Menopause: Is There Life Beyond Hormone Replacement Therapy?

Post-HRT, what are women doing to manage menopause symptoms? And are compounded bioidenticals safe?

Medically Reviewed by Brunilda Nazario, MD on April 24, 2009
9 min read

Menopause gets a bad rap, but there is an upside.

A major, essential, glorious one, says Renzie Richardson, a 51-year-old human resources consultant from Cumming, Ga. “I was definitely happy not to have a period anymore. That in itself was a celebration.”

Still, the wider ramifications of going through The Change threw her for a loop. “I thought the period was gone -- that was it. But now you’ve got all these other symptoms you have to deal with.” Richardson was taken by surprise by hot flashes, thinning hair, vaginal dryness, fuzzy thinking, and weight gain. She was officially in menopause -- her periods had stopped for more than a year -- but the pesky symptoms continued.

And so Richardson found herself caught up in a quandary that binds millions of American women. Now that hormone replacement therapy (HRT) is no longer prescribed as widely as it once was, what does a woman do for menopause symptoms that range from annoying to miserable and downright disruptive?

“I started doing a lot of research on what my options were, as opposed to hormone therapy,” she says, “because I was afraid of cancer and all this other stuff.”

What are women to do? First, keep in mind that menopause is not a disease, but a natural passage that usually occurs between ages 45 and 54. “Puberty in reverse,” says Susan Love, MD, in Dr. Susan Love’s Menopause and Hormone Book: Making Informed Choices. While some women barely notice a blip, others feel the change throws their lives into disarray.

“Menopause is a tough time for a lot of people,” says Mary Jane Minkin, MD, clinical professor of obstetrics and gynecology at Yale University School of Medicine, author of A Woman’s Guide to Menopause and Perimenopause, and an obstetrician/gynecologist in private practice. “Some breeze right through. Twenty percent of women get no hot flashes whatsoever.” But, she adds, many women are debilitated, “no matter how fabulously they take care of themselves.”

Not long ago, doctors routinely prescribed hormone replacement therapy to menopausal women, convinced of its power to relieve menopause symptoms and prevent heart disease and other ills. But women and doctors were stunned in 2002 when the NIH halted a Women’s Health Initiative study that indicated that long-term hormone use posed more health risks than benefits, such as an increased chance of heart attacks, strokes, and breast cancer.

Millions of women dropped conventional hormone therapy -- and droves have stayed away ever since. (Many others have turned to their doctors for a prescription for compounded bioidenticals, but are they safe? See below for more.)

“Patients are very reluctant. They’re very scared,” says Michelle Warren, MD, founder and medical director of the Center for Menopause, Hormonal Disorders and Women’s Health at Columbia University Medical Center. “There’s a whole different mindset out there.”

So where does that leave women who still need relief? They can try nonhormonal therapies first (more on these below), but if these attempts don’t work, the news about hormone therapy isn’t uniformly bad.

Doctors now use hormone therapy to relieve moderate to severe menopause symptoms but at the lowest dose that works for the shortest time needed. When women start hormone therapy within 10 years from the time they enter menopause, heart disease risk doesn’t seem to rise. In fact, preliminary evidence suggests that hormone therapy taken for menopause symptoms in the first few years of menopause may even help to protect the heart. But the longer a woman waits to start hormone therapy after menopause, the higher the risk of heart disease.

Doctors continue to prescribe hormone replacement therapy when benefits outweigh risks for women grappling with disruptive hot flashes or night sweats that lead to insomnia and irritability. “Estrogen still is the most effective intervention for just about all the symptoms of menopause, no question about it,” Minkin says.

But because of the potential for serious problems, menopausal women considering hormone therapy should carefully discuss individual risks and benefits with their doctor. For example, women who have had breast cancer would not be good candidates. Besides hormone therapy, some doctors prescribe antidepressants, which have worked moderately well to relieve hot flashes in clinical trials.

