6 questions to ask about hormone therapy for menopause : NPR

Women should not suffer from hot flashes, night sweats and poor sleep during menopause. This is the message from the FDA Commissioner. Dr. Marty Macari.

The agency announced it would remove “black box” warning labels from estrogen-based hormone therapy that treats menopausal symptoms, saying the warnings make women afraid to try the therapy and doctors reluctant to prescribe it.

Warnings began in the early 2000s when data from Women's Health Initiative Study found that hormone therapy increases the risk of heart attacks, strokes, blood clots and breast cancer.

But the women in that study were given a hormone therapy drug that is no longer used. And the average age of the women in the study was 63 years old, which is now considered too late to start hormone therapy.

Experts now say much more is known about safe and effective combinations when therapy is started earlier.

“If you are under 60 or within ten years of the onset of menopause when you start hormone therapy, you will notice improvements in hot flashes, sweating, and fewer sleep disturbances,” says Dr. Joanne Pinkertonmenopause expert at the University of Virginia Health Sciences.

It also indicates protection against bone loss and fractures, as well as potential benefits for heart health, brain fog and overall quality of life.

“With the right dosage, hormone therapy can be done safely and have many benefits,” she says.

But here's an important reality check: “Not all women can take hormone therapy,” Pinkerton says. She says some women have medical conditions or symptoms that may make hormone therapy risky.

“It's important for women to talk to an informed health care provider because you want to know what the benefits and risks are for you,” Pinkerton says.

So, here are some things to consider when talking to your doctor about hormone therapy for menopause.

1. When should you start hormone therapy?

Experts recommend starting estrogen therapy before age 60 or within ten years of the onset of menopause, which begins one year after the last menstrual period. Many women continue to take birth control during perimenopause, which can help with hot flashes and night sweats due to fluctuating hormones.

When you're going through the menopause transition and don't need pregnancy prevention, using birth control doesn't make much sense because it's usually stronger than the amount of estrogen used in menopausal hormone therapy, Pinkerton says, so now is the time to talk to your doctor about hormone therapy options.

2. How long should you take hormone therapy?

Typically, women continue to receive hormone therapy for three to five years, but this is not a strict rule.

“For women who have persistent symptoms or bone loss that can be treated with hormone therapy, we will continue it,” Pinkerton says. But it is important to continue the assessment every year. “It's about working with the patient to figure out what's safest and best,” Pinkerton says.

“We don't fire anyone. [hormone therapy] just because three to five years have passed,” says Lauren Streicher of Northwestern University. She points to differences in how long menopausal symptoms persist, noting that black and Hispanic women tend to experience symptoms last longer periods of time.

3. How has hormone therapy changed?

Science has has developed over the past 20 yearssince the results of the Women's Health Initiative came out. And, importantly, there have been changes in the way estrogen is administered, as well as new forms of hormones. For example, many women are now prescribed patches instead of pills.

“We know that oral therapy may slightly increase the risk of blood clots and stroke,” Pinkerton says, which is why doctors often choose transdermal therapy for women at risk for these conditions. Transdermal patches, gels, or rings deliver estrogen that is absorbed directly through the skin, which research shows may reduce risk blood clots

Additionally, women in the WHI study were given a synthetic progestin, which has been associated with an increased risk of breast cancer. But now doctors can prescribe micronized progesterone it has fewer side effects. Micronized progesterone bioidentical hormone with a molecular structure identical to estrogen produced in the ovaries.

4. Do all estrogen medications carry the same risks?

No. Topical estrogens, such as low-dose vaginal creams, work to improve symptoms such as vaginal dryness, painful sex, bladder control, and reduce the risk of urinary tract infections. This is different from systemic estrogen delivered as tablets, patches or gels. Systemic estrogen is a higher-dose treatment that circulates throughout the body to treat symptoms, including hot flashes and night sweats, and may carry a higher risk of side effects.

“I think most would agree that there are few risks with topical vaginal low-dose estrogen therapy,” says Dr. Monica ChristmasDirector of the Menopause Program at the University of Chicago. “For topical vaginal estrogen, it is reasonable to remove the black box warning. I don't think we need to scare people unnecessarily,” Christmas says.

However, for higher doses of systemic estrogen therapy that is absorbed into the bloodstream, including estrogen pills, Christmas and other menopause experts are more ambivalent about eliminating the black box warning.

“It gives pause,” says Christmas, and encourages patients to discuss risks with their providers.”

5. Who should avoid hormone therapy?

Some women have medical conditions that may make hormone therapy riskier. This includes women with estrogen-sensitive breast or uterine cancer, and women at high risk of or who have had a heart attack, stroke, thromboembolism, or pulmonary embolism.

“It's important for women to talk to an informed health care provider because you want to know what the benefits and risks are for you,” Pinkerton says.

6. Is there an alternative for women who do not want to take hormone therapy?

The Food and Drug Administration has approved two non-hormonal drugs to treat severe hot flashes during menopause. According to the FDA, about 80% of menopausal women experience hot flashes, which may include sweating, hot flashes and chills this lasts several minutes.

Connectionwhich was approved last month, and Veosaapproved in 2023, are oral medications that act targeting neural activity what causes hot flashes during menopause. Linkuet has been shown to reduce the severity and frequency of hot flashes.

National Institutes of Health tips for eliminating symptoms, including limiting alcohol and caffeine and maintaining a healthy body weight. And early research suggests that hypnotherapy and mindfulness meditation may help manage hot flashes.

Some people find herbal remedies help. Study of medicinal plants including sage, lemon balm, red clover and licorice, finds that they may be effective in treating menopausal symptoms such as hot flashes.