Q: Are there non-synthetic hormone replacement options?

You asked. Dr. Barb answered.There are plenty of bioidentical pharmaceutical hormone options to treat menopausal symptoms. Over 90 percent of my hormone therapy patients use these, and most physicians who treat menopause are familiar with the options. There are brand name and generic products available; to list some of them: Estrace, Vivelle, Minivelle, transdermal estradiol, Prometrium, micronized progesterone.

You also mention weight gain. I hope you know you’re not alone! We had a series on this topic this summer that may be of interest to you: an overview of the reality, how you can respond with diet alterations, and how exercise can play a part.

If you need a provider who focuses on menopausal treatments you can find one on the NAMS website (North American Menopause Society) at this link. Enter your zip code and a list of nearby providers will be listed.

Good luck!

Q: Will vitamins be effective for hot flashes and other symptoms?

You mention joint pain, weight gain, and food cravings in addition to hot flashes as symptoms of menopause. Menopause has such a variety of symptoms, depending on each individual. Lifestyle matters more; exercise is more important; adequate sleep and good nutrition—all of these have a greater impact to quality of life now than they did previously.

I wish I could tell you there is good data suggesting vitamins have a favorable impact on menopausal symptoms, but the trials looking at the specific supplements you mention and others suggest no benefit greater than placebo. But, hey, placebo has about a 30-percent response rate in any trial, so there is certainly no harm in using them. They provide some general vitamins that will not be harmful, and may help if you aren’t getting them in your diet.

The symptoms you mention could all potentially benefit from hormone therapy (HT). The loss of estrogen is huge for most women, and the loss of progesterone to some extent as well. For many women the only way to address symptoms adequately is to consider HT. More and more data suggests that HT is beneficial for women specifically with weight gain; that was a lead article in one of my journals just this week.

It’s a complicated journey that is nuanced, and each woman needs to assess her own symptoms and goals and determine the best approach to managing through menopause. It’s difficult to address all of the treatment options in a single Q&A. You might find the North American Menopause Society (NAMS) website helpful: menopause.org. They cover many issues related to menopause.

Good luck!

 

Q: What’s causing my yeast infections?

You say you’re using a vaginal estrogen cream, and using Kegel weights with an aloe vera gel. You’ve had two yeast infections since you started using both.

You asked. Dr. Barb answered.If you are fairly new to using estrogen vaginal cream, it may be the cream that is causing the vaginal yeast infections. The estrogen cream lowers your vaginal pH (and a lower pH is a healthier status; here’s a summary of healthy pH levels) over the first 8-12 weeks of use. The transition from the higher pH (atrophic) to the lower pH puts women at risk for yeast infections. This should not persist, and in the end the estrogen cream is likely to be beneficial to you.

Using the kegel balls shouldn’t cause a yeast infection, but if you’re prone to yeast infections, a pH-balanced lubricant like Yes WB may help prevent them. pH matters!

 

 

Q: What’s with this period after three years of HT?

You say you’ve had a period and some breast tenderness after three years of hormone therapy (HT). I hope you’ll make an appointment with your health care provider: Any bleeding that occurs postmenopausally (after 12 months with no bleeding) is considered “abnormal uterine bleeding” and it really deserves evaluation. This is true whether or not you’re on HT.

The evaluation is usually an endometrial biopsy, a quite simple office procedure. Women on hormone therapy are at very low risk of developing uterine cancer, but we still want to make sure the proper evaluation takes place. Usually the biopsy is completely benign or normal, and we aren’t able to explain why it happened.

You asked. Dr. Barb answered.When the bleeding is accompanied by other associated symptoms, like breast soreness, it is tempting to attribute it to a “last hurrah” or one last period, but that is unlikely. Any missed doses of the HT or changes in dosing can occasionally contribute to some breakthrough bleeding. The most likely scenario is that the hormone therapy contributed to the symptoms of the breast soreness and the bleeding, but without any changes it’s hard to explain why that might have happened now, three years after menopause.

Again, evaluation usually confirms that all is normal, but it’s worth making the effort to be sure!

 

 

Raging Hormones? Ways to Deal

In the last couple of posts we talked about the significant subset of women who suffer from debilitating emotional swings during the menopausal transition—and also about their loved ones who suffer right along with them.

It’s a Catch-22. You truly can’t control the hormonal storm that lashes you with sudden waves of uncontrollable rage, sadness, irritation, anxiety, and depression. Yet, you really can’t unleash these emotions on the people closest to you. People whom you love and have no wish to harm.

If you are caught in that cycle, there is work to be done, stat, to stabilize your emotions and allow you to get through this transition without further disruption to your life or hurt to your closest relationships.

I’m going to lay out your options, but you also need to have a conversation with your doctor, who will assess your risk factors and monitor your response to treatment.

