You say you’re in menopause and have been taking bioidentical hormones (including testosterone, progesterone, and estrogen) for a while. Your doctor advises going with the lowest dose of supplemental hormones for quality of life, which I generally agree with. But you don’t feel well, you’re achy, and you don’t sleep well. She’s told you the standard for estrogen is 30-60, and you’re at 19.2.
I would agree that an estradiol blood level of 19.2 is likely subtherapeutic. I rarely check levels as I don’t treat to a “lab result”; I more often treat to symptom management. I’ll check levels if I am concerned that a person just doesn’t seem to be absorbing the hormone being used, which happens very rarely.
There is no conclusive evidence that HRT significantly increases the risk of breast cancer. There just isn’t! But there’s the perception that there’s conclusive evidence, and therein lies the problem.
In Estrogen Matters, authors Avrum Bluming, MD, and Carol Tavris, PhD, explain in great detail why there’s a widespread belief—even by doctors—that HRT increases the risk.
While I don’t want to get deep into the science, I will highlight a few things that could help you quickly grasp where things went wrong. First, there’s that 2002 Women’s Health Initiative (WHI) study—the one we’ve mentioned in posts about estrogen and cognition, heart health, and bone health. That study found that women randomly assigned to take estrogen and progestin had a 26 percent increase in risk. That sounds big but, in the words of the report itself, that means it “almost reached a nominal statistical significance.” It may have been almost statistically significant, but the fact remained that it was not statistically significant.
The media latched onto the “26 percent increase” (it made for a compelling headline) but didn’t mention that 26 percent was not statistically significant. If a result isn’t statistically significant, that means it could have arisen randomly. Still, the WHI halted the study, everyone panicked, and the prescription rate for HRT fell by 50 percent.
To put the risk of HRT in perspective, the authors bring up other “risk factors” associated with the development of breast cancer. “The relative risks in almost all cases are very low, and the use of HRT is virtually the lowest, being less risky than eating fish or grapefruit, using antibiotics, or being a flight attendant.”
The second thing I want to highlight is that the WHI updated its study in 2006 and it found no increased risk of breast cancer. None. The entire reason that the study had been halted had vanished. “This news,” the authors wryly note, “did not make headlines.” No wonder so many women and their doctors and even professional associations still believe there’s incontrovertible proof that HRT increases the risk of breast cancer.
One final note: Even if you’ve had breast cancer, don’t automatically rule out HRT. There have been meta-analyses (comparing data from multiple studies) that show women who began HRT three to five years after their diagnoses and remained on it for an average of three years had a 10 percent decrease in chance of recurrence. Talk to your doctor!
You say you’ve tried Intrarosa, and it didn’t address your dryness. Even with lubricants, penetration is not working for you (or your husband). You recognize a “desire discrepancy” and are not alone in wanting a magic answer! And if there’s pain for you, it’s very hard to expect an improvement in libido or interest in sex. Resolving the pain is always my first order of business.
Intrarosa is a very effective treatment for painful intercourse, but not the only option. Trying another treatment may be helpful, but I also wonder whether there is another cause of painful intercourse that is not being completely addressed. Vulvodynia, which is commonly overlooked, comes to mind. A thorough pelvic exam is needed to diagnose that or another condition that may be contributing to your discomfort. It may be that vaginal dilators would help in regaining function (patency) to allow for penetration.
Hormone therapy could potentially be beneficial. It isn’t “magic” for everyone, but it can be helpful for many. That is a conversation worth having with your healthcare provider. I recommend you find someone with NAMS (North American Menopause Society) certification in your area; go to their provider locator and enter your zip code to find one in your area.
If you’ve been reading the series of posts we’ve been doing on estrogen (including how it relates to bone health and cognitive health), then you probably expect to learn something unexpected about heart health. This might be it: You should be more worried about dying from heart disease than breast cancer—even if you’ve had breast cancer.
“Heart disease kills more than twice as many women as breast cancer does, even young women under the age of forty, and it kills four times as many women between the ages of sixty and seventy-nine,” write the authors of Estrogen Matters. Furthermore, a study of 63,566 women who were diagnosed with breast cancer at age 66 or older “found that heart disease was responsible for more deaths among this large population than breast cancer.”
