Menopause Hormone Therapy Treatment Explained

Menopause can drastically affect a woman’s quality of life and can cause significant work impairment. Women spend about a third of their life in postmenopause, with little to no ovarian hormone production, therefore it is really important to know what your options are as you enter this phase of your life. Some of the most common symptoms menopausal and postmenopausal women experience are:

• Hot flashes (also known as hot flushes)
• Night sweats
• Dizziness
• Heart racing/skipping beats
• Tremors
• Feeling restless or tired
• Difficulty concentrating
• Forgetfulness
• Mood swings
• Vaginal dryness
• Breast tenderness
• Migraines
• Waking at night

Women need more options and they need options that work. Menopausal hormone therapy can be really beneficial, and yet many practitioners and patients alike are hesitant to use it based on older scientific data that suggests the risks outweigh the benefits. In this blog post, we do a deeper dive into what menopausal hormone therapy is, what the benefits and risks are, who is a good candidate, and the approximate timeline and costs associated with it. Keep reading to get all of your hormone therapy questions answered and learn more about why hormone therapy may be beneficial for you.

What Is Menopausal Hormone Therapy (MHT)?

Menopausal hormone therapy (MHT), also known as hormone therapy (HT), encompasses estrogen therapy, estrogen-progestogen therapy, progestogen alone, and estrogen combined with an estrogen antagonist/agonist. It does not encompass using local vaginal estrogen. Previously, Hormone Therapy used be termed “Hormone Replacement Therapy”, however replacement is not the correct terminology. Menopause is not a deficiency state for which replacement is required. The use of hormone therapy after menopause is therapeutic for menopausal symptoms, not replacement for a deficiency state (there are exceptions to this, for example in premature menopause). Let’s talk about what progestogens and estrogens are.

What Is A Progestogen?  

Progestogens are a class of natural or synthetic steroid hormones that bind to and activate the progesterone receptors in our body. Therefore a progestogen could be bioidentical, or it can be synthetic, in the form of medroxyprogesterone acetate and norethisterone. The most commonly used progesterone is called Prometrium, a natural progestogen in the body. Women who are on estrogen therapy and have a uterus need to take a progestogen because estrogen alone can cause uncontrolled growth of the lining of the uterus (endometrium), which can lead to endometrial cancer. Therefore, the progestogen protects against endometrial cancer.

What are Estrogens?

Estrogens can be divided into different subtypes. Nonhuman estrogens refer to conjugated equine estrogens (CEE). It is a mixture of at least 10 active estrogens, and it is taken orally. It is prescribed less often now as oral estrogens come with more risks compared to transdermal estrogen.

The estrogens produced in the human body are estrone, 17B-estradiol (often called estradiol), and estriol. Estradiol is the most biologically active estrogen. Estriol is a weaker estrogen produced during pregnancy, and  is only 10% as active as estradiol. Estrone is not often used as part of hormone therapy as it is 50-70% less active than estradiol.

What Is The Best Menopausal Hormone Therapy?

Estrogen is often prescribed transdermally (on the skin), and not vaginally. Vaginal estrogen can be used to help women with vaginal itchiness and dryness that occurs with menopause, however that does not help with systemic levels of estrogen, and therefore does not help reduce hot flashes and night sweats. Estrogen is often combined with a form of progesterone for the purposes of endometrial protection. Oral estrogen can be used, however often comes with more risks, including increased risk of blood pressure, triglyceride levels, and an increase in blood clots/stroke.  

Progesterone can be used on its own to treat hot flashes and night sweats, however the primary use in hormone therapy is to reduce the risk of endometrial cancer associated with unopposed estrogen. Progesterone is taken orally. Vaginal and transdermal micronized progesterone does NOT provide endometrial protection.

When Is Hormone Therapy Needed During Menopause

Many women are reluctant to initiate hormone therapy because of the propagation of dangers of hormones after the publication of the results of the Women’s Health Initiative in 2002. However, we have learned a lot since this study was published in 2002, and we know there are safe and effective ways to administer hormones to help women in this stage of life. Every women who survives the middle-age stage of life will experience menopause, usually between the ages fo 40 and 58. Here are some clinical situations where we would consider hormone therapy:

Vasomotor symptoms (hot flashes/night sweats): Hormone therapy remains the gold standard for relief of vasomotor symptoms. Estrogen alone or combined with a progestogen reduces the frequency of hot flashes and night sweats by 75% and significantly reduces their severity. No other therapy matches its effectiveness.

