In the 1970s, my friends and I learned everything we needed to know about menstruation from each other and from a popular Judy Blume book, “Are You There God? It’s Me, Margaret.” We even had a club, and we met after school to share stories about breasts, boys, periods and Kotex. We would no more have asked our mothers for such information than we would have asked a boy to dance.
In those days, it was simply not done.
Now that I am menopausal, at the far end of reproductive health, I find my friends and myself completely unprepared for the changes of menopause, for what these hormonal changes mean or how to deal with the worst of the symptoms, from hot flashes to painful sex. Our mothers didn’t tell us much about that, either. The extent of my knowledge about menopause was based on what I knew about hormone therapy (HT), which I thought had been roundly dismissed as dangerous and potentially deadly.
In fact, those early results from the National Institutes of Health’s Women’s Health Initiative — particularly a study that led to a huge drop in hormone prescriptions for menopause — have been revised. And while exercise and herbal therapies help some women, for many of those who face debilitating symptoms, hormone therapy now looks like the best option.
The more current analyses of the Women’s Health Initiative data, along with other recent studies, indicate that for women in their 50s, just entering menopause, HT is a relatively safe treatment that can be used for up to five years and is not associated with an increased risk of heart disease (although women should still be screened and treated for risk factors, such as high blood pressure and breast cancer).
Menopause is a slow process, with a transitional phase, perimenopause, that can last more than five years. Most women begin to experience these symptoms in their late 40s, reaching menopause at an average age of 51. A blood test that measures the level of follicle-stimulating hormone (FSH) can indicate whether a woman is in menopause.
Once a woman has experienced 12 months without a period, she is classified as being in menopause and for the remainder of her life is described as post-menopausal.
Preoccupied with my large family, I didn’t pay attention when my periods had all but stopped, and I didn’t notice any unusual symptoms. At one point, my gynecologist ordered blood work to test hormone levels. The results indicated that I was in menopause. But because my symptoms were not especially troubling, she offered no additional information, no road map for what lay ahead.
Over the ensuing year, I continued to ignore what was happening to my body. My weight, always a challenge, ballooned by 25 pounds. My hips spread and my waist vanished. My mood was often low, but I blamed that on other health problems. My energy evaporated. My old refuge, sleep, disappeared, replaced by insomnia and nights in which I would sleep for three hours, or four.
And then the hot flashes began. At first, just a few times a day, I would feel heat rising through my face and head, then spreading to my entire body. I would be suffused by it and would fan my face or look around to see if others had noticed the local climate change.
Within a few months, the hot flashes were occurring several times a day, and I would sweat in unlikely places: my knees and shins, my elbows. At night, my fitful sleep would end when a drenching sweat would wake me, leaving me soaked and shivering.
The last straw came during a meeting for work. In the midst of a conversation with senior leaders, a hot flash erupted, and sweat streamed from my brow.
I went to see my internist, a quick young woman early in her medical career, about hormone therapy. She suggested that I wait until other health complaints were resolved instead. She suggested black cohosh, an herbal remedy some women credit with ending hot flashes.
My doctor’s response reflects a widespread problem among new doctors: They are not taught to manage menopausal women’s symptoms. Richard J. Santen, president of the Endocrine Society, says that following the 2002 findings from the Women’s Health Initiative, which indicated that hormone therapy was harming women, prescriptions for it fell by 80 percent worldwide. At the same time, he says, medical training programs began to overlook training new doctors how to care for menopausal women.
The combination of these two factors, Santen says, creates a significant problem for women like me — that is, millions of baby boomers — whose doctors don’t quite know how to help us cope with symptoms that can, at times, be debilitating.
“For the average woman just going through menopause, the benefits of hormone therapy outweigh its risks,” Santen says. “This is true for women who are not at risk for breast cancer or who are not at risk for stroke or heart disease.”
While all women need to consider risks, those who have these additional risk factors should work even more closely with their doctors to weigh risks and benefits of treatment.
An unintended consequence of the early reports from the Women’s Health Initiative, Santen says, is that “young doctors have no experience taking care of menopausal women, and don’t even try to. When WHI came out, with the reports that women receiving HT had a 30 percent increase of breast cancer, heart disease and stroke, doctors changed their practice fast. But the good news from the study was not disseminated as broadly or as quickly. Nor was the news that the study was talking about women whose average age was 63.”