The people working hard to increase breast cancer awareness are doing their job well, and I’m grateful they are because their work is saving lives. But we need to also know that heart disease is a greater threat to women, and that the risk of heart disease goes up after menopause.
Multiple reputable studies before and after 2002 have shown that HRT in postmenopausal women reduces the risk of “a coronary event” by about 50 percent; others show that estrogen reduces the risk of coronary artery disease in postmenopausal women by 40 to 50 percent, compared to women who didn’t take hormones.
(There’s some debate over the way research is conducted—observational studies versus randomized controlled trials—which you can read all about in the book, if you’re interested. Personally, I’m satisfied that the research is sound.)
The Women’s Health Initiative (WHI) study from 2002 first said that women on HRT (but not ERT) had a slightly increased relative risk of “heart events.” But 70 percent of the women in that study were 60-79 years of age, many of whom had risk factors for heart disease and none of whom were excluded from the analysis because of those factors.
WHI revised that finding in 2007, write the authors of Estrogen Matters, “now concluding that women who started HRT within ten years of the onset of menopause actually reduced their risk of coronary artery disease, while those who started after that slightly increased their risk.”
HRT increases the risk to the heart in the first year of use and in older women because arteries become less elastic after menopause. Starting to take estrogen after a few years doesn’t reverse that, and it widens blood vessels, increasing blood flow to the heart.
What does all this mean to you? If you are under the age of 60 or within 10 years of entering menopause (when you haven’t had a period for 12 consecutive months), then talk to your doctor about whether the health benefits of HRT/ERT outweigh any risks. The research shows that when you begin HRT during that window, it significantly reduces coronary artery disease and overall mortality—possibly adding as many as three or four years to your lifespan, according to some experts. I think that possibility alone is worth a conversation with your doctor!
Whether or not you will need Vagifem (a vaginal hormone insert) or a moisturizer depends mostly on whether you are menopausal (one year past your last period). If not, you are likely to not need any treatment, since ovarian production of hormones should keep things comfortable.
If you are now menopausal, then initiating a moisturizer can be very helpful, or resuming a prescription hormone therapy may be necessary over time.
Among the choices we offer, I can’t say there’s one that’s better than the others for your situation. They are all safe and effective; we offer choices simply because some women prefer one over another. You can easily apply a moisturizer with your fingertip (like using OB or similar applicator-less tampons), especially if it’s a cream or gel consistency, or you can request a syringe you can use as an applicator with the moisturizer.
Forgotten names, misplaced keys, a missed appointment—who among us over the age of 50 hasn’t worried that these are harbingers of dementia, including Alzheimer’s? Losing some cognition—those misplaced keys, for example—is a normal part of aging, and the most we can do about it is to approach it with a sense of humor.
Alzheimer’s is a different matter. As Dr. Avrum Bluming and Carol Tavris, PhD, the authors of Estrogen Matters, point out, “a woman in her sixties is twice as likely to develop Alzheimer’s as to develop breast cancer.”
In our podcast about this topic, Dr. Avrum Bluming, one of the authors, told us, “The cure rate for Alzheimer’s disease is zero. In spite of everything you read and the drugs that are being tried —both those advertised and those requiring a prescription—nothing significantly delays or prevents Alzheimer’s disease except estrogen, which can decrease the risk of Alzheimer’s disease by up to 50 percent.”
That’s huge. And yet estrogen isn’t being prescribed because of the 2003 WHI Memory Study, which claimed that estrogen plus progestin nearly doubled the risk for dementia in women 65 and older.
There were many problems with the study (you can read them all in the book). What’s most important, though, is that when investigators looked at the study more closely in 2004, they found that “ERT and HRT were indeed associated with cognitive impairments, but only among women who were already cognitively impaired at the outset [of the study].... The cognitively healthy women on HRT did not become cognitively impaired!”
