, though we are also available for virtual visits. Menopausal hormone therapy may not only be good for you, it may save your life!

closeup of a doctor with a stethoscope in his pocket and a sexual health pin on his lapel

We are pleased to share a recent article in Washingtonian Magazine featuring an interview with our own Dr. James Simon, “The Menopause Whisperer.” In the article, Dr. Simon discusses female sexual dysfunction, the state of sexual healthcare for women, and his hopes for the future.

Read the full article “Sexual Dysfunction in Women Has Long Been Taboo. Washington’s Menopause Whisperer Is Here to Help” in Washingtonian Magazine.

Here is an excerpt from the article about one of Dr. Simon’s patients who consented to share her experience:

Palim stumbled on a Washington Post article that mentioned [IntimMedicine Specialists; Dr. Simon] put [Palim] on testosterone, and her condition rapidly improved. But if she hadn’t happened upon that story, “that might have just been the end for me of a part of my life and of my relationship with my husband that was meaningful and fun—and why? Why should I have had to give that up just because nobody bothered to tell me about it?”

If you or someone you know might benefit from seeing Dr. Simon or one of our sexual medicine experts at IntimMedicine Specialists, please share this post or give us a call at 202-293-1000 to make an appointment.

Pellet Hormone Replacement FAQ

We know that Hormone Replacement Therapy is essential for managing severe menopause (or “manopause!”) symptoms, and hopefully there is an easy way to deliver it, right? Fortunately, there is! IntimMedicine offers an easy outpatient procedure to place a bioidentical hormone pellet under the skin. Outta sight, outta mind, and you get to start living your life again!

What is it?

Pellets are compounded bioidentical hormones for women (our team of experts will determine exactly what’s right for you – the right amount can help you regain your hormonal balance). Pellet therapy is actually FDA approved for men, as well. Pellets are typically naturally occurring hormones that are pressed into a solid, little insert, about the size of a grain of rice.

How does it work?

Your pellet will release a small amount of your hormonal regimen straight into your bloodstream, similar to what your ovaries or testes would normally have produced in your younger years. Research shows that pellets are able to deliver a consistent level of hormones to your body, unlike some creams, gels, or pills which are also compounded. Pellets also reduce the risk of blood clots (venous thrombosis) associated with oral hormone replacement therapy because the hormones released from pellets enter the bloodstream directly and do not cause changes in blood clotting factors made in the liver the way oral medications can. It’s a win-win!

How is it used?

Hormone Replacement Pellets are used like any other Hormone Replacement Therapy to help our bodies regain some of its hormonal balance, which will improve everything from the emotional roller coaster to hot flashes. The pellet is just a convenient delivery method! It’s not for everyone, but getting your hormones “just right” no matter the method is critical.

How long does the procedure take?

It is a quick and painless (with numbing medication) outpatient office procedure. We will insert the HRT pellet right into your hip, abdomen or buttock area, and you’ll be on your way and back to your life!

How long till I see results?

It will only take 7-10 days for you to notice your HRT Pellet working on your symptoms.

How long will my pellet last?

HRT Pellets typically last 3-6 months for men and women.

How can I make an appointment? Call us at 202.293.1000 or email us to set up a consultation appointment with one of our specialists here in Washington, DC. Don’t wait to get back to living your normal life – call us today!

As the number of postmenopausal women continues to grow — reaching an estimated 1 billion worldwide — patients might believe that doctors have a good sense of the full range of menopausal symptoms and how they affect daily life. But despite numerous studies, detailed information on the full spectrum of menopausal complaints are actually lacking in large randomized trials.

But following a recent study that measured the quality of life in postmenopausal women aged 50-70, researchers hope to more fully identify menopause-related symptoms and help clinicians connect symptomatology with overall health.

The Connection Between Age and Menopausal Symptom Severity

During menopause, women may find themselves experiencing a range of associated symptoms, like hot flashes, night sweats, joint stiffness, vaginal dryness, pain with sexual activity, mood swings and insomnia. Researchers in this study wanted to evaluate the relationship between the severity of these menopausal symptoms and women’s reported quality of life.

The Menopause-Specific Quality of Life-Intervention (MENQOL) questionnaire was given to 932 women enrolled in the Minnesota Green Tea Trial, a larger study that was examining whether green tea extract influences the odds of developing breast cancer. Responses to the questionnaire — which assessed vasomotor, physical, sexual and psychosocial symptoms in the years following menopause — were scored on a range of 1 to 8, with higher scores indicating more severe symptoms.

