Hi Beautiful Friends,
This post comes courtesy of a request from a friend who just turned 45. She is having trouble staying asleep through the night and libido is hit or miss. She wants to know how she should approach her next doctor’s appointment so that:
she isn’t dismissed
she is offered individualized, effective, and safe solutions to relieve symptoms
she experiences informed choice, in other words, she and her provider are in a collaborative partnership in the process of making decisions about her body
First, I am not a doctor and I’m not ever providing medical advice. Period.
Second, if your practitioner isn’t NAMS-certified, or isn’t someone who has specifically made it a point to pursue menopause education, you are likely seeing a provider who is basing their clinical recommendations on the WHI. More on that here:
Third, you can find a NAMS-certified practitioner by going to the NAMS website and searching by zip code. The fact is there are not many, especially compared to the number of women in need, and not all NAMS practitioners are covered by insurance. Also, many of us patients are loathe to embark on yet another new relationship with a stranger (unless we’re newly single and it’s a hot date).
The approach I offer below is based on these assumptions:
you are healthy
you are younger than 60 or within 10 years of menopause (contraindications vary from individual to individual so if you are outside this window it doesn’t always mean you can’t take hormones)
you are having symptoms that you want to alleviate
you want to get the care you need with your current provider
In general, middle-aged women would do well to take stock of overall health. Diagnostic tests for metabolism, liver, heart, thyroid health, and deficiencies can all be done through fasted blood work, which I’ll write about soon when I post about medicine 3.0 (preventive medicine) ala Dr. Peter Attia, longevity doctor and author of New York Times bestseller, Outlive. He also recommends several preventive screenings such as the DEXA scan for body composition and bone health, a CT scan or CT angiogram for heart health, a colonoscopy, regular pap smears and mammograms.
None of the above testing is required for hormone therapy.
However, if you have a history of clots or you have already developed some heart disease, taking estrogen may pose more of a risk, especially by oral route. Oral estrogen passes through the liver first so if you have any liver issues, you may want to choose transdermal. Dr. Corinne Menn, in a recent reel on Instagram, eloquently explains why the current favoured MHT (menopausal hormone therapy) prescription is transdermal estradiol and micronized oral progesterone, including an explanation about the biomolecular differences compared to what was used in the WHI. Dr. Mary Claire Haver and Dr. Corinne Menn discuss a hot-off-the-presses article, A Contemporary View of Menopausal Hormone Therapy, which just came out in the March issue of the Journal of the American College of Obstetrics and Gynecology. This article may have a profound impact on making evidence-based hormone therapy treatment more common practice. The abstract is accessible, but unfortunately I haven’t been able to access the entire article that the reel details.
If you’ve had a DEXA scan that shows you have bone loss, estrogen is the first-line FDA approved and recommended treatment to prevent osteoporosis.
The top three obstacles you might face:
WHI-informed clinical practices and messaging
Time restriction of appointment (but with preparation you’ll be ready!)
Cultural biases around unavoidable female suffering and aging
Assumption of “doctor knows best” contributing to lack of cooperative decision making about your own body
The Conversation:
You:
“As a healthy woman with no contraindications, I’d like to try a low dose transdermal patch of estradiol twice weekly to see if my symptoms improve.”
If you have a uterus:
You:
“To oppose the estrogen and protect the lining of my uterus and help with sleep, I’d like to start oral progesterone 100 mg nightly.”
You (If you have any of the following: vagina, bladder, urethra, labia):
“To preserve healthy tissues in my pelvic floor and prevent UTIs in the future, I’d like to use a low does vaginal estrogen cream.”
The Journal:
I highly recommend keeping a journal of symptoms or tracking them using an app. I use the free FLO app and keep notes in my phone. If you come into the appointment an expert of your own experience, you’ll feel more confident to ask for what you need and want. You’ll also be able to track progress or lack thereof once you’ve begun treatment.
The Dismissal:
If they ask why you want treatment, be ready with your list of symptoms or the symptom that you will not tolerate because of how it impacts your quality of life. They may try to normalize what you are experiencing by telling you that you’re just getting older. They may try to minimize your experience by telling you it’s not that bad or asking if it’s “debilitating,” or asking you to put it on a pain scale, which to someone who has had bad menstrual cramps, or had a baby, or endometriosis, or who suffers from migraines, all common female ailments or experiences, that pain scale can seem silly. Some of us are troopers and wouldn’t know “debilitating” until it killed us (many women are sent home with heart attacks, reducing their survival rate by 50%, but that’s for another post). I’ve seen both of my sisters handle situations of unfathomable pain with disproportionate courage and strength. But even if you have a more delicate constitution, you still get to decide what you won’t tolerate and what risks you are willing to accept to improve your quality of life.
With any medication, there are risks. Because you read Zevah Substack, you are informed and aware that the risks associated with hormone therapy are much smaller than most believe them to be.
Be ready to stand by your lived experience. You are the one living it.
You:
“The sleep deprivation (or fill in the blank) is deeply impacting my quality of life.”