In fact, “brain and animal studies support the conclusion that memory, neurotransmitter function, brain plasticity, blood flow, glucose metabolism, and neural protection are all enhanced by estrogen.”
After menopause, estrogen production drops to just one percent of what it is prior to menopause. To all those who say, “taking estrogen isn’t natural,” the book's authors (and I) would reply: In 1900, only five percent of American women lived past age 50. As far as Mother Nature was concerned, she had timed things perfectly. But life expectancy has increased to 80 years; women are simply outliving our supply.
There is a “window of opportunity” for effectiveness, however: Estrogen therapy needs to begin in the 10 years after menopause. And in order for your body to maintain its benefits, the estrogen needs to be taken for the rest of your life, or as long as you want the benefit.
Estrogen replacement therapy isn’t for everyone. But if you think it might be something you want to explore, I encourage you to both read the book and talk to your doctor about it.
In the meantime, if you have questions, post them here or use our contact us page!
This is the second in a series of posts based on Estrogen Matters: Why Taking Hormones in Menopause Improves Women's Well-Being, Lengthens their Lives—and Doesn't Raise the Risk of Breast Cancer and on Dr. Barb's interview with the authors. You can read the first in the series, about hormone replacement therapy, here.
You may want to sit down while reading this post, because everything you think you’re doing to protect your bone health probably isn’t—or at least not as much as you think.
Like thinning hair, bone weakening is a normal part of aging. Osteoporosis is different. It’s when cavities develop inside the bone, thinning the bone and making it more brittle. When that happens in the femur, the result can be a hip fracture. And people who have a hip fracture are twice as likely to die in the five years after as people who haven’t had a hip fracture.
Taking calcium to prevent osteoporosis doesn’t help. Yes, you read that right.
Here’s why. Bone is made of an outer shell and the osteoid, an inner network of collagen fibers that allow the bone to flex without breaking. Calcium strengthens the outer shell, but it doesn’t help the osteoid, write the authors of Estrogen Matters. “Calcium supplements... are ineffective in preventing postmenopausal osteoporosis or fractures because they do not affect bone resilience.”
And while weight-bearing exercise makes bones stronger and more resistance to fracturing before menopause, it doesn’t after you’ve gone through menopause.
So, calcium and exercise don’t help with osteoporosis. What about Fosamax, Aredia, Zometa, and other bisphosphonates? They can, but only in certain circumstances. They can stave off osteoporosis in women who are at high risk (i.e., women who are white or Asian, very thin, or went through menopause early), and they can hold further bone loss at bay in women who already have it. But once you have osteoporosis, bisphosphonates won’t reverse it.
Not every woman tolerates bisphosphonates well, with side effects including digestive issues, fatigue, and insomnia. In addition, when taken over the long term, bisphosphonates may actually increase the risk of atypical hip fractures.
Is there a better answer? Estrogen replacement therapy or HRT was the standard approach in the 1970s, 80s, and 90s—until the WHI report—because it was effective. Multiple studies have shown that estrogen significantly reduces the risk of hip fracture, some by as much as 50 percent. In fact, no therapy has proven to be better at preventing osteoporosis and fractures in the spine and hips.
In order for it to be entirely effective, however, women have to begin taking it in menopause and continue for the rest of their lives. We need to think of osteoporosis as a chronic condition, like hypertension or diabetes. Treatment through medication is of benefit, and when the treatment stops, the chronic condition continues its progress. Once a woman stops taking estrogen, she loses its protection. And, of course, being on any medication for the rest of your life isn’t something you should take lightly.
I encourage you to investigate HRT or ERT as an option regardless of what you’ve heard about it. As always, talk to your doctor about your bone health, your particular health history and condition, your quality of life goals, and what course of action is best for you.
Mood disruptions are a known symptom of perimenopause, and my experience is that anxiety is at the top of that list (with irritability running a close second). It’s also possible that this is an anxiety disorder that is not related to hormones.
Then there are anti-anxiety medications. There are a variety of options to consider, and your primary care provider can help you navigate the choices and trade-offs.
