The Truth About Hormones During Menopause

Menopause inevitably happens for every woman, yet the information surrounding the topic can be sparse. The information available is often confusing or contradictory, especially around hormone replacement therapy (HRT) and its necessity.

Deciding whether HRT is right for you starts with an understanding of how hormones work in the body, (refer to Part 1 for a more in-depth description of hormone fluctuation during menopause.) and then analyzing the risk/benefit ratio for you personally. Women approaching menopause should first consider whether to continue using hormonal birth control.

Hormones & Birth Control

Many women are on birth control, which can make identifying perimenopausal symptoms and the onset of menopause difficult. It is also a good idea to talk with your doctor about the risk/benefit ratio of being on the pill because there are a number of factors to consider.

“When women turn 40, I try to encourage a longer-term and lower hormone birth control method like an IUD, or even encourage their partner to get a vasectomy,” Kimberly Kesler O’Rourke, MD, board-certified OB-GYN with GBMC Health Partners Perinatal Associates, said. “But some people need the pill. We try to at least get them on the lowest dose pill if they need to be on something.”

Guidelines generally suggest if a woman aged 50 has not already gone through menopause, she should go off birth control pills for one to two months. If there is no period, an OB-GYN will check the Follicle-Stimulated Hormones (FSH) in the estradiol. With an FSH level above 50, there is almost no risk of pregnancy, which may indicate menopause is present or at least on the horizon.

For women who are over 40 with a BMI of 35 and/or a history of breast cancer in their family, it is considered less safe for them to stay on the pill.

“The risk/benefit ratio in that example would indicate it’s safer to look into other options rather than stay on birth control pills until 50,” Dr. Kesler O’Rourke said. “But I also see healthy women with low-risk families who will stay on low-dose pills until they're 50, if that’s what works for them and that’s what they prefer.”

Once off birth control, is it necessary to replace those hormones with something else?

History of Hormone Replacement Therapy

Hormone replacement therapy (HRT) was the mainstay of treatment in the eighties, but treatment stopped abruptly when results from a Women's Health Initiative study were released early and out of context.

The purpose of the study was to evaluate whether putting women on estrogen decreased their risk of heart disease. There were two arms of the study: an estrogen/progesterone arm and an estrogen-only arm.

Women who had had a hysterectomy were put on estrogen only because they didn’t need progesterone. Women who had a uterus were put on both. The average age of women in the study was 60.

The estrogen and progesterone arm saw increased heart disease and they stopped it before it was finished due to the possible dangers. The estrogen-only arm with no progesterone did not see the same increase. The flaw in the study was testing it on women who were 60, often 10 years out from menopause, who likely already had heart disease or precursors for it.

Word got out, however, that HRT caused heart disease and women everywhere who were on HRT immediately called their doctors to stop treatment.

Hormone Replacement Therapy Today

HRT pills can still present a problem because of the nature of hormone levels in the body.

“Say we take a blood sample of your hormone level, and your estrogen comes back at 10 and the bottom normal is 25,” Dr. Kesler O’Rourke said. “Theoretically, you would be prescribed 15 to make up the difference. But you can't really do that because hormones change all day, every day. At 8 a.m., you might need 10, but at 10 p.m., you need 40.”

HRT has developed since the 80s, and is available in pill form as well as patches, vaginal suppositories, creams, and sprays. The latter forms all have less risk of clots and strokes than the pill, and they distribute hormones throughout the body more consistently, rather than up and down dosing or an oral pill.

Dr. Kesler O’Rourke recommends HRT as a temporary management option in women who are experiencing symptoms across the board. But if they describe isolated symptoms, such as just hot flashes or just vaginal dryness, those can be treated with easier, specific and less risky methods.

The hormones given in HRT are intended to stabilize the body while ovaries undergo the transition. While some women stay on HRT forever, there are risks and benefits to consider.

“At some point in time, your body is through menopausal transition and the risk/benefit ratio changes,” Dr. Kesler O’Rourke said. “When you stop HRT, you're going to get a little bit of withdrawal from the hormone replacement, but your levels aren't changing as much anymore. You're in a new, steady state and the steady state doesn't bother people as much as the fluctuations.”

Bodies are constantly changing, and the onset and persistence of symptoms can be heavily influenced by outside factors such as lifestyle, family history and preexisting conditions. Every treatment plan is going to be different and is subject to change as the body changes.

The important takeaway is menopause is normal and manageable and OB-GYNs can help.

Part 1: The Truth About Menopause