Initial results suggested that menopausal symptoms — including negative mood, more frequent night sweats and hot flashes, decreased memory, and decreased energy — were reported as most severe in women aged 50-55 and steadily declined in severity as age increased.

While it’s clear that menopause can significantly affect the quality of life, there was some maybe good news reported by these women: There were no reported differences among age groups in the Sexual domain of the MENQOL. Women of all age groups suffered a similar decrease.

What These Findings Mean for Postmenopausal Women

While managing menopause-related symptoms might seem like a challenge, there is a silver lining: As women age past their early 50s, the severity of symptoms seems to lessen significantly. But that doesn’t mean menopausal symptoms should be taken lightly, as they can have significant effects on a woman’s daily life.

And because women are remaining active and productive long after menopause, clinicians like us can offer services tailored to this unique population.

The results of this study continue to inform us as we initiate important conversations with postmenopausal patients about their sexual health and the physical and psychosocial changes associated with aging. Many women are reluctant to talk about vaginal dryness, for example, so health providers must be prepared to discuss sensitive issues like these with their patients and cover symptoms and conditions that might not traditionally be associated with menopause. But we’re here to help you.

By implementing these findings into practical solutions, we can offer their clients helpful, actionable advice for postmenopausal women as they manage their expectations and search for menopause treatment options.

If you have questions about menopause or your sexual health, please call our compassionate staff at (202) 293-1000 to make an appointment.

Personalized Care

Any medical treatment should be considered specific to the needs and hormone concentrations of each individual patient. This is why we share our full breadth of knowledge about endocrinology, medical safety, and treatment efficacy in addition to treating gynecologic function and overall wellness.

 

So we were dismayed to read that the U.S. Preventive Services Task Force (USPSTF) final recommendation statement on the use of menopausal hormone therapy in post-menopausal women, citing health risks such as breast cancer, heart attack, dementia, and stroke. The key words are post-menopausal. The USPSTF recommendations did not address the overwhelming evidence that hormone therapy (HT) greatly benefits women who are going through the menopausal transition (aka with menopausal symptoms) and who do not have additional health problems. The USPSTF again failed to highlight the population of women who need hormones the most and are most likely to benefit from taking them (see Part 1 of this two-part blog). We can agree with their statement that women who START on their hormone therapy when they are older than 60, or more than 10 years following their last menstrual period, shouldn’t use hormones for the prevention of most diseases. But it doesn’t apply for the women a decade younger; that is, the patient population most often experiencing the symptoms that need treatment (hot flashes, night sweats, vaginal dryness, painful intercourse, mood swings, etc.). The safest time to use HT is during the so-called “estrogen window,” which is the decade-long time-frame between the ages of 50 and 60, or 10 years from the time of menopause (where menopause is defined as the start of at least 12 consecutive months menstrual period-free.

 

Hormone Therapy (HT) Is Effective for Hot Flashes, Night Sweats, and More

The North American Menopause Society’s most recent position statement (2017) concludes that HT remains the most effective (italics are mine) treatment for hot flashes and night sweats and the genitourinary syndrome of menopause (vaginal atrophy, painful intercourse, recurrent urinary tract infections, etc.), and it has been shown to prevent bone loss and fractures (osteoporosis). The risks of HT differ depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen or progesterone is used. Treatment should be individualized to identify the most appropriate HT type, dose, formulation, route of administration, and duration of use, using the best available evidence to maximize benefits and minimize risks. Also, check-ups with each patient during this time to evaluate benefit should be ongoing.

 

Where the Women’s Health Initiative (WHI) Erred

The WHI hormone studies have increasingly come under fire for the way they were designed, most importantly for the inclusion of women up to age 79, and results reported as if all women are the same. The results of these studies have reverberated through the medical community, causing changes that may have been both too broadly applied and, in some cases, simply incorrect (see commentary by David. L. Katz, MD, MPH, FACPM, FACP on such overgeneralizations. The findings that hormone therapy was putting many women at risk for conditions like breast cancer and cardiovascular conditions caused many women to go off their hormone-replacement therapy “cold turkey” without knowing how to address the consequences and not fully understanding the risks versus rewards. For example, some of the patients in the WHI study were already at increased risk for cancer or cardiovascular disease because of lifelong smoking, being overweight and the age at which they started hormone therapy (> 60 years, and up to age 79). However, otherwise healthy women should be able to use these therapies to ward off the symptoms that affect sleep, mood, sexual health, pleasure, etc.

