In a sense, the most “natural” replacement for lost estrogen is estrogen, which is a prescription product (like Premarin or Estrace vaginal cream, Estring, Vagifem, or the non-estrogen Osphena).
If, for a number of reasons, you prefer not to take that path, the next-best option is to maintain vaginal tissues by using a moisturizer regularly, two to three times a week. Moisturizers are designed to bring more moisture--no surprise--into the vagina to prevent the progressive dryness that occurs in menopause with the absence of estrogen.
One more option might be an oral nutritional supplement, Stronvivo, which some research shows improves vaginal moisture. It does this by improving blood flow, and that circulation also supports tissue health.
As if the hot flashes, mood swings, night sweats, and sexual challenges weren’t enough, now you can add weight gain to the menopausal whammy.
That’s right. In case you hadn’t noticed (fat chance!), women tend to gain about 10-15 pounds on average—from 3 to 30 pounds is the typical range—during and after menopause. And because our entire metabolic mechanism is different now, that weight is blessedly hard to take off.
“I feel like my body has betrayed me,” said one of my patients.
“Prior to menopause I was able to maintain a weight loss of 70 pounds. I see that 25 pounds have come back and nothing I seem to do is helping,” said another woman.
Weight gain during menopause isn’t totally related to “the change.” Lifestyle, genetics, and, yes, hormonal fluctuation all play their respective roles, for better or for worse. But the weight goes on, and the way that happens is different from weight gain in previous years.
So, if you’re accustomed to losing weight easily—or not gaining it in the first place—this development may come as a puzzling and unpleasant surprise. And if you struggle with your weight, be forewarned: The deck is about to be reshuffled, and that struggle may become harder yet. The single bright spot is that you’re in a very big boat with a lot of other menopausal gals—up to 90 percent of us gain weight during this transition, according to this article.
Menopausal weight gain is different because:
In order to effectively tackle this unsettling turn of events and to grasp why the things you did before aren’t working now, it helps to understand the underlying mechanism.
For one thing, muscle mass, which is an efficient burner of calories, slowly decreases with age. Now, even your resting metabolism (when you aren’t active) is lower. Adding insult to injury, loss of estrogen compounds this effect. Studies of lab animals suggest that estrogen has a regulating effect on appetite and weight gain. Animals with lower estrogen levels ate more and moved less.
When the ovaries stop producing estrogen, fat cells tend to take over. Ovaries produce estradiol, a “premium” estrogen; fat cells produce estrone, which is a weak, inefficient estrogen. This hormonal change increases the body’s efficiency at depositing fat, especially, we find, around the abdomen.
A recent study confirmed that certain proteins and enzymes that enable cells to store more fat and to burn it less become more active in post-menopausal women. “Taken together, these changes in bodily processes may be more than a little surprising—and upsetting—for women who previously had little trouble managing their weight,” comments Sylvia Santosa, assistant professor in Concordia University’s Department of Exercise Science in this article.
You got that right, sister.
Menopause packs a couple more weight-inducing changes: insomnia and stress. When you don’t sleep well (and who does, what with night sweats and cratering mood swings?), levels of ghrelin, known as the “hunger hormone,” rise and levels of the “fullness hormone” leptin drop. That’s why you get the nighttime munchies. A study of over 1,000 volunteers (The Wisconsin Sleep Cohort Study) found that those who slept less had higher ghrelin levels and lower leptin levels—and also had a higher body mass index (BMI), i.e. they weighed more.
And we all know what stress eating does to our waistline.
So, what’s a stressed-out, sleep-deprived, menopausal woman to do? It’s a challenge, without doubt. However, when we understand the mechanism—what’s happening to our bodies on a biological level—then we realize that doing what we did before isn’t going to work. We need to change up the paradigm if we want to control our weight and maintain a healthy, active post-menopausal lifestyle.
This paradigm shift involves a different approach to both diet (Note: I did not say dieting!) and exercise. No magic pharma pill or painless regimen. Still, we can regain control of the bathroom scales despite the slings and arrows of our slowing metabolism and estrogen-storing fat cells. And honestly, we might end up with better health habits than we ever had before.
Estrogen, as you know all too well these days, does a lot of good things for your body and your mood. Maybe you didn’t know that it also does a lot of good things for your brain.
“In preclinical studies, estrogen was shown to improve energy production, reduce oxidative stress, increase brain cell survival during damage, enhance the release of protective chemicals, and improve memory,” according to this recent article.
So, you may ask, what the heck happens in the brain when estrogen disappears after menopause? Researchers are also asking if estrogen, or the lack thereof, plays a role in Alzheimer’s disease, the most common form of dementia, which disproportionately affects women.