Before you consider medications, you must lay a foundation of good health habits, if you haven’t already. I’ve mentioned this, oh, maybe a thousand times before, but that’s because it’s so important. Good health hygiene is even more critical now because some of those bad habits could be messing with your mood.

Exercise regularly. Just 30 minutes of moderate daily exercise improves circulation, relieves stress, improves sleep, makes your heart stronger, and more to the point, improves mood by releasing endorphins, which gives you a little euphoric lift.

Bad habits could be messing with your mood.You also have to eat moderately and healthfully. That means cutting down on sugar and caffeine, which causes mood and energy to peak and crash. In Great Britain, fish and veggie-eating folks had fewer depressive episodes than their junk-food-eating colleagues. In Spain, those who filled up on nasty trans-fats from pastries and fast food were 48 percent more likely to be depressed than those who ate good fat, such as olive oil. (And these folks weren’t even menopausal!) Magnesium is also linked to mood and sleep, so a magnesium supplement might be in order.

At the risk of being an absolute killjoy, you also have to stop smoking and cut back on alcohol, both of which affect mood. Alcohol, of course, is a depressant. I’m not talking about a glass of wine with dinner, but about regular and/or heavy drinking.

A further brick in that health foundation is to develop a strategy for relieving stress—meditation, yoga, mindfulness practice, or another religious practice that is meaningful to you. These are known to relieve stress, stabilize mood, relieve pain, including psychic pain, and generally make life more hopeful.

I am not for a minute saying that an honest self-improvement plan will be easy or immediate—in fact, it’s a lifelong endeavor. I’m also not saying that good health alone will adequately address your menopausal mood swings. But I can assure you that getting in shape, eating well, and implementing a spiritual practice will absolutely help, both now and later.  


Now let’s address the medical options. Your healthcare provider will need to work with you to find the best treatment. So it’s time for a heart-to-heart with your doctor. Ask her about:

  • This is a journey, with turbulence and change.Hormone Therapy (HT). We've learned a lot about HT over the last decade. For many women, it's hormone fluctuations that lead to disruptive symptoms. Using hormones systemically to counter that can be a good choice for some women. Reviewing your health status and risks can help determine whether you're a good candidate for HT. It’s even possible that going on a birth control pill for the hormonal effect might bring relief.
  • Mood medications. This approach, using anti-anxiety, sleep aid, or antidepressant medications, works on your brain rather than your hormones, and many women find them effective during this menopausal transition. Antidepressants work because the brain has many estrogen receptors, and when you lack estrogen, the feel-good neurochemical, serotonin, tends to break down. So, the class of antidepressant that may give you relief is called a selective serotonin reuptake inhibitor (SSRI), such as Prozac, Zoloft, or Celexa. Antidepressants can dampen libido, which is the last thing you need right now, so work closely with your healthcare provider to find the right medication and the right dosage. And addressing lack of sleep or an excess of anxiety can break the cycle just enough for some breathing room for taking control in other ways.

Medication isn’t a substitute for those common-sense efforts to improve your overall quality of life, but they can help you get through this bad patch.

This is a long journey, ladies, accompanied by a lot of turbulence and change. Life will be different—and very likely better—on the other side.

Traveling mercies.

 

 

Still Seeking Options

We’ve been following the development of Flibanserin, also called “pink Viagra,” since 2010, when its developer shelved it after hitting a bump in the road to FDA approval. Several years later, we were talking about alternatives, Librido and Lybridos, which were moving forward with clinical trials (and have not yet been approved).

We’ve just learned that the manufacturer that now owns Flibanserin has filed an appeal of the FDA denial, saying that other drugs have been approved with less data and more extreme side effects. And that’s reignited discussion about whether pharmaceutical products targeting women’s sexual disorders are evaluated on a level—or relevant—playing field.

Flibanserin, Librido, and Lybridos (and a small handful of others) are all drugs designed to play a part in awakening libido for women. They counter hypoactive sexual desire disorder (HSDD), in physicians’ terminology (the rest of us call it “not tonight—or tomorrow night, either” syndrome). There are, for context, a couple of dozen FDA-approved drugs for the comparable problem among men, including Viagra.

I don’t have the insider information I’d need to assert a double standard, although people I know and respect—like my colleague Sheryl Kingsberg—suggest there is one. Women’s health psychologist at University Hospitals MacDonald Women’s Hospital, Sheryl said, “There’s a double standard of approving drugs with a high risk for men versus a minimal risk for women.” The side effects for Flibanserin, for example, were reported as dizziness and nausea; Sheryl compares those to side effects of penile pain, penile hematoma, and penile fracture—all from a drug that was approved.