 

We’ve Done Our Homework

In wanting to help my patients find effective ways to treat their symptoms, I analyzed a database of 13 million patients to investigate whether two forms of estrogen therapy (oral versus transdermal) differed in how patients experienced negative effects, particularly focusing on heart attacks, strokes and deep vein thromboses (blood clots in the veins) (see: Simon JA, Laliberté F, Duh MS, Pilon D, Kahler KH, Nyirady J, Davis PJ, Lefebvre P. Venous thromboembolism and cardiovascular disease complications in menopausal women using transdermal versus oral estrogen therapy. Menopause. 2016 Jun; 23(6): 600-10). I concluded that patients who used transdermal estrogens had significantly fewer blood clots in their veins, pulmonary emboli, and heart attacks than those who took an oral estrogen (i.e., pills). Stroke risks were also slightly lower for transdermal estrogen users.

 

I used this information to hypothesize just how different the WHI results would have been had that study used transdermal estradiol and micronized progesterone (see: Simon JA. What if the Women’s Health Initiative had used transdermal estradiol and oral progesterone instead? Menopause. 2014 Jul; 21(7): 769-83.). Those investigations showed that HT type, dose, formulation, route of administration, and duration of use can be tailored to maximize benefits while reducing or eliminating risks. “One size doesn’t fit all,” as the USPSTF suggested.

 

Key Points

  • HT benefits in early menopausal women include reduced coronary heart disease and all-cause mortality.
  • Randomized trials in women initiating HT after age 60 have shown benefit primarily for osteoporosis and fracture but overall increased harm.
  • Reassessment of clinical trials in women initiating HT treatment close to the onset of menopause and newer studies and meta-analyses now show benefit and rare risks.
  • More studies show benefit with estrogen alone than with estrogen plus progestogen.
  • No available medication except HT has demonstrated prevention of osteoporotic fractures in women not previously identified as having osteoporosis.
  • The effects of reduced cardiovascular disease and mortality in women initiating therapy around menopause (the “estrogen window”), and the beneficial effects of HT on the skeleton at any age, together suggest a role for hormone-replacement therapy in disease prevention.

 

Stop Suffering, Start Living

Please contact our office at (202) 293-1000, and make an appointment to get your questions answered and determine the best course of HT treatment that is specifically tailored to you.

We unequivocally support the use of menopausal hormone therapy to mitigate menopause symptoms and prevent disease for a variety of patients. Let’s review the facts of the case. THIS IS NOT FAKE NEWS!

 

When our institutions fail us, it’s time to openly and directly say so. No, this is not a political rant. I’m talking about the United States Preventative Services Task Force (USPSTF), a well-meaning, highly educated group of 12 so-called experts (no endocrinologists, no reproductive endocrinologists, and no menopausal specialists), consisting of two pediatricians, a PhD specialist in health management and public policy, four internists, four family physicians, and our token Ob/Gyn (who isn’t a menopause or hormone therapy expert). Yes, this is the same group (some different players) who recommended every-other-year mammography — and you may remember the backlash and public outcry over that suggestion. (FYI, the major organizations in women’s healthcare didn’t accept that recommendation.)

 

Well, this group is at it again, this time over postmenopausal hormone therapy. Last month (December 2017), the group gave a “D” recommendation for the use of postmenopausal hormone replacement therapy for disease prevention in both naturally menopausal women and women who have had a hysterectomy. A “D” recommendation means: recommends against the use of combined estrogen and progestin (in women with a uterus) or estrogen alone (in women who had a hysterectomy) for the primary prevention of chronic conditions in postmenopausal women. You can read their recommendations for yourself.

