Whenever we mention HRT—that’s hormone replacement therapy—on our Instagram, we’re instantly flooded with questions. Who’s this treatment for? What are the risks? Can they help us beat those hot flashes!? We rounded up your Qs and went straight to Dr. Sherry Ross, women’s sexual health expert and author of she-ology and the she-quel. Let’s just say she has a LOT to say on the matter, and we’re so grateful for her experience and knowledge. Read on for the questions we got most—and Dr. Sherry’s take. (And if you think HRT might be for you, talk to your doctor for more information.)
Why should I consider taking HRT? What are the benefits?
Women who have disruptive and unmanageable menopausal symptoms including hot flashes, night sweats, sleep problems vaginal dryness, burning, and pain with or without sex, frequent bladder infections, brain fog, depression, fatigue, and loss of libido are potential candidates for hormone replacement therapy (HRT). HRT, especially for women at risk for osteoporosis, has also been shown to prevent bone loss and bone fractures. The main benefits of HRT are reversing the disruptive symptoms of menopause and reducing the risk of bone loss.
HRT is a safe and effective treatment for common menopausal symptoms especially if a woman is under 60 years and doesn’t have any medical problems that prevent her from taking them.
Taking the lowest dose of estrogen and progesterone (if you have a uterus) can be taken safely as long as you have discussed the risks and benefits with a health care provider who is comfortable and up to date on managing and prescribing HRT.
Menopausal symptoms that are specific to the vagina and bladder such as vaginal dryness, burning, painful sex, and recurrent urinary tract infections can take vaginal estrogen without having to take oral or transdermal hormone replacement therapy. Using vaginal estrogen does not increase a woman’s risk of breast or any other female-related cancer and literally has no risks.
You only want to take HRT to prevent disruptive symptoms of menopause as opposed to using it to prevent chronic medical conditions including heart disease and diabetes.
Quality of life is everything. Menopause and its disruptive symptoms can be manageable. The benefits of hormone replacement therapy often outweigh the risks when it comes to your quality of life.
What are the different types of HRT?
Treating the symptoms of menopause is individualized and often based on your philosophies for the various treatment options. Working with your healthcare provider on optimal dosing will vary and allowing your body 3 to 6 months making necessary adjustments is normal and should be expected.
Thanks to your BFF, social media, celebrity testimonials and Dr. Google, there are many myths and misinformation when it comes to HRT. The experts agree that for women younger than 60 and within 10 years of being in menopause, the benefits of HRT outweigh the risk.
Estrogen can be prescribed orally or transdermal, either as a patch, gel, cream or spray and progesterone is given orally, if a woman has a uterus. You can take HRT continuously or daily where a woman will not get a period or you can take them “cyclically” where you will get a period. There is not a health benefit, more of a woman’s preference of getting a period or not, in the way she takes HRT. If you don’t have a uterus, you would take estrogen daily by itself. Estrogen and progesterone that Western doctors prescribe are FDA approved and have been properly tested in reliable medical studies, proving their safety and efficacy. (The FDA is an independent and trusted group that regulates medication prescribed by medical doctors for patient safety.)
Compounding bioidentical estrogen and progesterone hormones. Compounded bioidentical HRT—creams, drops and pellets—have not been tested in clinical trials in the same manner as hormone replacement therapy and are not FDA approved. They are marketed as being “more natural, safer and better” for your body but there are no medical studies to support these claims. It’s true that they are made from plant products such as soy and yams, but they still need chemical processing to become active in the body. In truth, many estrogen pills, patches, gels, creams and sprays are also bioidentical, so just because hormones are termed bioidentical, it doesn’t mean that they are more natural or safer to use.
When should I start taking HRT? Do I need it during perimenopause? Can I start taking it again if I have stopped?
Everyone has a different journey when it comes to starting, stopping and taking HRT all together. Depending on how disruptive and unmanageable peri-menopause or menopausal symptoms become will determine when you start taking HRT. Perimenopause refers to those years in the reproductive life cycle where the ovarian function becomes irregular. It occurs up to 10 years before menopause with the average of being 51 years. Estrogen production from the ovaries is erratic and unpredictable causing menopausal symptoms. The same disruptive symptoms occur during peri-menopause and hormone replacement therapy can ease these symptoms even before menopausal begins. Some women will start a low dose birth control pill or HRT to improve their quality of life as they cross over into menopause. Starting and stopping is common, acceptable and completely safe depending on your needs and preferences.
Here’s something to keep in mind: menopause is the next chapter of a woman’s life, not a phase that you go in and out of like puberty. Many women believe that once the obvious and most common symptoms of menopause lessen—such as hot flashes, sweating, insomnia, depression, anxiety, apprehension, weight gain or loss, fatigue, poor concentration, memory loss, heart palpitations, exacerbation of migraines and vaginal dryness—menopause is done. Not so, rather, it may be just the beginning of your new “normal.” Yes, many of these symptoms do improve over time, but knowing that doesn’t help when you’re at the height of discomfort. All of these symptoms can disrupt the quality of life, but they can be lessened and, in some cases, eliminated with simple medication, lifestyle modifications and HRT—albeit oral, transdermal and vaginal.
What are the cancer risks associated with HRT? How does my family history play into the decision about taking HRT?
HRT dose and duration should be individualized and personal risk factors should be evaluated and discussed with your healthcare provider before starting any medication.
Those women with increased risk of venous thromboembolism/blood clots, stroke, ischemic heart disease and breast cancer may not be a candidate for HRT. Women with a strong family history of breast cancer involving a first degree relative—mother or sister, especially if they carry the BRCA gene—may not be candidates for HRT.
Women who have uteri must take progesterone with estrogen so they are not at increased risk of endometrial cancer.