Neither menopause nor lack of estrogen is directly linked to dementia, or specifically, to Alzheimer’s disease. No smoking gun or causal connection has been found despite numerous studies comparing women who have taken estrogen with those who haven’t.
“…Evidence from cohorts in Melbourne, the United Kingdom, and rural Taiwan suggests that the natural menopausal transition probably does not have important effects on episodic memory or most other cognitive skills,” states this National Institutes of Health (NIH) article.
So, what does happen in the brain when estrogen production declines after menopause? Are all those “senior moments” really the result of our estrogen-starved gray matter? Does estrogen replacement therapy (ERT), have any effect on brain health? Finally, although no treatment exists for Alzheimer’s disease, could estrogen play a role in preventing or delaying its onset?
While these are all tantalizing questions that researchers are beginning to tease apart, no actionable answers are forthcoming, yet. Frankly, research results are all over the map. You may remember the groundbreaking 2002 Women’s Health Initiative that was responsible for a seismic shift in the routine use of estrogen therapy after concerns about risk of breast cancer and heart disease--some of which were misunderstood or at least miscommunicated.
Less well-known was that a cognitive component to that study (the Women’s Health Initiative Memory Study) found that the risk of dementia increased, sometimes dramatically, for women over 65 who were on hormone therapy.
However, several recent studies suggest that beginning hormone therapy at a younger age may have a protective effect on the brain. A recent study in Norway and another in Finland determined that taking estrogen before and during menopause, resulted in increased brain volume, especially in the hippocampus, which is the area associated with memory and sense of place and which is most disrupted by Alzheimer’s disease.
These conflicting results have led to the “critical window” hypothesis: that at some points in the menopausal transition, estrogen may help preserve brain function while at others, not so much.
“Most researchers seem to accept the idea that a critical window exists during which estrogen treatment is most likely to be beneficial. ‘The question is, when is that window open, and when is it closed?’ ” said Roberta Diaz-Brinton.
Diaz-Brinton suggested that healthy cells may be more likely to respond positively to estrogen but older or “sickly” cells may not. This is the “healthy cell bias of estrogen.”
Frustratingly, for those of us approaching menopause, the data continues to roll in and not much is consistent enough to define a course of action. Obviously, a bunch of variables confound the picture: how the estrogen is administered (whether by pill or patch); what kind of estrogen is administered (bioidentical, equine, or some other formula); certain genetic factors; the combined effect of estrogen plus progestogen (for women who still have a uterus); plus all the other variables of country, culture, health, and lifestyle.
The current position of the NIH, which can be expected to take a conservative position, is that “it is unknown whether estrogen effects on Alzheimer risk are modified by age of use or by use during a critical window close to the time of menopause.”
Probably the most reasonable course of action is to continue to follow general medical guidelines to take the smallest dosage of estrogen for the shortest period of time to relieve menopausal symptoms. According to the most recent studies, that’s when it might do your brain the most good. Beyond the menopausal years, evidence suggests that it either has no effect or it has a negative one.
And, for our daughters’ sake if not our own, let’s continue to speak out about the importance of research in women’s as well as men’s health. We are not the same.
The symptoms you describe--moodiness, depression and anxiety, hot flashes, sleep interruptions, less sensitivity in nipples and clitoris--are all consistent with stopping the hormone therapy (HT). Sensitivity to the effects of hormones varies among women, and you’re definitely in the “responder” category!
You mention that you discontinued the HT because of concerns for long-term health. It’s important to consider the form of HT you’re using: The Combipatch that you were using is a transdermal estrogen (and progestin) delivery method, and that method has significantly less risk for stroke or thrombosis. If estrogen is taken orally, it is metabolized through the liver, which increases a blood clotting factor and puts women at a slightly greater risk for stroke and blood clots. Transdermal (through the skin) delivery doesn’t pose the same risk, because it bypasses the liver metabolism and enters the bloodstream directly.
You’re in your 50s, fit, and low risk: You’re a perfect person to consider continuation of HT for all the reasons you mention. It sounds like HT definitely improves your quality of life, which is to me a determinative factor. We don’t really have a clear time frame in which we know that HT starts to pose additional risk.
You've noted that in addition to vaginal dryness, you're now using drops for dry eyes, a treatment for dry mouth, and more hand lotion than ever before. Yes, dryness is generalized in menopause, because the estrogen receptors we have from head to toe (and especially in genital tissues) have far-reaching influence! As we lose estrogen, we lose moisture in all kinds of tissues.
Systemic estrogen is a possible solution; it can make remarkable improvement. Every woman is different, though, in the extent of the effect, so a three-month trial might be considered to see if there is a notable benefit.
Otherwise, it sounds like you're taking advantage of the topical solutions available to you—moisturizers for every body part! This is a good time of life to develop a good hydration habit, too, if you don't have one already.