You can always resort to the request for a trial on hormone therapy.
You:
“I’d just like to try it for three months to see if my symptoms improve.”
Many of us know the feeling of the time pressure in the doctor’s office. That next appointment is looming ahead. Time to act fast! If you stay confident and persistent, they may hear you and hear you more quickly.
False Fears
If your doctor raises any concerns about blood clots, cardiovascular risks, breast cancer, or dementia, it’s likely they are basing their concerns on the WHI. It is not your job to educate them, but it might be easy enough to print out a copy of the 2022 hormone therapy position statement of the North American Menopause Society. Ask them if they’re familiar with the guidelines and show them the highlighted statement:
“Benefits of hormone therapy use generally outweigh risks for healthy women with bothersome menopause symptoms who are aged younger than 60 years or within 10 years of menopause onset.” (bottom right p. 783)
You could also refer to the recent article in the Green Journal mentioned above.
Put It in Context
This might be a little too hardball for your taste.
You can try asking them if they’d be willing to put you on oral birth control. If they say “yes” you can remind them that a transdermal estradiol patch beginning at the lowest dose and oral micronized progesterone at 100 mg nightly are much less potent, lower dose hormones that are molecularly more similar to what the body produces. You might remind them that birth control does not come without its own risks of clots (which according to the evidence is higher with oral contraception than with transdermal estradiol), and of breast cancer. You might add that unlike birth control, hormone therapy doesn’t typically lower testosterone and libido (or shrink the clitoris, no thank you), not to mention some of the headaches and mood disorders some experience from the progestins in oral birth control pills.
Contraception Versus MHT
As long as you are menstruating you can still get pregnant. Your provider might say that is a reason to choose oral birth control rather than hormone therapy. For those still menstruating, you might manage birth control without oral contraceptives. If you are significantly concerned about pregnancy then oral birth control may be the best option for you.
Some do not experience the side effects mentioned above and do experience relief of the hormonal swings when taking oral birth control. Others will still suffer perimenopausal symptoms while taking oral birth control. One last thing to consider is that depression and mood disorder, more common in perimenopause, can also be a side effect of oral birth control whereas hormone therapy is often very effective at treating depression and anxiety.
Another birth control option where you could still use transdermal estradiol is the Mirena IUD with levenorgestrel, a local progestin that is not systemic so tends to cause fewer side effects. With the Mirena IUD you wouldn’t need to worry about pregnancy, periods, or proliferation of the uterine lining that happens when you take estrogen alone. However, the Mirena IUD won’t have the calming, drowsy effect of oral micronized progesterone that often helps women fall asleep. Hormone therapy is not one size fits all. I know someone who has the Mirena IUD and in addition takes oral micronized progesterone.
For more, see Dr. Jen Gunter’s posts on her substack: The Vajenda, “Menopausal Hormone Therapy vs. Estrogen-Containing Contraception: Understanding the Difference.”
If Sleep Is the Issue
From the research (and from my own personal experience), while oral micronized progesterone has “mildly sedating effects, reducing wakefulness without affecting daytime cognitive functions….A systematic review and meta-analysis concluded that MP improved sleep-onset latency but not sleep duration or sleep efficiency.” Estrogen, on the other hand “may benefit sleep in perimenopausal women, independent of VMS” (hot flashes).
Dosing
It can take a while to find the dose of hormones that produce the optimal balance of alleviating symptoms without causing side effects. Don’t give up if at first you don’t feel benefits. Some tweaking may be necessary.
Not a Cure-All
Hormone therapy is not a panacea. You’re still going to get wrinkles, probably gain some weight, and maybe lose some hair. You’re still going to age. But once the fluctuations in hormones are smoothed out a little with the help of some hormones, you also may feel more like yourself again.
Antidepressants Versus MHT
Hormone therapy has been shown to help with both depression and anxiety. In a comparison of trials for treatment of depression in perimenopause, estrogen (and cognitive behavioural therapy) was found en par in efficacy as commonly prescribed anti-depressants that often come with their own host of side effects. (Tackling Depression/Anxiety in Menopause: It's Not All in Your Head)
Side Effects
The most common side effects of hormone therapy are breast soreness, unexpected vaginal bleeding, and headaches. They tend to be mild and improve over the course of 3 months.
Your Body, Your Choice
Ultimately, you can tell your provider that you’ve weighed the benefits and risks and believe your quality of life is worth the risks associated with treatment.
It’s your body. It’s your decision.
It might be that your provider’s discomfort with hormone therapy is too much for you to overcome.
Ideally, we wouldn’t need an arsenal of our own medical research to go into battle for best practices for our health. But until that day comes, arm up!
Great information. Thank you for putting this together. My doctor recently prescribed antidepressants in light of my breast health history, but I'm not 100% confident that's the right choice for me. Will be using the link provided to help find a practitioner who might give me a second opinion. Thank you!
I just booked a NAMS-certified practitioner using your link. First appt available is 2 months from now, and I’m taking it. Feeling empowered. Thank you.