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!
You describe the top symptoms of menopause: interrupted sleep, heart palpitations, hot flashes, night sweats, memory loss, vaginal dryness, painful sex, and irritability. You note that this is affecting everyone around you--people you love--as well as yourself, which I hear described by many.
You say you’ve been researching hormone replacement therapy, and have found a lot of different opinions. For the combination of symptoms you describe, the most effective treatment option for you will be systemic hormone therapy (HT).
If you have one or two or even three of the symptoms, you can think about a sleep aid and an antianxiety/antidepressant for the irritability--and continue to address the symptoms one by one. But to address all of these, the answer is HT. A recently published book does a great job of reviewing HT; it’s called Estrogen Matters, by Avrum Bluming and Carol Tavris. Your personal health history may determine the specifics of HT selection: when was your last menstrual period, do you have a uterus, and so on.
The good news is that these symptoms won’t last forever (the vaginal dryness and painful intercourse will likely recur when you stop HT at some future time, but can be addressed with localized therapy).
You sound like the perfect candidate to trial HT. If it works fabulously, great! Use it and enjoy the benefits for a year, a decade, or four decades. If it isn’t that helpful, then you know and can look to other options. There’s always the options of just “toughing it out,” but I wouldn’t recommend that. Life is too short.
I remind women that you just had 40 years of an abundance of circulating hormones; do you think a couple of more years (or a decade) is harmful? No, it isn’t, and the evidence (best reviewed in Estrogen Matters) strongly suggests important health benefits--not to mention an improved quality of life, which is no small factor!
You say you’re considering removal of ovaries because of a BRCA2 gene mutation; you’ve already had prophylactic mastectomies. The good news is yes, a woman can still orgasm after removal of the ovaries. For a few women, the removal of the ovaries can impact sex by lowering libido and making it harder to arouse and orgasm, but the majority have no significant impact sexually. A woman’s age makes a difference as well: A 35-year-old will likely have a more notable loss of function than a 55-year-old.
And hormones can be added back. Even with the BRCA2 gene mutation present, there is no contraindication to using hormone therapy. Hormone therapy may include estrogen and/or testosterone to address sexual concerns. These are not always the complete answer for every woman’s sexual concern, but they can be very helpful for some. (Unfortunately testosterone is not FDA-approved for women, so its use is “off label” and not all providers are comfortable prescribing it.)
Removing ovaries seems like the clear right choice with your knowledge of having a BRCA2 mutation. Best wishes for your continued health!
I so appreciate your question, first because it tells a story that’s shared by many, many couples, and also because it shows how much you care. Your partner had a hysterectomy a few years ago, including the removal of both ovaries. She’s not using any hormone therapy. Intercourse is “dry” for both of you, and therefore uncomfortable. She describes a sensation like “being stuck by needles.” You both miss the intimacy you had earlier in your relationship, and you believe your partner is experiencing some depression.
You’re feeling like there aren’t treatment options, because you’ve heard about side effects and risk of cancer. And yet, you want to “be there for her” and to make love again.
Let me start by saying that your understanding of effective treatment options as causing harm is misguided. A great resource for dispelling some myths and informing yourselves about treatment options is Estrogen Matters: Why Taking Hormones in Menopause Improves Women's Well-Being, Lengthens their Lives--and Doesn't Raise the Risk of Breast Cancer. You can get a preview of the content by listening to this interview I did with the authors for our podcast.
Your partner is experiencing painful intercourse as a result of progressive genitourinary syndrome of menopause (previously called vaginal atrophy), and there are safe and effective (and even non-hormonal) prescription options. Some of the terms you use to describe her pain suggest she may also have vulvodynia. Unfortunately, once things get to the point you describe, over-the-counter, non-prescription options (like moisturizers and lubricants) aren’t really therapeutic. Those are best used early in the process for prevention.
When I say this is “progressive,” I mean it will naturally, if untreated, get worse. Of course it’s not realistic to expect her to be interested in sex when it causes pain, and we recommend she not have sex if it is causing pain. Having painful sex will in turn cause additional problems involving pelvic floor muscles (vaginismus), another condition contributing to pain.
I explain to women this is a “fork in the road”: You move forward without intercourse as part of your intimate relationship, or you seek treatment to regain/retain comfort, and then continue treatment as long as you want intercourse to be a part of your relationship.
You’ll be best served--and I believe you’ll both be happy--if you confront this situation and have an honest conversation about mutual desires and needs (and your message to me was a good starting point!). There is little pleasure for you knowing that intercourse is causing pain for her. Use this website, if you like, to talk about how things change for women and the available treatments; you can start by sharing this page, and then navigate to related topics.
