Early-onset menopause
According to observational studies,18 early menopause is associated with a higher risk of osteoporosis, coronary heart disease, cognitive changes, vaginal dryness, loss of libido, and mood changes. Studies have shown that women with early menopause who take HT, without contraindications, to the average age of menopause (age 52) decrease the health risks of early menopause (bone loss, heart disease, mood, and cognition changes).13,14,18
Women with early menopause, whether spontaneous or following bilateral oophorectomy or cancer treatment, should be counseled to get adequate calcium (dietary recommended over supplementation) and vitamin D intake, eat a healthy diet, and exercise regularly. Evaluation should include risk for bone loss, heart disease, mood changes, and vaginal changes.
Extended use of HT
Up to 8% of women have hot flashes for 20 years or more after menopause.19 The decision to continue or to stop HT is not always clear for women:
- with persistent hot flashes after a trial period of HT discontinuation
- with bone loss that cannot be treated with bone-specific medications
- who request continuation for quality of life.
Extended use of HT should include an ongoing assessment of its risks and benefits, periodic trials off of HT, and documentation of rationale and informed discussions about continuing. Lower doses and transdermal therapies appear safer, as does micronized progesterone instead of more potent synthetic progestins.13-17
Genitourinary syndrome of menopause
Once women are further into menopause, they may notice vaginal dryness, vulvar itching or burning, bothersome vaginal discharge, or urinary urgency or frequency. The development of painful intercourse frequently occurs, a combination of the loss of estrogen with thinning of the vaginal mucosa, a loss of the acidic vaginal milieu with less elasticity, and spasm of the levator muscles. Some women develop urinary tract infections after intercourse or have more frequent reoccurrences. First-line therapy is often vaginal moisturizers and lubricants. Vaginal therapies (estradiol, conjugated estrogen, or dehydroepiandrosterone) or oral selective estrogen-receptor modulators (SERMs; ospemifene) improve vaginal dryness and dyspareunia.13,14 Pelvic therapy has also proved valuable for incontinence, pelvic floor dysfunction, and levator spasms.20
Where are there gaps in clinician knowledge?
Studies on emotional health, mood, and sleep need to incorporate measures of menstrual timing into data collection and analyses. Does the sleep disruption occurring premenstrually during perimenopause disproportionately contribute to a woman’s vulnerability to depressive disorders? The risk of clinically significant depressive symptoms increases 1.5- to 2.9-fold in the menopause transition.5 Research into premenstrual dysphoria during the menopause transition may identify different trajectories in the timing of symptoms related to either cycle itself or the ovarian hormone fluctuations or both.21 Gamma-aminobutyric acid (GABA)-modulating drugs, such as sepranolone, which blocks allopregnanolone’s actions at the GABAA receptor, may allow treatment of menstrual-related mood disorders without the need for hormonal interventions.21
Despite extended observational trial data, more data are needed to inform us about the long-term risks and benefits of using menopausal HT, particularly when initiated at menopause and to help address the timing of HT discontinuation. Furthermore, there are many unanswered questions. For instance:
- How much safer are lower dose and transdermal therapies?
- Do untreated hot flashes increase the risk of cardiovascular disease or dementia?
- Will newer non-HT options, such as the neurokinin receptor antagonists that are in testing but are not yet available, lower cardiovascular or dementia risks?
- What will be the risks and benefits for the newer estrogen in testing (estetrol, or E4), considered a natural estrogen and which appears to have lower thrombotic risks?
- What will be the role of intravaginal energy-based therapies, such as vaginal laser or radiofrequency devices?
- How do we address diverse populations and the effects of menopause on race, gender, culture, prior trauma, and socioeconomic status?