Finding a doctor with menopause expertise can help women come up with a good plan, says Karen Giblin, founder and president of Red Hot Mamas, a national menopause education group. A starting point: The North American Menopause Society’s website, which lists doctors who have earned menopause credentials from the organization.

Another HRT alternative for women on the road to menopause: low-dose birth control pills, believe it or not, are also good for calming dreaded hot flashes and heavy or irregular bleeding.

Perimenopausal women aren’t officially in menopause until they have gone 12 months without a period. In the several years leading up to that milestone, a woman ovulates less and can produce less estrogen and progesterone. “We’re not ovulating as well and our estrogen levels are variable,” says Minkin. “Your hormones look like the Dow Jones industrial average -- especially these days: up, down, up, down.” Symptoms fluctuate with the wild hormonal swings, she adds.

Birth control pills or patches “put your ovaries to sleep,” she says. They take over delivering hormones. When estrogen levels are steadied this way, hot flashes and other menopause symptoms often improve, according to Minkin. (Some women, though, should avoid all birth control pills, including very-low-dose kinds: smokers over age 35, women with uncontrolled high blood pressure, and women who have had breast cancer, heart disease, or deep blood clots.)

Very-low-dose birth control pills are sometimes a better option than hormone therapy because they shut down the ovaries, Minkin explains. In contrast, perimenopausal women on hormone therapy might still have irregular cycles and bleeding.

Millions of women remain leery of any type of drugs and choose not to use either HRT or birth control pills. After doing her menopause homework, Richardson opted for a solution with only lifestyle changes. “I created a plan to maintain my health and deal with menopausal symptoms naturally.” Starting an exercise program helped control hot flashes and weight gain, Richardson says. She began working out at the gym after years of hectic 60-hour workweeks that left little time for exercise. “It alleviated a lot of my symptoms.”

Avoiding extreme changes in temperature, layering clothing, and saying no to both caffeine and spicy foods are other ways to help with hot flashes. So is reducing stress through meditation or deep breathing, say experts.

What about alternative treatments for hot flashes, such as black cohosh or soy products? They may be worth a try, but aren’t strong bets for everyone, says Margery Gass, MD, director of the University Hospital Menopause and Osteoporosis Center at the University of Cincinnati.

“When you look at a critical review of all the studies, none of them have turned out to be highly effective,” she says of alternative menopause products. “But that does not mean that, on an individual level, one particular person might not benefit. If people want to try those products, they just need to keep an open mind and consider a one-month trial to see if there’s any benefit.” But women should inform their doctors about what they’re taking, she adds.

You may have heard that Oprah Winfrey’s taking “bioidenticals” for menopause relief. And Suzanne Somers endorses them in her books and on TV. But are they safe?

Bioidentical hormones are chemically derived from extracts found in yams or soy. For many years, doctors have prescribed clinically tested, FDA-approved, bioidentical hormone drugs, such as pharmaceutically manufactured estrogen patches, pills, creams, and natural progesterone, to ease menopause symptoms.

But these aren’t the products generating the current buzz -- and controversy. In recent years, Somers and other celebrities have promoted these compounded bioidentical hormones as safer, more effective, and more natural than synthetic hormones.

That’s not necessarily the case. Consider:

Bioidenticals aren’t FDA approved. The drugs are mixed to order, so there is no testing of their efficacy or safety. Compounding pharmacies do use some of the same ingredients found in FDA-approved products. However, their compounded bioidentical mixtures are not FDA-approved or regulated. They may even pose potentially serious side effects.

Bioidenticals may have side effects. “Don’t go in thinking these things are totally risk-free and that there’s tons of data,” says Mary Jane Minkin, MD, an obstetrician and gynecologist who fields numerous requests from patients, yet urges them to steer clear of these unregulated drugs. Both doctors express frustration, though, that their warnings are often drowned out by the chorus of endorsements from celebrities and others with no medical training.