If restoring sexual health to the relationship is to include intercourse, I’d recommend that your partner see a certified menopause care provider (I often suggest the North American Menopause Society’s “find a provider” link) who can help her to understand her condition, based on a careful examination, and then the treatment options.Good luck! I know from my own research and practice with patients that there are safe and effective treatment options and we can almost always restore comfort and pleasure.
You say you continue to have incontinence after doing both Kegel exercises and physical therapy. There isn’t any evidence to date that the Mona Lisa (laser) will be effective treatment for urinary incontinence. There are some very preliminary, small-scale studies suggesting radio-frequency devices (like ThermiVa and Viveve) may be effective treatments for mild to moderate stress incontinence, but this is still investigative: None of these is approved for this indication in the U.S. at this time.
I would recommend a urology consultation to consider surgery.
You say you’re good with libido and continue to be sexually active. You’ve been on bioidentical hormone replacement therapy (BHRT), but notice that orgasm doesn’t happen with intercourse any more--although you still experience orgasm with vibrator use. You’re wondering if there are blood pressure (BP) medications you should avoid.
Any blood pressure medication has the potential to interfere with arousal and orgasm, as does hypertension and any other cardiovascular disease. The ability to arouse and orgasm is a complex process, and any nerve or vascular impairment may make it harder.
Unfortunately, simply aging adds to some of that risk. Our blood supply to all tissues declines with age, including genital tissues. Most women have never been able to have an orgasm with intercourse, and, for those who have, that ability tends to disappear over time, too, as you experienced.
Using a warming lubricant can help by increasing blood supply to the genitals. A nutritional supplement, Stronvivo, has clinical trial data to support improved blood supply to the genitals, which improves sexual function.
I’m not sure which hormones are in your BHRT formulation. If testosterone is not included, it could be of benefit, although it is not FDA-approved for this use. You’ll need to be followed carefully while you’re on it to minimize risks.
Good luck! I’m happy to hear that you’re still invested in your sexual health.
I’m happy to have friends and colleagues who keep up on the news on my behalf. I can’t count the number of them who texted or emailed me a link to the story that unfolded at the Consumer Electronics Show (CES), which is truly not something I normally pay attention to.
If you missed the story, I’ll try for a short objective summary: A tech company was notified they’d won an innovation award, and then, before the show opened, the company was informed that the award was being rescinded and they were blocked from exhibiting at the show. Crazy, huh? It’s one kind of crazy all by itself; it’s another kind of crazy when you consider that the product was, essentially, a vibrator with some cool new technology. (Here’s the open letter the company’s CEO published after the award was rescinded; here’s a different kind of explanation from Wired magazine.)
I wish I could ignore this controversy. But the reality is that I run into cultural barriers nearly every day in my practice, preconceived notions and prejudices that make women reluctant or entirely resistant to taking simple steps that could improve their sexual health. My correspondence with women across the country through this website tells me that cultural barriers get in the way of frank discussions between patients and their doctors about sexual health and sexual satisfaction.
I watch “Grace & Frankie” and I imagine that we’re turning a corner in willingness to talk about women over 50 as full humans. Then I read about the CES controversy, and I feel a need to restate the obvious, from my medical perspective:
I’d really prefer to be practicing medicine, rather than musing about cultural dynamics. But I can’t help but think that for most Viagra users, the drug is really about pleasure, not about procreation—and yet there has seemed to be ready adoption of the concept. We don’t call Viagra a “recreational drug,” and many insurance companies don’t balk at covering the cost.
Women can be helped by a simple device, one not requiring a prescription and with no adverse side effects. Approaching and beyond menopause, we lose some sensation, which can make an orgasm more elusive. All it takes is some additional stimulation—which a vibrator provides without taxing our (or our partners’) dexterity or endurance. For us, a vibrator isn’t a “sex toy,” however playful we might be with it. It’s like a hearing aid (“audio toy”), a cane (“mobility toy”), or reading glasses (“vision toy”)—devices that help us mitigate the effects of growing older.
We’re not where we need to be. And we won’t make progress—in making options available to women and assuring they’re comfortable pursuing them—if we don’t acknowledge that’s true. Did you read the Wired article? I was struck by the reminder that the full shape of the clitoris wasn’t mapped until 1998. We can’t take for granted that women matter, that women’s sexual health matters, and that women’s pleasure matters, too.
Join me. Speak up. We can make this part of life different for ourselves, our sisters, and especially our daughters.
