Gavin Guard: A Guide on Hormone Replacement Therapy for Menopause

Intro

Technically, menopause is characterized by the cessation of regular periods. But it’s much more than that. 

It’s also accompanied by awful hot flashes, depression, lethargy, bloating, joint pain, insomnia, and brain fog. Some women even report a “midlife crisis” as they enter into their menopausal years.

More sinister health consequences can also result from menopause. This includes osteoporosis, Alzheimer’s, and cardiovascular disease.

The average age is 51 years old- some women earlier, and others later. However, 95% of women become menopausal between the ages of 45 to 55 years old. 

On average, this menopausal transition and associated symptoms last for 7 years. But again, this can vary- some women less and unfortunately, some women more. 

In this article, I will walk you through what you can do about your menopausal transition to make it a seamless transition that is relatively free of symptoms.

I will also present evidence of the pros and cons of hormone replacement therapy so you can make an educated decision about what to do.

A woman’s guide to understanding her hormones

It shocks me how few women understand their hormones. And to be honest, I didn’t really care too much about understanding it either. That was all until I got married and had two girls. I also had a few women in my life enter menopause and start experiencing insomnia and hot flashes. All of a sudden, my interest peaked and I started my deep dive into this topic.  

There are 4 major hormones a woman needs to know about:

1. Estrogen
2. Progesterone
3. Follicular stimulating hormone (FSH)
4. Luteinizing hormone (LH)

The first two are produced mainly by the ovaries during the reproductive years. That all changes during menopause when the adrenal glands (the “hat-shaped” organs that sit on top of the kidneys) become mainly responsible for producing them. The last two are produced by the brain and coordinate the rhythm and flow of estrogen and progesterone production. 

Without going into too much detail, estrogen levels peak right around ovulation (day 14 of a 28 day cycle). Progesterone then peaks around day 21. Both estrogen and progesterone then fall in the last week of a menstrual cycle- This is what causes monthly bleeding. This rapid fall in progesterone is also what may be causing PMS symptoms many women experience.

This all becomes less rhythmic as a woman enters menopause. Instead of a rise and fall of estrogen and progesterone, levels of these hormones become more stagnant. Not only that, but overall levels reduce dramatically. 

This rapid plummet of estrogen (and progesterone) is what can lead to hot flashes, bone loss (osteoporosis), cardiovascular disease, and potentially dementia as well. 

What is hormone replacement therapy (HRT)?

Hormone replacement therapy (HRT) is just that- replacing the hormones that fall as a result of menopause. Specifically, it is where a woman takes estrogen and progesterone in a pill, patch, or gel form.  

We will talk more about the best forms of HRT a little later.  

Who should take HRT?

So who should take HRT? Admittedly, this is a contentious topic for reasons explained later. 

In my perspective, HRT is a good option for a woman who is experiencing symptoms of menopause (e.g. hot flashes, insomnia, brain fog) or detrimental health effects of menopause (e.g. osteoporosis). 

HRT is best started within 10 years of menopause. However, this should be a personalized decision made with your doctor as some women may have a net benefit even if started outside this time frame. 

There are some reasons for pause in regard to starting HRT. Such reasons are:

• Active liver disease
• Unexplained vaginal bleeding
• Endometrial cancer
• History of clot
• History of heart attack

Again, these are not absolute contraindications to start HRT and a decision is best made in conjunction with a knowledgeable doctor.  

Evaluating the risks of HRT 

Before I talk about the multitude of benefits of HRT, I want to give a nod to the potential risks of HRT. With any medication, you will inevitably go on Google only to find that this medication has 1,000 side effects, one of which is death. I’d like to prepare you for what you may find online and discuss how accurate these claims truly are. 

The reported risks of HRT include:

• Possible increased risk of stroke
• Gallstones
• Increased risk of clots
• Increased breast cancer

To me, the largest risk that holds up to the research is that of clots. This is mostly a concern in women with other risk factors such as prior cardiovascular disease, smoking, and inflammation. So if a woman comes to me who is very overweight, has had a past blood clot, smokes, and drinks a lot, I think it would be best to address these risk factors before putting her on HRT. In this case, there is a net negative of taking HRT.

Regarding the stroke risk, there is a relatively low absolute risk increase in those >60 years old. To be exact, 0.15 out of 100 women will experience a stroke who are on HRT as compared to 0.13 out of 100 women not on HRT. This is a very small increase. 

The biggest controversy out there is that of HRT and breast cancer. Let’s discuss that next.

Does estrogen cause breast cancer?

Back in the early 2000’s, major news headlines wrote “Estrogen Kills” and “Estrogen Causes Breast Cancer”. Why did news organizations write this and is it even true?

This warning came out of a result of a major study. The Women’s Health Initiative (WHI) was the largest and most expensive study ever performed in the United States. However, there were many problems with this study:

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