You say a prescription for estrogen seemed to increase your libido at first, but that effect has diminished. No, you haven't become immune to estrogen. Unfortunately, libido is a bigger and more complicated issue than just one hormone. Many women don't find any improvement in libido with estrogen; I tell patients it certainly won't make it worse, and it may make it somewhat better. And it's not uncommon for the initial effect perceived from a new treatment to wane over time.
You also ask whether where you apply the estrogen cream makes a difference to its effect on your libido. The medical answer is that because its effect depends on its entering the blood stream, it can be applied to skin anywhere it is likely to be absorbed. If you have pain with intercourse or dryness because of menopause, applying the cream to genital tissues may help, but that's a different issue than libido.
Women's libido is complicated (several hormones and numerous neurotransmitters in the brain are involved, as well as emotional and psychological factors), and the treatment options for low libido are currently limited. We offer a number of suggestions on our website, but I also encourage women to talk frankly with a menopause care specialist.
You say you've completed five years of regular tamoxifen, and your doctor has suggested Vagifem 10 mcg to address symptoms of dryness and itchiness. Vagifem 10 mcg is a very, very tiny dose of bioidentical estrogen, delivered as a tablet to dissolve in the vagina. I have many, many breast cancer patients who use it or other "localized estrogen" or "vaginal estrogen" options. Like you, they've had significant issues without it; over the counter creams, lubricants, and moisturizers may have had some benefit, but over time they've not done enough.
From what we know, localized estrogen doesn't enter the blood stream and get disseminated throughout your system; it is absorbed only in the genital area where it's needed. I like Vagifem because the dose is very low and there appears to be consistent absorption. But it is still estrogen, and there is sometimes reluctance to add this to a woman's regimen, especially after breast cancer.
There is a new non-estrogen treatment option for this condition. Called Osphena, it is a SERM (Selective Estrogen Receptor Modulator), the same class of medication as tamoxifen. They both target tissue and affect estrogen activity: tamoxifen targets breasts to block; Osphena targets the vagina to activate. Osphena is oral, daily, and in my practice has been well tolerated and effective. While it's been on the market for two years or so, it has not specifically been trialed in breast cancer patients (and nor have other medications, a reality I hope will change—and soon). There's not yet data on safety for women like you, but other SERMs on the market are favorable for breast health, it makes sense to think this one may be, too.
We don't have all the answers yet, unfortunately! Ultimately, the decision comes down to quality of life for you, and I'm glad it sounds like you have a health care provider who is helping you consider your options.
Most topical or localized estrogen creams are prescribed to be used twice a week, which is the level at which they typically provide the most benefit with the fewest unintended consequences. If the usual application isn't helping you regain comfort, a conversation with your health care provider could be in order.
Localized estrogen is most effective for vaginal atrophy; if you have other "systemic" symptoms of menopause, like hot flashes or night sweats, systemic estrogen may be worth considering. Systemic estrogen also improves vaginal health, but because it enters the system (as opposed to "localized" estrogen), there are more overall health considerations for its use.
If we had a conversation about how you measure "more effective," I might suggest other, nonhormonal options that could be helpful to you. Moisturizers can improve tissue health, lubricants increase comfort and pleasure, warming products and vibrators enhance sensation, and massage oils encourage intimacy, for example. I encourage women to experiment with all of them!
You've noted that your clitoris appears to be smaller, which is a normal part of aging. With the absence of estrogen, it's estimated that a woman loses 80 percent of her genital volume—unless there is some intervention. The two most effective ways to minimize this diminishment are to remain sexually active (that "use it or lose it" thing I've talked about before) and to use localized estrogen. Both help to maintain the integrity of the genital tissues.
Our intent is not to "prevent" menopause, because it's a normal part of our lives. With my patients, my aim is to mitigate enough of the symptoms of menopause to be able to maintain the sexual intimacy that's an important part of life for many of us.
More often than you'd think, a patient who thought she was "done with sex" comes to me for help when she enters a new relationship. It's possible to reverse some of the atrophy that happens naturally with inactivity, but it's more difficult than maintaining sexual health along the way. If a woman is certain that she has no interest in being sexually active, there's no negative health effect of the genital atrophy—beyond the loss of the positive health benefits of sex.
Estrogen--and vaginal moisturizers--generally lower the pH level, making it a more healthy environment. The vagina is typically slightly acidic, like tomatoes or wine. The loss of estrogen with menopause can throw off our pH levels, reducing circulation and lubrication. Being able to generate enough moisture is part of what allows our vaginas to reregulate pH level after intercourse, when semen, which is more alkaline, is temporarily disruptive.
(To ask your own question of Dr. Barb, use the "Let's Talk" button top and center on our website.)