Perimenopause and menopause are called “the change of life” because they signify a huge transition in women’s health and mental wellbeing. This is a time when women’s moods can become irritable, tempers can flare,  and energy diminishes. Women can also experience sleep fluctuations and a feeling like their brains are in a fog. These changes, along with physical changes to women’s bodies, such as night sweats, decreased sex drive and weight gain, are just a few troublesome experiences that are caused by changes in hormones.

Perimenopause and the change to menopause is a lengthy process, which can last up to 10 years. Perimenopause is the transitional three to four-year phase of hormonal changes before the end of a woman’s menstrual cycle, whereas menopause is the permanent end of menstruation, typically occurring around the age of 52 in the United States, and marks the end of a woman’s reproductive years. Unfortunately, the medical community is lagging in its education on the recognition and treatment of how to navigate this transition into menopause. No one woman’s journey through the maze of perimenopause and menopause is the same, but by becoming informed and recognizing that there is a road map on this path to the future, women can feel empowered to build physical and mental strength moving forward to a healthy and happier lifestyle.

In addition to stopping menstruating, menopause is related to an increase in emotional and physical symptoms. Each woman’s symptoms may differ, but can include: breast tenderness; worsening of premenstrual syndrome; irregular periods or periods that are heavier or longer than usual; racing heart, palpitations; headaches; joint and muscle aches and pains; changes in libido; brain fog or difficulty concentrating; weight gain; hair loss and thinning.

In addition to menopausal symptoms, there are long-term implications of the loss of hormones. Women experience a significant increase in heart disease, osteoporosis, stroke, and other ailments around menopause. Estrogen is a hormone that affects many areas of the body. It is not just a pretty hormone. It is responsible for so much more. There are estrogen receptors throughout almost every organ system in your body, and as your level drops, these cells begin to lose their ability to assist in maintaining your health.

Importantly, estrogen influences bone and lipid metabolism, cardiovascular health, cognition, and sexual function. Postmenopausal estrogen replacement therapy is known to alleviate vasomotor symptoms like hot flashes and has a positive effect on improved serum lipid profiles and reduced cardiovascular disease factors if started soon after menopause.

If you are a candidate for hormone therapy, its use may prolong your life. A study published in the journal, Menopause, reported that a woman starting estrogen at age 50 can expect to live up to two years longer than women who do not, and per year, it’s associated with a 20-50 decrease in dying from any cause.

The Misunderstood Women’s Health Initiative Study
Despite the positive effects of hormone replacement therapy (HRT), in 2002, the Women’s Health Initiative (WHI) study reported that hormone replacement for women was related to a 24 percent increased risk of invasive breast cancer with no beneficial effects against cardiovascular disease, stroke, or thromboembolic disease. Within three months of this public report, 63 percent of women stopped HRT practically overnight. This misrepresentation of the WHI report led to an irrational fear of HRT by the general population and the medical community. The problem was that the WHI study used oral conjugated equine estrogen and synthetic progesterone in women long after menopausal onset (the average age was 63 years). For women aged 50-59 years in the WHI study, hormone replacement therapy did not increase breast cancer or cardiovascular deaths after a median of 18 years follow-up compared with women not taking hormones. With estrogen alone, mortality rates due to breast cancer, Alzheimer’s disease, or dementia were reduced.

Despite these findings, the misinformation about hormone therapy is still present 20 years later. Even the medical community is still lacking, and many physicians are deficient in training on the need to address HRT.

We now know that menopause hormone replacement therapy initiated soon after menopause has very few risks and many positive health benefits. It is important when considering HRT that a woman receive an individual assessment with a knowledgeable physician to evaluate her personal and family health history. The risks of HRT differ on the type of dose, duration of use, route of administration, timing of initiation, and whether a progesterone is used.

Estrogen and Progesterone
There are many forms of hormones for HRT. In the WHI study, an oral estrogen derived from horse urine (conjugated equine estrogen) and a synthetic progesterone (medroxyprogesterone acetate) were prescribed to women. Now there are formulations of estradiol and progesterone that are biologically identical to the hormones in a woman’s body, and some research indicates they have fewer health risks. For example, transdermal estradiol does not appear to increase the risk of pulmonary thrombosis (a blood clot in the lung), as has been found with estrogen. For women who still have a uterus, progesterone is necessary to keep the lining of the uterus healthy. Micronized progesterone may have less health risks for venous thromboembolism than other progestins. Intravaginal estrogen treatments are effective for genitourinary symptoms like vaginal dryness and sexual function. Intravaginal estrogen also does not increase the risk of coronary heart disease, stroke, thromboembolism, colorectal cancer, endometrial cancer, or breast cancer recurrence with its use.

Testosterone
We often think of testosterone as a male hormone, but surprisingly, women produce three to four times more testosterone than estrogen. Testosterone is linked to sexual arousal and interest, but also to mood, energy level, and overall wellbeing. Testosterone levels decrease over a woman’s life span. Despite the important functions of this hormone, research is needed to address forms of testosterone that can help with female hormone replacement. Testosterone therapy for women aims to treat a deficiency, while keeping levels within a physiological range, which should not result in “masculinization.” Research in testosterone therapy shows improvement in urinary tract health, bone density, muscle mass, energy, and mood with improved cognitive function. Studies of transdermal testosterone have not found any increased incidence of heart disease, stroke, venous thromboembolism, or cardiac death. In addition, testosterone has not been associated with increasing risk of breast cancer. There is evidence that testosterone can have anti-cancer effects when used with traditional breast cancer treatment.

Hormones after Breast Cancer
Women with estrogen receptor positive breast cancer often receive anti-estrogen treatment which can include tamoxifen or aromatase inhibitors. These treatments often cause a sudden drop in estrogen levels that trigger symptoms of severe menopause. The positive news is that almost all studies of hormone replacement after breast cancer have shown no change in cancer recurrence and there does not appear to be any negative effect on mortality. It even appears that estrogen may contribute to breast cancer cell death after a period of treatment with anti-estrogens. Testosterone may have positive effects when used in conjunction with traditional breast cancer treatment such as tamoxifen. Further research is needed in HRT with breast cancer.

Be Informed/ Talk with Your Physician
Every person born as a woman will arrive at menopause one day. The paths we take may be different, but no one should ever feel lost. Gaining an understanding of the process of menopausal transition and the potential benefits and risks of biological hormone replacement therapy may be an option for women who have symptoms associated with hormone levels that are low or otherwise imbalanced. Being empowered with information can assist you with talking to your healthcare provider.