The age issue turned out to be important. Before 2002, women were given hormone therapy not only to treat menopausal symptoms but also to reduce the risk of heart disease. The 2002 study found that the drug actually increased the risk of coronary heart disease, but the reanalysis showed that this applied more to the older women in the study and was statistically insignificant for the younger ones.
Santen says low doses of estrogen (and, for women with a uterus, progesterone) can do much to relieve menopausal symptoms and improve quality of life. He advises that hormone therapy be considered for women who are younger than 60; for them, the benefits of treatment may outweigh its risks. In my case, with hot flashes that were leaving me drenched from head to toe around the clock, I needed to do something. Disrupted sleep was taking a toll, too — and I was younger than 60.
There is no rule for how long such treatment should continue, although Santen says he uses it for five years and then reevaluates each patient. According to the Endocrine Society, women who start hormone therapy shortly after the beginning of menopause and who use it for five years experience no increased risk of heart disease and a 90 percent reduction of menopausal symptoms.
Carol Kuhle of the Women’s Health Clinic at the Mayo Clinic of Rochester, Minn., says that studies published in the last few years support hormone therapy. She cites the Kronos Early Estrogen Prevention Study, which found that the treatment is safe and effective for women experiencing “natural menopause” (unlike surgical menopause, the consequence of a hysterectomy).
“In general, we treat with the lowest effective dose for the shortest time frame,” Kuhle says. She notes that women have several treatment options to consider, including whether to take estrogen as a pill or as a patch. The benefit of the latter, Kuhle explains, is that the estrogen is not metabolized through the liver, which can increase the risk for blood clots in the legs. The patch can also lower triglycerides, making it a safer option for women with high blood pressure.
Kuhle recommends that women who are experiencing common menopausal symptoms, such as hot flashes, try non-drug approaches.
“It can help to find out what triggers them for you: caffeine, alcohol, too little exercise, too much stress. Managing these can help to manage the hot flashes,” she says. She adds that recent studies have found that certain antidepressants and the anti-seizure drug gabapentin can relieve hot flashes for some women.
I asked Lori Sweitzer, my Annapolis gynecologist, about alternative treatments. “Some women want to try over-the-counter approaches, which is okay,” she said. “But others will find that is just not enough, and they really cannot function at the ability they want to, or they can’t manage their daily routine. For women who have really severe hot flashes or such poor sleep that they cannot function, treatments are important.”
She adds that for women experiencing vaginal dryness and painful intercourse, prescription creams and pills inserted in the vagina can provide relief.
Alice Chang, a Mayo Clinic endocrinologist, said that women whose quality of life is compromised by menopausal symptoms should start by talking to their gynecologists.
“For someone who has been debilitated by symptoms, you need to find a doctor who will really talk to you and listen to your concerns. The doctor should assess your risk factors and understand the benefits and risks you face. Right now, people just don’t know enough about the data, and it is easier for doctors not to prescribe at all,” Chang says.
Reversing this trend is likely to require research on hormone therapy, better training for doctors who see menopausal women regularly and improved patient understanding. Santen says that professional societies are beginning to push for new standards and requirements. The North American Menopause Society has guidelines for managing hormone therapy in women younger than 60 and is in the process of issuing a syllabus for physician training. The Endocrine Society released a scientific statement on menopausal hormone treatment, detailing the science as well as the data that capture the risks and benefits of treatment.
Staness Jonekos, co-author of “The Menopause Makeover: The Ultimate Guide to Taking Control of Your Health and Beauty During Menopause,” says, “Getting informed is the first step. Then, surround yourself with supportive people, and build a good relationship with your health-care provider.”
All of this is surely better than what Gay Hanby’s sister resorted to. As a journalist in the days when newsrooms kept film in the fridge, Hanby’s sister would rush to put her head in the freezer during a hot flash. That is an immediate but impractical cure — though it carries few side effects, to be sure.
Lynch Schuster is a freelance journalist who lives in Maryland.