Sleep: Most of the research concludes that hormone therapy alleviates subjective sleep disturbances, particularly if vasomotor symptoms are present.

Bone health: Hormone therapy is indicated for the prevention of osteoporosis. Estrogen specifically is responsible for preventing bone resorption.

Vaginal dryness: Local vaginal estrogen can help women experience less pain, irritation, burning or dryness during sex, and less bleeding and/or spotting from vaginal atrophy.

Hormone therapy can also help with other concerns such as joint/muscle pain, mood swings, low libido, and can also be protective for cardiovascular events if initiated at a specific window of opportunity.

Contraindications for Menopausal Hormone Therapy

Here are some contraindications to hormone therapy and situations where it may NOT be suitable for you:

• Undiagnosed abnormal genital bleeding
• Known or suspected estrogen-dependent neoplasia
• Active or history of deep vein thrombosis, pulmonary embolism
• Active or recent (within the past year) arterial thromboembolic disease (e.g. stroke, myocardial infarction)
• Liver dysfunction or disease
• Known or suspected pregnancy
• Known hypersensitivity to estrogen or progesterone
• Porphyria cutanea tardis
• Known, suspected, or history of breast cancer, except in appropriately selected patients being treated for metastatic disease or with oncology involvement

Here are some situations where hormone therapy can still be used, but where more caution is advised:

• Endometriosis (it may reactivate)
• Migraine with aura (may worsen this)
• Leiomyomas (fibroids may grow in size)

In all other situations, hormone therapy may be indicated for you based on your menopausal symptoms.

Getting Started With Menopausal Hormone Therapy

You can start hormone therapy by booking an initial consultation with one of our Naturopathic Doctors who have additional training in hormone therapy. A thorough assessment is needed in order to effectively prescribe hormone therapy. Follow-up appointments are also essential to appropriate management and care. The first follow-up appointment is booked 3 months after the initiation of hormone therapy, and then 6 months thereafter to assess risks and benefits of use.

A study of healthcare providers found that 81% of physicians in training (residents) reported having limited training in menopause medicine, and 50% reported low comfort with managing menopause studies (link to study).

This is why it is important to speak to a practitioner who has had additional training and can help you navigate the confusing world of hormone therapy.

Menopausal Hormone Therapy in Ontario

Menopausal hormone therapy can be initiated with Naturopathic Doctors who have additional training in hormone therapy. It can also be initiated with nurse practitioners who have had additional training in this area. The most important part of a hormone therapy appointment is to make sure you have the proper assessment done to see if you would be a good candidate, and additionally, have the appropriate follow-up appointments and monitoring of treatment if therapy is initiated. Laboratory testing is required to obtain a baseline level prior to hormone prescribing.

Annex Naturopathic Clinic

At Annex Naturopathic Clinic, we have two clinicians who are extensively trained in hormone therapy – Dr. Marnie Luck, ND and Dr. Daiana Castleman, ND.  Both Dr. Marnie and Dr. Daiana are completing their training in June 2022 to become North American Menopause Society (NAMS) Certified Menopause Practitioners. We believe strongly that menopause is not a disease, it is a stage of life, it is an opportunity. Menopausal symptoms can be treated effectively, and some even prevented. We also believe that educating women in this stage of life is integral to successful health outcomes. We are here to eliminate confusion and bring you accurate, up-to-date information on hormone therapy.

Potential Complications When Doing Hormone Therapy

Side effects can occur when on hormone therapy, and this will be discussed during your visit. You will be informed of the signs and symptoms to pay attention to and when further testing may be indicated. Potential side effects include:

• Uterine bleeding (starting or returning)
• Mood changes (particularly with progestin)
• Breast tenderness (sometimes enlargement)
• Nausea
• Abdominal bloating
• Fluid retention in the extremities
• Changes in the shape of the cornea (sometimes leading to contact lens intolerance)
• Headache (sometimes migraine)
• Dizziness
• Angioedema

All of these effects can be mitigated by changing the dose, changing the ratio of estrogen to progestogen, changing route of administration, changing the type of estrogen or progestogen, or other lifestyle changes.

Conclusions

If you are on the fence about hormone therapy, it’s important to speak to a practitioner who is qualified to speak to you. Knowing what the benefits and risks are for you is an important part of informed consent in order to initiate menopause hormone therapy. You should not have to suffer because your doctor doesn’t have up-to-date information on hormone therapy. If you are interested in learning more about hormone therapy, give us a call at the link at (647) 624-5800 or book online with Dr. Daiana Castleman.  We look forward to working with you!