 

So, what happened? First, let’s be clear. Experts looking at the same scientific information can disagree on its meaning. But that’s not what happened here. I know this because a real group of menopause and hormone therapy experts replied to the draft recommendations of the USPSTF, attempting to explain the errors of their draft recommendations (see: Langer RD, Simon JA, Pines A, Lobo RA, Hodis HN, Pickar JH, Archer DF, Sarrel PM, Utian WH. Menopausal hormone therapy for primary prevention: Why the USPSTF is wrong. Menopause. 2017 Oct; 24 (10):1101-1112. doi: 10.1097/GME.0000000000000983., Or Langer RD, Simon JA, Pines A, Lobo RA, Hodis HN, Pickar JH, Archer DF, Sarrel PM, Utian WH. Menopausal hormone therapy for primary prevention: Why the USPSTF is wrong. Climacteric. 2017 Oct; 20(5): 402-413. doi: 10.1080/13697137.2017.1362156. Epub 2017 Aug. 14.).

 

These two publications are essentially the same. One was meant for the U.S. audience of menopause and hormone therapy experts, the other for the international menopause and hormone therapy audience. These same recommendations were sent to and received by the USPSTF during their comment period. Nothing from our suggestions was incorporated into the USPSTF documents. One conclusion could be that the USPSTF didn’t care, they had their minds made up, and no amount of scientific information was going to change their opinion. That’s not what happened, in my opinion.

 

The USPSTF opted to do two things to support their forgone conclusions:

  1. They so severely limited the evidence they were willing to consider that they made their judgement based only on the evidence in support of their opinion
  2. They made simplified judgments to apply to every menopausal woman as if they were all the same.

 

This first tactic is prime territory for every lawyer. You define the evidence in such a limiting way as to exclude all evidence not in support of your client. The USPSTF, by excluding so much of the scientific information available, was left with only a few important studies … the usual suspects, the Women’s Health Initiative (WHI) being so large and all encompassing, that it overwhelmed any analysis of the other studies considered.

 

The second tactic, treating all menopausal women as if they were the same, fits well into tactic 1, since the WHI Investigators initially reported on their study “overall” (Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, Jackson RD, Beresford SA, Howard BV, Johnson KC, Kotchen JM, Ockene J; Writing Group for the Women’s Health Initiative Investigators. JAMA. 2002 Jul 17; 288(3): 321-33.), lumping together women aged 50 through 79 as if they were all the same. And that was 15 years ago (prehistoric in scientific years).

 

These two errors in judgment are elegantly summarized by David. L. Katz, MD, MPH, FACPM, FACP who published another paper showing that NOT taking estrogen therapy following a hysterectomy actually resulted in a minimum of 18,601 — and as many as 91,610 postmenopausal women — dying prematurely because of the avoidance of estrogen therapy (ET) over a 10-year span, starting in 2002. Prevention of death is what I would call the ultimate prevention of disease. (See: The mortality toll of estrogen avoidance: an analysis of excess deaths among hysterectomized women aged 50 to 59 years. Sarrel PM, Njike VY, Vinante V, Katz DL. Am J Public Health. 2013 Sep;103(9):1583-8. doi: 10.2105/AJPH.2013.301295. Epub 2013 Jul 18.)

The symptoms of menopause are numerous and we now know that a large part of women’s working memory is affected by menopause. Memory is affected by both the levels of hormones and their fluctuations. As a result, researchers are looking for ways to mitigate memory problems. Thankfully, we are more aware of this risk as more treatments are studied to help women stay as sharp as they were in their pre-menopausal days.

Memory Decline Offset by Estradiol Therapy
A recent study published in the prestigious Journal of Clinical Endocrinology & Metabolism suggests that postmenopausal women who were prescribed estradiol therapy (ET) had better cognition than those who did not take the medication over the course of the study. Estradiol is a naturally occurring, sometimes called “bioidentical” form of estrogen. The research team used word tests to see how patients would be able to recall words at the ends of a sentence during times of stress or no stress, and with or without estradiol.

It should be noted that the 49 women on the study were not already taking any other medications that could affect working memory (e.g., antidepressants, amphetamines, etc.) so that the results would be directly related to taking ET versus the control group, and the women did not have any co-morbid medical conditions such as cardiovascular problems that could have an effect (likely adverse) on the results of the study.

Age, Stress and Working Memory
It’s that “tip of the tongue” phenomenon, when you know a person’s face but not her name, or you know exactly what you want to say but are grasping for the key word to help the sentence make sense. A friend once forgot the word for the season “winter” and said, “You know, a time of snow,” in exasperation when the word escaped her in a moment of poetic forgetfulness.