Then there is estrogen. Studies suggest estrogen works as well as mood meds for perimenopausal mood disruptions. If you are still menstruating, estrogen alone is all that is necessary (no progesterone); if you are missing many periods, then adding progesterone may be necessary. Usually I’ll start women on a transdermal estradiol 0.1 mg 2 times per week. I recommend women do this for 3 months and then reassess to see if it is beneficial—and explore other options if it’s not.
I hope this is helpful and that you find a path to less anxious days!
Thanks for listening to our podcast on HRT! The relative safety of oral versus transdermal hormone therapy is something we didn’t discuss, and the authors’ book, Estrogen Matters, doesn’t directly address it either.
This is a timely question. The British Medical Journal just recently published a large study about route of delivery of estrogen. Their conclusion was that transdermal treatment was the safest type of hormone replacement therapy when risk of venous thromboembolism was assessed. Transdermal treatment appears to be underused, with the overwhelming preference still for oral preparations.
That being said, for women with very low risk of blood clot formation/thrombosis, the risk for oral estrogen is very low, especially for someone like you, non-obese, non-smoker, no hypertension, not sedentary, etc. So oral HRT would take a very, very small risk in you and make it a bit higher—but still very low.
The other implication of oral estrogen is that it lowers your circulating testosterone. We (postmenopausal women as a whole) already have low testosterone levels, and, in theory, we don’t want to make them lower. For most women the oral estrogen reduction of testosterone is not clinically noticeable, but some may find it harder to experience orgasm or have lower libido.
I hope this is helpful in considering your options!
In the last 25 years, I’ve had many conversations with my patients about hormone replacement therapy (HRT). They’ve heard that HRT can reduce the hot flashes, insomnia, headaches, and sex-related discomfort, and they desperately want relief from those things. But they also believe that HRT is dangerous to their health. There’s a good reason for that, which is why I want to explore HRT in depth over the course of several posts.
Here’s a brief overview of HRT’s history. As Avrum Bluming, MD, and Carol Tavris, PhD, explain in their book Estrogen Matters, in the early 1990s, estrogen seemed poised to be the go-to treatment for controlling symptoms of menopause. It also came with a host of health benefits. Fifty years of evidence showed that it reduced the risk of heart disease by 40-50 percent, hip fractures by 50 percent, colon cancer by 50 percent, and Alzheimer’s by 35 percent. And it increased longevity in most women.
Then in 2002, reports from the Women’s Health Initiative (WHI), an organization funded by the National Institutes of Health, claimed the exact opposite of all those findings. Furthermore, it claimed that taking estrogen in menopause increased the risks of breast cancer. Alarmed, women who were taking it stopped, and doctors, equally alarmed, stopped recommending it or recommended that it be taken only briefly.
I remember vividly the sunny July day the WHI hit the headlines. By noon, I had numerous phone calls from alarmed patients—and I hadn’t seen, wouldn’t see for at least another week, the research and clinical data behind the headlines. I don’t remember another time in my decades of medical practice when a single study upended everything.
The distress it caused was understandable: The WHI was considered a reliable, trustworthy source. In the years since, a number of contradictory studies have been shared, and questions about the original WHI study have bubbled up in various places. So when the authors of Estrogen Matters reviewed the reports, they already suspected that the WHI got many things wrong and overstated others. They feel strongly that “the medical professionals, in their concern about what turn out to be small risks for some women, are overlooking the overwhelming evidence of estrogen’s very large benefits for most women.”
I was thrilled to interview Avrum and Carol for our podcast, The Fullness of Midlife, about their book, which I found to be a clear, credible detangling of the myths surrounding and choices implicit in decisions about hormone therapy. You can listen to that conversation for an overview of where we are with understanding estrogen and its role in women’s health. And because I find this topic to be relevant—and potentially life changing—for so many, I’m also going to address specific areas of women’s health in articles here. In upcoming posts, I’ll cover the major estrogen-related health concerns: the cancer connection (or not), heart health, bone health, and cognitive health.
Depending on your comments or questions, I may also address the quality of life assessment that’s part of informed consideration of hormone therapy. Let me know what you’re curious about!