A decade after women tossed out their hormone pills in disgust and prescriptions for drugs like Premarin and Prempro plummeted, the management of menopause and its related symptoms has become much more personal, with highly individualized treatment plans and more nuanced assessments of risks and benefits.
Dr. JoAnn Manson, of Brigham and Women’s Hospital and Harvard Medical School, was a principal investigator at the Boston site of the pivotal Women’s Health Initiative hormone trials, and says the initial results and subsequent analyses triggered a radical transformation of clinical care that “really changed women’s lives.”
“The WHI is an historic trial that has changed clinical practice and, ultimately, has helped lead us towards a more rational interpretation of the place of hormone therapy in menopause management,” Manson writes in a new editorial commemorating the 10th anniversary of the WHI trial report, published in the journal Menopause with co-author Lubna Pal, of Yale University School of Medicine.
This “more rational” approach to menopause management involves a much closer look at a woman’s personal medical history and specific risk factors, an in-depth discussion with a well-informed clinician on the risks and benefits of drugs and an honest assessment of how bad the symptoms are (whether hot flashes, or night sweats, sleeplessness or sex issues) and what the individual woman is willing to risk in order to alleviate those symptoms.
Manson offered the top takeaways for women currently facing menopause and wondering how to handle it:
1. If You Are Suffering
Hormone therapy continues to have a clinical role in the short-term treatment of hot flashes and night sweats, notes Manson. “If women have symptoms that are interfering with sleep or undermining quality of life, they should talk to a health care provider to see if they’re appropriate candidates for hormone therapy.”
2. Don’t Take What You Don’t Need
Women should not take hormones if they’re asymptomatic, she says. “You don’t go around taking thyroid medication if you don’t need it,” Manson said. “So don’t take hormones with no indication — no medication is free of risk.”
3. Complex Decisions
The decision over whether or not to take hormones is complex, and involves weighing many factors, including, the amount of time since the onset of menopause, personal risk factors for heart disease and breast cancer and other health information. All of these elements play a role in figuring out the benefit-risk equation. Some risks are more clear than others, for instance, hormone therapy increases the risk of blood clots in the legs and lungs, pulmonary embolism and stroke, Manson says. In the end some women will simply not be good candidates for hormone therapy. But to figure it all out, it’s critical to have these discussions with a clinician familiar with the latest, ever-shifting data, Manson says.
6. Lifestyle Matters
Some lifestyle modifications may help decrease symptoms, including avoiding hot beverages, like coffee, and spicy foods, as well as losing weight if you’re overweight or obese, turning down the thermostat and getting used to wearing layers. Of course, quitting smoking is also highly recommended. Other types of drugs, like antidepressants, may also be effective, Manson said.
7. Evolution Happens
As far as the evolving science goes, Manson says: “I’ve learned that you need to keep an open mind, don’t try to prove your prior hypothesis. This is a polarizing topic, people tend to dig in their heels on one side or the other — either hormone therapy is good for all women or it’s bad for all women. It’s important to remain objective and remain open-minded and let the evidence determine the interpretation. Don’t bring your own biases to it. There is not a one-size-fits-all answer and these oversimplifications end up being really harmful.”
8. Figure Out Your Priorities
People have different priorities, Manson said. “For some women it’s really important to get a good night’s sleep and be at the top of their game at the board meeting. Others are highly risk-averse.” These priorities can lead to different decisions on whether to take the drugs or not.
I asked Manson whether she ever took hormones.
She said: “I haven’t taken these drugs. I have a history of a certain type of cancer, so I can’t take [the hormones]. I’ve thought about, ‘Would I?’ I probably would have struggled with the decision for a while…I’ve only gone through menopause fairly recently, and my symptoms weren’t to the point where I would have needed it.”
For those who didn’t closely follow the hormone replacement saga, here’s a bit of the the backstory, from Manson’s editorial and the Brigham & Women’s news release:
The WHI hormone trials were designed to assess the role of hormone therapy in the prevention of heart disease, as well as to evaluate the benefits and risks of hormone therapy when used for chronic disease prevention. The trials were done in postmenopausal women ages 50-79 (with a mean age of 63) and tested the types of HT (Premarin and Prempro) that were in common use at the time the study started. The estrogen plus progestin trial was stopped three years early because of an increased risk of breast cancer, heart disease, and concerns that the overall risks exceeded the benefits. The estrogen-alone trial (in women with hysterectomy) showed fewer risks but was stopped one year early due to an increased risk of stroke. Estrogen-alone did not appear to increase risk of heart disease or breast cancer. In fact, estrogen-alone seemed to lower the risk of heart disease in younger women (in the 50-59 year age group) and seemed to have a favorable benefit-risk profile in that age group. However, the harmful findings in the older women in both hormone trials tended to be extrapolated to younger women, resulting in dramatic (>70%) reductions in prescriptions for hormone therapy.
Manson, one of the principal investigators of the WHI since the start of the study and current president of the North American Menopause Society, said, “The WHI deserves credit for stopping the growing clinical practice of prescribing hormone therapy to older women who were at very high risk of heart disease. In fact, these women did not receive heart benefit from estrogen therapy and may even have suffered harm. Unfortunately, the findings in older women were extrapolated to newly menopausal healthy women who tended to have a favorable benefit to risk ratio with HT.”
At least 70% of newly menopausal women have hot flashes and/or night sweats, and about 20% have moderate-to-severe symptoms that disrupt sleep and impair quality of life. Over the past 10 years, research from the WHI and other studies has provided a critical mass of evidence for the timing hypothesis, which suggests that younger women closer to the onset of menopause tend to have better outcomes on hormone therapy than older women who are distant from menopause onset. The younger women are also more likely to have hot flashes and other menopausal symptoms, and thereby derive quality of life benefits. Manson said, “The recent findings highlight the importance of individualized care for women. The ‘one size fits all’ approach to decision making is no longer acceptable.” Manson adds that it will also be important to understand whether different types and formulations of hormone therapy (such as patches, pills or lower doses of hormones) will have a different balance of benefits and risks.
If you’re still confused, consider exploring this new, interactive Menopause Map, which may help clarify some of the options.