You say MiddlesexMD has been a valuable resource to you, and you’ve begun to use dilators and lubricants. I’m thankful to hear MiddlesexMD has been helpful to you, and happy to coach you through this next step! We’ve talked about vibrators quite a lot; you can be assured you’re not the only person considering that option! Here are some quick references:
Don’t be intimidated! Read all that’s helpful, stop when you want to, and know that your own experimentation is most important. I recommend you select a vibrator that can be inserted into your vagina. That will provide some of the important benefits to maintaining vaginal health, stimulating circulation, which is good for healthy tissue. You can also use that style externally, directly on the clitoris, as well; that’s where most women need the stimulation to achieve orgasm (and, as you mention, orgasm helps with pelvic floor muscle tone). These are the vibrators we call “mid-size” on our website. I don’t think you’ll have issues with insertion of any of those if you’ve been able to use dilators as you’ve described.
Enjoy! And I’m so glad you’re taking charge of your sexual health--finding your own resources for learning about your body and acting on what you learn.
When you think “selfcare,” you think about eating right, getting regular exercise, and making sleep a priority. But our podcast guests have also offered lesser known tips and techniques. From them, we’ve learned that selfcare can mean...
Just breathing (right). Amy Eller explained how “combat breath”—breathing in through your nose for a count of four, holding it for four, releasing it on four, and remaining empty for four—battles shallow breathing and eases anxiety. The beauty of it is, she says, that you can do it anywhere. Another tip from Amy: practice gratitude.
Getting in touch with your creative side. Women excel at thinking of others first. But, as Kate Bolt realized when she started her Living Lark blog, “It’s okay for us to do fun things! And it’s helpful to everyone else when we’re happy.” Remembering what brings you joy and then finding a way to do it—even a small way—will remind you that you are more than a partner or a parent. As I said in that conversation, it’s okay to be happy!
Advocating for yourself when it comes to your healthcare. No one can do it as well as you can. Marta Gray Hill says, “Make a list and be your own champion when you go see your doctor. Ask questions. And it’s okay to fire your doctor. . .I think people see the white jackets and think: well, they know everything, and they’re all powerful. But they’re not. And if you don’t believe them or you don’t like them, if they don’t make you feel comfortable in that environment talking about your personal health issues, find someone else.” I agree!
Discarding the idea that there are “rules.” Wear whatever hairstyle you want, whatever clothes you want. “Forget what people are saying about your age, it’s your vibrancy, not your number,” says Charla Miller. And, she adds, if there’s something you’ve been wanting to do, do it. She did, once riding a mechanical bull. She called the joy that experience brought her “the best skin care I could have done.”
Giving yourself some grace—which is easier to do once you understand yourself. For that, our friend Valerie Atkin suggested learning about the Enneagram, which she says is “a system that engenders compassion for ourselves and for others. Once we are able to identify what our core type or style is, we can begin to amplify the positive aspects of that style and also begin to address some of the limitations of that style.” The Enneagram can also help you understand and extend grace to your partner.
Reinventing yourself. “Even if you’ve been at your job for 25 years, and you love it and they love you, you need a reinvention idea in your back pocket,” says Lesley Jane Seymour. “Because reinvention may be forced upon you. When that company is absorbed, or goes out of business. . . [When something like that happens] You can either decide you’re going to run away and you’re not going to deal with where we are today, or you’re going to face it head-on and tackle it; and you need to look at other people who are doing that.” (She knows from experience.)
Do you have any selfcare tips? Please share them!
You ask whether estrogen that is “sent through your body” (systemic) causes increased risk of cancer and heart disease, and also whether topical application (localized) estrogen helps with brain fog.
This is an important topic, and complex, as well. There is a newly published book, Estrogen Matters, Why Taking Hormones in Menopause Can Improve Women’s Well-Being and Lengthen Their Lives—Without Raising the Risk of Breast Cancer by Avrum Bluming MD and Carol Tavris PhD that I think you should read. The synopsis is does neither: It doesn’t increase the risk of cardiovascular disease—in fact, it likely protects—, and it doesn’t increase the risk of breast cancer.
Localized/vaginal estrogen doesn’t provide any cognitive benefit (or bone or heart benefits, either); it is providing benefits to the vagina only. The products available for localized estrogen are all very similar in their risks (nearly none) and benefits (they all work very well), so I think the best option for each woman is dependent on cost, convenience, and consistent use. Select based on what you think is best for you.
And really, I do encourage you to read the book! It may give you additional factors to consider when evaluating systemic hormone therapy.