Lack of recognition of menopausal symptoms, particularly in the workplace
Clinicians need to understand the varied physical and emotional symptoms that may occur with hormonal changes as women traverse perimenopause and early menopause. We need to recognize that the lack of discussion about women’s health during this time may make women feel ashamed and fearful of bringing up their symptoms due to fear of being dismissed or stigmatized.22 Women may not seek help until a crisis at home or work occurs, as they may fear that admitting symptoms or a need for help or time away from work will threaten how they are viewed at work or affect their chances of promotion. Although there are economic costs around menopause for appointments, tests, therapies, and missed time at work, not addressing menopausal health leads to poorer performance, workplace absences, and additional medical costs.22
Conclusion
Menopause occurs naturally as a part of a woman’s life cycle. However, women need assistance navigating perimenopausal hormonal fluctuations and decisions about HT once in menopause. Increased awareness and education about perimenopause and menopause will allow compassionate, individualized, informed care, including lifestyle changes, behavioral or complementary strategies, or medical therapies, hormonal or nonhormonal.27 As a medical society, we need to challenge the stigma associated with aging and menopause and educate ourselves and our patients to help women navigate this challenging time. ●
Demystifying 4 myths of menopause by providing accurate information
Myth 1: All hot flashes are the same
The truth: Seventy-five percent of women will have hot flashes, but only 25% are severe enough to cause women to seek treatment. Duration varies with identified patterns, including starting early or late, being mild or starting early, and going late. Ethnicity affects the duration of hot flashes, with longer durations seen in Black and Hispanic women. About 15% of women have had hot flashes for more than 15 or 20 years.1,2
Myth 2: There is no help for hot flashes
The truth: For some women, lifestyle changes are helpful, such as dressing in layers, turning down the thermostat at night, avoiding hot beverages or alcohol, or using technology (Femtech) for cooling devices. Over-the-counter products that are available, but are not clearly proven to help more than placebo, include soy (which may be estrogenic), black cohosh supplements, and nutritional supplements. Cognitive behavioral therapy, hypnosis, weight loss, or mindfulness may help.3 Nonhormone medications such as low-dose antidepressants or gabapentin have shown benefit. Newer treatments in testing, including neurokinin receptor antagonists, appear to work quickly and as effectively as HT. When initiating HT, healthy women with bothersome hot flashes under age 60 or within 10 years of menopause are the best candidates for HT; many lower doses and oral and non-oral therapies are available.
Myth 3: Compounded bioidentical hormones made by a compounding pharmacy are safer and more effective than FDA-approved ones
The truth: Compounded bioidentical hormones are touted as safer or more effective, but there is no good evidence to back up those claims. Whether US Food and Drug Administration (FDA)-approved or compounded, hormones come from the same precursors and have potential risks. With custom compounded HT, there is additional concern about precisely what is in the compounded product, whether levels are similar batch to batch, and the degree of absorption of progesterone, which is better absorbed oral.4-6 FDA-approved bioidentical HTs have been tested for safety, proven to contain consistent, effective levels of hormones, and are monitored by the FDA. For menopausal symptoms, FDA-approved therapies are available as estradiol (oral, patch, spray, gel, lotion, and vaginal ring) and progesterone (as an oral compound or combined with estradiol). Pellets made of compounded hormones have shown higher serum levels and more adverse events.5,7
Myth 4: Menopause causes weight gain
The truth is that fluctuating and declining hormones and the slowing of metabolism affect weight. Weight gain is not inevitable, just harder to prevent. Many women gain an average of 5 lb (2.27 kg) at midlife, which is mainly related to aging and lifestyle and not to menopause or HT. However, menopause may be related to body composition and fat distribution changes. Counsel women to decrease portion sizes, limit carbs, and increase exercise intensity, including strength training. The goal is 30 minutes of moderate aerobic activity per day, all at once or through smaller time increments, to improve their energy, mood, and sleep.
References
1. The NAMS 2017 HT Position Statement Advisory Panel. The 2017 HT position statement of The North American Menopause Society. Menopause. 2017;24:728-753.
2. Pinkerton JV. HT for postmenopausal women. N Engl J Med. 2020;382:446-455.
3. Paramsothy P. Duration of the menopausal transition is longer in women with young age at onset: the multiethnic Study of Women’s Health Across the Nation. Menopause. 2017;24:142-149.
4. Kingsberg SA, Schaffir J, Faught BM, et al. Female sexual health: barriers to optimal outcomes and a roadmap for improved patient-clinician communications. J Womens Health (Larchmt). 2019;28:432-443.
5. Eisenlohr-Moul TA, Kaiser G, Weise C, et al. Are there temporal subtypes of premenstrual dysphoric disorder? Using group-based trajectory modeling to identify individual differences in symptom change. Psychol Med. 2020;50:964-972.
6. Seibel M, Seibel S. Working through Menopause: The Impact on Women, Businesses and the Bottom Line. Bookbaby. March 8, 2022.
7. Kingsberg SA, Schaffir J, Faught BM, et al. Female sexual health: barriers to optimal outcomes and a roadmap for improved patient-clinician communications. J Womens Health (Larchmt). 2019;28:432-443.