There may be a gradual increased risk of breast cancer for women using estrogen and progesterone for prolonged periods of time. The risk is seen after taking HRT for more than 5 and 10 years under the age of 60. The longer the use of combination HRT the higher the risk. The risk is small and getting yearly mammograms is recommended. Quality of life may be worth this small increased risk of breast cancer. I recommend women who “need” their HRT to get up in the morning and function throughout the day, to find other ways through lifestyle changes to decrease their breast cancer risk. Once women stop HRT, the risk of breast cancers decreases.
Women taking estrogen alone do not have a higher risk of breast cancer.
There is no increased risk of ovarian, colon, lung or skin cancer for women using HRT.
What type of doctor should I talk to if I am considering HRT?
Recommendations and guidelines surrounding HRT in menopause are very confusing, not only for patients, but also for healthcare providers. Finding a healthcare physician who is updated on current guidelines by the North American Menopause Society (NAMS) and well trained in caring and treating women experiencing hormonal changes caused by peri-menopause and menopause is so important. I cannot emphasize this enough. Gynecologists, endocrinologists, family and primary care doctors are all medical doctors that can be considered, depending on where you live and how easy access you have to healthcare. Telemedicine and virtual consultations are an easy, cost-friendly and helpful way to now manage disruptive peri-menopause and menopause while sitting at your home computer. Women should do their research, ask others going through the same hormonal challenges, read YELP and other independent reviews on the doctors and patients experiences.
One reputable telemedicine site to get easy and well-priced consultations on menopause is https://gennev.com/plans.
If I can’t take HRT, what are alternative treatments? How about natural remedies?
A healthy lifestyle goes a long way at any time in your life, but especially in this later chapter of life. Inactivity, unhealthy diet (fast food!), smoking, obesity, excessive alcohol consumption...if you’re still waiting to remedy any of it, now is the time! All of these factors only make menopause worse than it needs to be. These are simple lifestyle adjustments you can start making today.
- A diet focused on fresh fruits, vegetables, whole grains and fish, with limited alcohol intake and little red meat (similar to the Mediterranean diet) not only benefits your heart, it improves cognitive function. The Mediterranean diet is associated with the highest life expectancy and lowest heart disease rate and is proven to help menopausal symptoms. Absolutely no downside with the Mediterranean diet.
- Ditch the fast food, fast! The saturated fats and excessive sodium in fast food gives you no “value” whatsoever, in fact, depression is more common in those who eat fast food regularly. Within weeks of removing this food, you will show a decrease in cholesterol levels and even a decrease in weight gain.
- Removing or decreasing “sweets” in your diet will not only limit your calorie intake; it will often reduce your intake of fat. A reduction of sugary foods will immediately reduce blood sugar, which will help in decreasing the bloating and water retention so common in menopausal women.
- Avoiding hot and alcoholic beverages and avoiding hot and spicy foods also helps prevents mild to moderate symptoms of menopause.
- Exercise. Regular exercise improves metabolism, breathing, energy and emotional stability. Exercise makes you feel more confident and helps ease the stress of menopausal symptoms. It strengthens your heart and improves your sleep patterns. Exercise abstinence not only puts you at risk for heart disease, high blood pressure and other chronic health problems, it leads to weight gain, obesity, fatigue, insomnia and depression, all of which worsen the transition into menopause. Exercising as little as 30 minutes, three days a week can show immediate health benefits. I’ve become obsessed with my Fitbit because I can be very sedentary some days. Keeping track of your steps, aiming for 7,500-10,000 a day, will make you more accountable and successful in monitoring your daily activity.
- Smoking. Just stop, if not for the fact that smoking increases the risk of heart disease, stroke, lung cancer and death, but because it makes hot flashes more frequent and severe during menopause. A recent study showed women who stopped smoking at least five years before menopause had a significant decrease in the severity and frequency of hot flashes.
- Limit alcohol consumption. Alcohol increases your risk of heart disease, liver disease, high blood pressure, diabetes, colorectal and breast cancer, and, now we know (drum roll please), worsens hot flashes—and, by the way, one five-ounce glass of wine is equivalent to 1½ ounces of hard liquor, which may surprise and depress many of you. It’s recommended that you consume no more than three to four servings of alcohol a week. Removing alcohol, even one or two drinks a few times a week, has immediate effects on blood sugar levels, water retention, blood pressure, weight loss, energy level, emotional stability, sleep changes and pulse rate.
- Sleep. It’s necessary and hard to come by in menopause. Getting at least seven hours a night is ideal.
- Acupuncture and relaxation techniques including mindfulness, biofeedback, hypnosis, cognitive behavior therapy, yoga and Tai Chi may be helpful in controlling mood swings, depression, anxiety, hot flashes and other mild symptoms of menopause.
There are many safe alternatives and supplements to use to treat common symptoms of menopause. You may be surprised to know that there are many scientific studies showing certain herbs to be helpful in managing the symptoms of menopause. Passionflower extract, L-Theanine, Chasteberry, Royal Jelly, Ashwagandha, Chromium, Fenugreek, Ginkgo Biloba Leaf Extract, Maca Root and CoQ10 are some of the better researched herbs shown to combat symptoms and improve your life. Although herbs are not FDA approved like pharmaceutical medications, well-regulated supplements can be as effective as, if not safer than, prescription medication.
Plus, a personal note from Dr. Sherry
As a women’s health educator, I am constantly talking to women and hearing new medical concerns and stories occurring due to aging and hormonal changes. As I transition into menopause, I have personally witnessed the bodily changes, both physically and emotionally, that occur with the lack of estrogen. It’s transformative and I am on a mission to improve the quality of life for all women of all ages. Aging should be embraced by women.
I am here to empower women to have courageous conversations about their bodies with their healthcare provider…because quality of life matters!