Cognitive decline as we age is common, but perhaps it doesn’t have to be as fast, or as permanent, and maybe it can even be reversed. Aging has been associated with dysfunction in parts of the brain in response to stress. Such dysfunction can have a snowball effect when people experience chronic stress along with aging and estrogen deficiency. Taken together such circumstances can lead to additional memory problems as well as related health implications.

Although the current study was small, its findings have significant implications, and could benefit from a repeat with a larger patient population. The research team concluded that ET provides relief from menopause-related symptoms, including limiting the effects of stress on working memory. This is good news at a time in history when memory issues appear to be common among the older population. Anything to keep brains as strong as bodies as people enter the third of life, is most welcome. The bottom line is this: estrogen replacement therapy can reduce the stress response, and its “downstream” adverse effect on memory. However, it remains unclear whether such hormonal interventions can fully mitigate the effects of stress on cognition. Further study will help us gain a clearer understanding of just how best to protect memory in postmenopausal women.

I’d like to clear up some confusion regarding the use of estrogen to offset the symptoms of menopause. I won’t bury the lead; vaginal estrogen IS a safe menopause treatment for almost all menopausal women to use. Women using vaginally applied estrogen to minimize menopause symptoms do not increase their risk of heart disease, stroke, deep vein thrombosis, dementia or certain cancers including breast cancer in spite of what it might say in the Information for Patients (the package insert) which comes with this therapy.

But now, the back story.

The federally funded Women’s Health Initiative (WHI) Clinical Trials studies documented that oral estrogen or oral estrogen plus progesterone pills increased the risks for heart disease, stroke, deep vein thrombosis, dementia and certain cancers including breast cancer. These results from studies published in 2002 and 2004 have come into much clearer focus more recently. Unfortunately, the patient population evaluated in these studies included women who had pre-existing health conditions such as being overweight, having high blood pressure, etc., and most importantly the study participants outside of the “estrogen window” for safety FOR SYSTEMIC HORMONE THERAPY. This confounded the results of the study, since most of the study participants were over 60 years old, and some were 79 years old, when they started on their treatments. However, the WHI researchers continued to look into safer options for the correct patient population, in order to alleviate symptoms which hinder a women’s overall quality of life and sexual wellness.

The “Estrogen Window”

Following the confusing outcomes of the WHI Randomized Clinical Trials (referred to above), researchers began to closely review other WHI data. The latest publication from the Observational part of the WHI (Carolyn J. Crandall, MD, and colleagues. Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women’s Health Initiative Observational Study. Menopause: The Journal of The North American Menopause Society. Vol. 25, No. 1, pp. 000-000, 2017. ePUB ahead of print) focuses on vaginal application of estrogen only for the treatment of vaginal symptoms of menopause. These included women’s experiences related to the deficiency of estrogen on the vagina, bladder and urethra, and particularly focused on the safety of vaginal estrogen treatments.

These symptoms investigated include:

  • dyspareunia (insertional or deep pain during sex)
  • lubrication/dryness issues during sex
  • vaginal atrophy
  • recurrent urinary tract infections
  • painful urination
  • generalized vulvar or vaginal discomfort
  • bleeding after sex

The one common group of symptoms that vaginal estrogen does not mitigate is hot flashes, night sweats, and disturbed sleep.

Risks and Rewards

The team aimed to find out if and how severe health risks affected women who were using this vaginal form of estrogen. Cardiovascular disease, breast, colorectal, and endometrial cancer, as well as deadly blot clots were health events that warranted a risk assessment in this study.

The data showed that among women with an intact uterus, the risks of stroke, invasive breast cancer, colorectal cancer, endometrial cancer, and pulmonary embolism/deep vein thrombosis were not significantly different between vaginal estrogen users and nonusers.

I will emphasize that this was estrogen-only administration of therapy and none were taken by mouth. Oral therapies that travel through a patient’s digestive system and blood stream may also be safe for many, but that is not the administration route under the microscope in this paper recently published in the Menopause journal; by the North American Menopause Society. The “take home” message: vaginal estrogen can be safely used without fear of cardiovascular events caused by such therapy, after menopause.

It is important to visit a practice like ours that understands hormones and the role that they play during each phase of a woman’s life. The fluctuations you experience are not only normal, but very treatable. If you have questions about hormones, the menopause window, or whether you can safely use hormones, please call our office at (202) 293-1000 to make an appointment with our compassionate and knowledgeable staff.

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