That does sound like some extra protectiveness of women. Given my focus on sexual health for women, I run into a lot of cultural expectations and hesitations; we Americans are still just a bit prudish when it comes to, especially, older women having sex. That’s in spite of what I see in my practice every day: Women themselves want to live whole lives, which means being physically active, emotionally engaged, and sexually active within their relationships.

I recognize that sexuality for women is complex, and there won’t be a “magic bullet.” For women, arousal and desire is a mix of emotional intimacy, biological responses, and psychological responses; a drug won’t address all of the components. But because I’m often working with patients to untangle interlocking causes of problems with sex, I’m eager for as many tools as possible, including pharmaceuticals.

As a physician, I also see the need to evaluate trade-offs and risks. I’ve talked before about the pros and cons of hormone therapy. For some women, living longer doesn’t really count if they’re not able to be active—including being actively sexual. “Pink Viagra” drugs may well require the same kind of close collaboration between women and their doctors to evaluate risks and benefits. Again, Sheryl: “Give women a chance to decide for themselves, within reason. There is no drug out there that has no risk.” In the case of Flibanserin, only 8 percent of testers said the side effects were bad enough to make them want to drop the drug.

These decisions by the FDA are also important because pharmaceutical research is done by businesses, businesses that can decide that one problem or another is too expensive or too complicated to take on. Sheryl sees this, too, saying, “My worry is that research in this area will dry up and will leave many women without a pharmacological option.”

One way to make your voice heard about the importance of continued research is by signing the International Society for the Study of Women’s Sexual Health (ISSWSH) WISH petition. Our sexual health is integral to our overall health, and we need more investigation and even-handed, common-sense consideration of therapies for women.

Q: Is there a trade-off between hot flash relief and libido?

You're wondering whether your hormone therapy, designed to address your hot flashes, is having an unintended negative effect on your libido. The good news is that adding estrogen is better for sex, in general terms. So you don't have to take back your hot flashes to get your libido back!

The less good news is that libido is sometimes a puzzle to solve. I've found that non-oral estrogen addresses hot flashes with fewer unintended effects on sexual desire. The reason is that oral estrogen enters our systems in ways that affect metabolization in the liver and resulting circulating testosterone levels. And testosterone, though not entirely understood, is as important to women's sexuality as it is to men's!

You might start by changing to non-oral or transdermal estrogen; it will likely take up to 12 weeks to see whether there's an effect. And if that doesn't make enough difference, there are other options you can explore with your health care provider.

Bioidentical Hormones Revisited

Recently, I was browsing through an online discussion board about the pros and cons of hormone replacement therapy. I ran across this comment from a participant: “I’m going to try bioidentical hormones like Suzanne Somers. I’ve heard they’re safer.”

Whoa! I thought. Let’s do some objective homework first, and weigh the risks before you jump in.

Celebrity endorsements notwithstanding, bioidentical hormone replacement therapy (bHRT) is neither the miracle cure nor fountain of youth touted by Ms. Somers. Nor is it some kind of snake oil concocted by salacious quacks or unscrupulous doctors and pharmacists.

The truth is, of course, much more nuanced.

As a physician, I’d always opt for more treatment choices when it comes to helping women with the unpleasantries of menopause. I want more drugs in the arsenal, more ways to treat hot flashes, sleeplessness, and loss of libido. However, the entire topic of bioidentical hormones is so laden with emotion and misinformation that it takes a very fine point to tease fact from hyperbole.

We laid the groundwork on bioidenticals before, but the issue continues to befuddle and mislead, so let’s circle back and fill in some gaps.

Any hormone therapy, whether bioidentical or synthetic, is only intended to ease menopausal symptoms. Hormones were never meant to keep your memory sharp or your hair shiny or your skin taut. Hormones are not a fountain of youth. The latest medical guidelines state that hormones should be taken at the lowest possible dose for the shortest period of time needed to ease symptoms. This is because hormones, whether bioidentical or synthetic, are drugs and they interact with other systems in the body, sometimes in ways that are not well understood.

Point #1. Menopause isn’t a disease; it’s a natural transition. Hormone therapy is intended neither to keep your hormones “in harmony” nor to keep menopause at bay indefinitely. Hormone therapy is intended to ease the symptoms of the menopausal transition when they are interfering with your life.

Next, bioidenticals aren’t necessarily “natural” and therefore “safer.” The marketing message that hooks women is that bioidentical hormones are derived from “natural” sources and are therefore safer than hormones from other sources.

Bioidenticals are estrogens that are indeed made from plant sources, but they are processed (synthesized, if you will) to create a hormone that can be absorbed by humans. “All plant-derived hormone preparations, whether they come from a compounding pharmacy or a large commercial pharmacy, require a chemical process to synthesize the final product,” writes Dr. Oz in this article.

With bioidenticals, however, you end up with a molecule that is exactly like (identical to) human hormones, whereas non-bioidentical hormones are similar but not identical.