Frequently Asked Questions Regarding Menopausal Hormone Therapy

How much does hormone therapy cost?

The cost of hormone therapy will vary depending on where you live and if you have insurance coverage. One bottle of estrogel (transdermal estrogen), for example, will cost approximately $65 for 1 month supply, and $170 for 3 months supply. If you are using a patch instead of a gel, the cost of 1 box (1 month supply) will cost approximately $50, and 3 boxes (3 month supply) will cost $127. Progesterone capsules will cost approximately $94 for 1 month supply and $240 for 3 months supply.

How long does hormone therapy take?

It does not take long at all to start hormone therapy once your healthcare provider determines that hormone therapy is suitable for you. Following your initial assessment, if your healthcare practitioner believes you are a good candidate, a prescription will be sent to the pharmacy on the same day. You will then get a call from the pharmacy within 1-2 business days to go over the prescription with you, including cost, route of administration, and clarify any other questions you may have.

How long after starting hormone therapy do you feel a difference?

When it comes to relief of vasomotor symptoms, expected timeline for benefit is typically seen within 1 month of initiating hormone therapy. To assess if hormone therapy is working for you, we recommend consistent use for at least 3 months to assess efficacy.

Can I take hormone therapy if I’m 62 and it’s been 10 years since my last period?

We don’t recommend hormone therapy for someone who is over 60 years old or who is more than 10 years from their last period. In these situations, the risks outweigh the benefits. This is pretty clear from the scientific literature we currently have. That being said, you can start vaginal estrogen, which is very effective for vaginal dryness and not considered menopausal hormone therapy. Vaginal estrogen is considered local therapy and it does not enter the bloodstream, therefore it will not increase your risk of cardiovascular disease or dementia.

If vaginal dryness and pain with intercourse is my only concern, should I still consider menopausal hormone therapy?

The short answer is no, if that is your only concern. Systemic hormone therapy only helps around 50% of the time with vaginal symptoms, therefore local vaginal estrogen is the best option in this case. Vaginal estrogen is great for not only treating symptoms, but also in helping reduce the risk of urinary tract infections and helping with urinary incontinence. Talk to your health care provider if you have a history of hormone receptor positive breast cancer.

My menopausal symptoms don’t “bother” me. So do they need to be treated?

This is a great question and one that deserves more attention. If you are experiencing 2 or more menopausal symptoms even if they are not bothersome to you, you should still bring this to your provider’s attention. There is a link between cardiovascular disease and symptoms of menopause. Women with 2 or more moderate to severe symptoms have been shown to be 40% more likely to have a stroke and 35% more likely to have cardiovascular disease of any kind. Now, this doesn’t mean causation (having more menopausal symptoms does not CAUSE cardiovascular disease). We need to learn more about this association, so please don’t panic. This should be empowering. Knowing that you can be at a higher risk of cardiovascular disease can help you take the necessary steps to lower that risk. This includes getting yearly bloodwork with your provider to assess cardiovascular markers, monitoring your blood pressure, as well as discussing dietary and lifestyle changes. There is a lot we can do from a diet and lifestyle perspective to help you improve your cardiovascular health. You can look at the American Health Association guidelines to get you started.

I am experiencing a lot of brain fog. Can I start hormone therapy for cognitive reasons?

Menopausal hormone therapy is not indicated for cognitive changes. The good news is that a lot of the cognitive changes that we see around menopause are temporary, and not directly related to low estrogen levels. It’s important to assess other conditions that could be causing brain fog, such as a thyroid disorder, sleep apnea, depression, and others. It may be possible that hormone therapy can indirectly impact cognition by improving sleep, and thus, making cognitive changes less disruptive.

I have a history of breast cancer. Can I start hormone therapy?

It’s very important to explore all your options, hormonal and non-hormonal, when it comes to helping you with symptom management. Naturopathic Doctors will work with your oncologist team to make sure that the best decision is made for you. It matters whether your breast cancer was estrogen receptor positive or negative. Hormone therapy is contraindicated in active breast cancer cases. The decision to use low-dose vaginal estrogen in women with breast cancer should be made in conjunction with their oncologists. This is particularly important for women on aromatase inhibitors medication.

Side note: Women treated for breast cancer are more likely to die from cardiovascular disease than breast cancer itself, therefore cardiovascular assessment becomes a really important part of your care. The focus needs to be on health maintenance and prevention.