Bioidenticaldoses aren’t regulated. “The doses they’re promoting are much greater than what patients should be taking,” says Michelle Warren, MD, of the Center for Menopause, Hormonal Disorders, and Women’s Health at Columbia University Medical Center. And, because compounded hormones aren’t regulated, they carry no black box warnings, nor are there requirements to report adverse effects to the FDA.

Bioidenticals are chemicals. Many women mistakenly believe that compounded hormones are “all natural” and come straight from plants, but they’re actually chemically manufactured in a lab, Minkin says, and the actual compounded hormone product isn’t FDA-regulated. Experts say there’s no way to vouch for potency, purity, safety, or efficacy.

Flagging libido bedevils many women during menopause. Midlife is often jam-packed with major responsibilities: a job, a household, children, and aging parents among them. The stress, combined with hot flashes that create insomnia and fatigue, can drive sex to the bottom of a woman’s priority list.

What’s more, some menopausal women start to dread sex because it hurts. As estrogen levels drop, skin, eye, and vaginal tissues become drier. “I call it ‘the Sahara decade,’” Giblin says of the perimenopause years leading up to menopause. Vaginal tissues get thinner and less elastic. As a result, “the pain during intimacy can flatline sex.”

Gass also sees patients who are reluctant to acknowledge midlife dissatisfactions that interfere with sexual desire. “Take a big step backward and ... try to be honest about feelings you might have,” she advises. “Maybe the husband has gained a whole lot of weight and isn’t very attractive to the woman anymore, and yet they don’t want to admit that to themselves. In reality, things like that serve as a wet blanket to our libido.”

By bringing such problems into the open, women -- and their partners -- can find solutions that enable them to relish their sex lives again. For starters, a water-based lubricant can make intercourse more comfortable. If women still have pain, they should talk to their doctors about other options for treating vaginal dryness, such as vaginal estrogen creams and pills, moisturizers, and low-dose estrogen rings.

Some more good news: Having regular sex increases blood flow to a woman’s genital area, helping prevent vaginal pain that comes with menopause.

Although menopause brings difficulties, the experience also prompts women to think anew about their health and sexuality -- and to consider future directions in their lives as they accept aging.

Easier said than done, but experts say Richardson and other women her age can look forward to a number of payoffs once they get through menopause: freedom from fear of pregnancy when menstruation stops, freedom to reignite a loving relationship after children leave home, and freedom to undergo a personal metamorphosis as another life stage begins.

To help chart her way through the big M, Richardson read everything she could “to understand what was happening to my body as it shifted into this new me,” she says. Her hope was “to recapture some of the things that I enjoyed when I was youthful ‘me’ and not feel embarrassed or ashamed about the changes my body was experiencing.

“I will take a ‘menopause’ to celebrate this midpoint in my life,” she adds. And to get the party started, reports Richardson, she has started to dance again.

Show Sources


Renzie Richardson, Cumming, Georgia. Mary Jane Minkin, MD, clinical professor of obstetrics and gynecology, Yale University School of Medicine. Michelle Warren, MD, medical director, Center for Menopause, Hormonal Disorders and Women’s Health, Columbia University Medical Center. Margery Gass, MD, director, University Hospital Menopause and Osteoporosis Center, University of Cincinnati. Karen Giblin, founder and president, Red Hot Mamas. Love, S. Dr. Susan Love’s Menopause and Hormone Book, Three Rivers Press, 2003. U.S. Department of Health and Human Services: “Facts About Menopausal Hormone Therapy.” “Understanding Menopause.” The Endocrine Society: “Statement of Leonard Wartofsky, MD, on Behalf of The Endocrine Society Before the Senate Special Committee on Aging on Bioidentical Hormones” April 19, 2007. North American Menopause Society: “Bioidentical Hormones.”  American College of Obstetricians and Gynecologists: “No Scientific Evidence Supporting Effectiveness or Safety of Compounded Bioidentical Hormone Therapy.”  The Endocrine Society: “Bioidentical Hormones.” DA: “FDA Takes Action Against Compounded Menopause Hormone Therapy Drugs.” “Women’s Sexual Health Quiz”



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