Any hormone, whether those your body produces or those you ingest, affects your body. Also, the delivery method, whether a patch, pill, or vaginal cream, also affects the way your body absorbs and responds to the hormone.

Point #2: Don’t equate “bio” with something “natural” and therefore risk free. Taking any hormone involves some risk. (Decisions about hormone therapy need to be based on careful consideration for each individual—understanding both the potential risks and benefits for that woman.) Bioidentical hormones are so-called because the molecule is identical to the human hormone and because they are derived from plant sources, even though they must be synthesized to be useful.

“So ‘natural’ doesn’t necessarily equal ‘safe’—and may simply be a euphemism for ‘unregulated,’” according to this article in the Harvard Women’s Health Watch.

You can, we should note, get bioidentical hormones that are FDA approved and regulated. Many familiar brands of hormonal rings, creams, patches, pills, and gels are both commercially manufactured by pharmaceutical companies and bioidentical. These include Estrace, Femring, Vivelle, Vagifem, and Prometrium, and more. You know what you’re getting with these products.

You know that the active ingredient is in the form and dosage that the label says it is. That kind of uniformity and “safety” is the assurance provided by FDA testing and approval.

Point #3: Many major brands of commercially manufactured hormones are both bioidentical and FDA approved.

Next, let’s understand what “custom-compounding” means. Many bioidenticals are touted as natural, safe, and custom-made just for you to bring your hormones back in balance. Custom-compounded drugs are made in small, customized batches by pharmacies that specialize in custom-compounding. They can be prescribed by a clinician.

Custom-compounding is very helpful when a patient needs a special dosage of a medication, or a different delivery method, or is allergic to a filler in a commercial drug. Maybe, for example, you need a lower dose of progesterone than is commercially available, or you need it in a vaginal cream, and the big pharmas only make it for administering orally.

However, neither the process nor the product is FDA-regulated or approved, and in fact, studies have shown that they are much less consistent than commercial products. In a few highly publicized cases, contaminated medications distributed by custom-compounders have been responsible for serious illness, infection, and death. An example is the outbreak of fungal meningitis in the fall of 2012.

The problem with custom-compounded hormones arises with claims of customized products that are safe, natural, and that will restore hormonal balance, among other things.

In actuality, it’s not possible to accurately pinpoint hormonal levels in an individual because they are constantly changing. The hypothalamus, pituitary and ovaries (the HPO axis, as we call it) work in a very integrated and precise way to direct hormone production. Our replacements aren’t able to replicate that concert of events, but we can do a good job of replacing the hormones more consistently, which many women prefer to the ‘ups and downs’ we’re familiar with. The only way to determine an effective dose is through symptom control—the lowest dose that relieves a woman’s symptoms. “Salivary and blood testing of hormone levels used by custom compounders is meaningless for midlife women as their hormone levels vary throughout the day, and from day to day” is the North American Menopause Society position.

“This doesn’t mean that you shouldn’t consider compounded hormones. Just realize that, in a real sense, you’re going to be an experiment of one,” says the Harvard Medical Watch article.

Also realize that custom-compounded drugs usually aren’t covered by insurance, and the regimen of testing and compounding gets expensive very quickly.

Point #4. Custom-compounding of drugs is a time-honored practice of making drugs in small batches or according to specific needs (while the processes and products aren’t subject to federal regulation or oversight). Claims that these products are healthier, safer, or somehow contain properties lacking in commercial products should be viewed with suspicion.

Q: Is weight gain associated with hormone therapy?

I assume that your hormone therapy is oral or transdermal and systemic. There isn't evidence that says hormone therapy contributes to weight gain. In fact, some of the research suggests that it can be helpful in maintaining a healthy weight.

Based on my experience, I believe hormone therapy is weight neutral—although if it makes you feel better and sleep better, it can be very helpful to an overall healthy lifestyle, which includes exercise and a good diet.

Q: Can low-dose hormone therapy affect libido?

Overall, estrogen is helpful to libido and sexual desire. Oral (systemic) estrogen can have the unintended effect of decreasing testosterone, which is linked to libido in women as well as men. The reason is complicated, but has to do with liver metabolism and a binding protein that reduces circulating testosterone.

The approach I take with patients is to use non-oral, transdermal (systemic) estrogen, which bypasses the liver and therefore doesn't affect testosterone levels. I've had patients who couldn't experience orgasm on oral estrogen but could with non-oral estrogen.

And for some women, I do consider adding testosterone. There isn't a product for women, so I use a very low level of male testosterone "off-label" and then monitor blood levels during use. Sometimes, as an alternative, Wellbutrin (buproprion), an anti-depressant, helps restore libido by affecting the neurotransmitter dopamine.

I'm afraid we women are complicated! There are, though, a number of options to experiment with until you've achieved the sex life that makes you happy.