Frequently Asked Questions

Menopause is a natural stage of life that represents the post-reproductive phase and may last for one-third of a woman’s lifespan or longer. Changes in the menstrual cycle signal the start of the menopause transition (perimenopause) and ends 1 year after the final menstrual cycle at which time a woman is menopausal. Menopause is caused by the decreased production of ovarian hormones, including estrogen and progesterone. The timing of onset, duration, and symptoms experienced during the menopause transition vary from woman to woman.

 

Many women are not menstruating, for example if they have had a hysterectomy or have a progestin IUD in place. These women can still develop the symptoms of perimenopause and menopause as described below. Since the purpose of treatment is to help with symptoms, we don’t have to know exactly where they are in the transition process. Blood testing can help if the symptoms are unusual or if their age is younger or older than the usual range where menopause transition occurs.

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The most common symptoms associated with the menopause transition include:

• Vasomotor symptoms (hot flashes and night sweats)

• Changes in mood (feeling more depressed, irritable, or worried)

• Vaginal dryness, irritation, burning, or itching

• Sleep problems

• Decreased sex drive

• Pain or bleeding with sex

• Muscle and joint aches

• Weight gain

• Changes to skin and hair

• Difficulty remembering things

• Recurrent urinary tract infections

• Urinary frequency or urgency

Staying on oral contraceptive pills (OCPs) is a great way to sail through the menopause transition. When and how to stop them depends on your symptoms, risks, need for contraception and your preferences. Basically we have 3 options:

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1. Continue on OCPs until you are 55 years of age. At that point, >95% of women will be infertile, so youcan trust menopause for birth control.​

2. Stop OCPs and see if you develop perimenopausal or menopausal symptoms. Then we can decide whether restart the OCPs or start menopausal hormone therapy.​

3. Transition directly from OCPs to menopausal hormone therapy.

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If you continue on your OCPs, it’s recommended to use the ultra-low estrogen dose OCP that is designed for perimenopausal women and to take it continuously, meaning not taking sugar pills so that you don’t have to have periods.

There are actually very few contra-indications for MHT: a history of an estrogen-sensitive cancer such as breast or uterine cancer, a history of heart attack or stroke, and a history of blood clots. Choice of treatment depends on symptoms we’re treating, medical risks, your preference, and cost. HT is recommended for treatment of symptoms, not for prevention of any diseases, and the HT dose is based on your symptom improvement, not on hormone levels in your blood. The FDA approved indications for HT are VMS, GSM, premature menopause, and prevention of osteoporosis. The indirect benefits include sleep, joint pain, mood symptoms, sexual dysfunction. There is no evidence that HT prevents dementia, heart disease, skin changes; but the risks include breast cancer, heart disease, blood clots, and stroke.

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I recommend discussing which symptoms you are experiencing, reviewing your medical history to get an idea of your risks from the various options for treatment, and discussing your comfort level with the various options. From there, you can make an individualized informed decision. Each woman should consider the following factors when choosing between hormone and non-hormone therapies: which symptoms we’re trying to treat, effectiveness, and risks of the different options.

Hot flashes and night sweats, also called vasomotor symptoms (VMS), are feelings of warmth that can be associated with flushing and sweating. They are very common during menopause, occurring in up to 80% of women and lasting a mean of 7 to 10 years. Vasomotor symptoms may also contribute to sleep and mood issues that can negatively affect quality of life.

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Women may choose to use hormone therapy (HT) to treat their VMS, but for those who cannot because of medical conditions (such as breast cancer or a history of heart attack, stroke, or blood clot) or for those who choose not to use HT, there are non-hormone options available to provide relief.

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A complete list of non-hormonal treatment options can be found HERE.

Perimenopause is kind of a different animal than post-menopause.​ Perimenopause is defined as the period of time starting when your menses get more irregular (like more than 7 days off) until you’ve gone a whole year without a menses.​ Experts say that the symptoms of perimenopause (mood swings, brain fog, irregular and/or heavy bleeding, breast tenderness and hot flushes) are more related to the ups and downs of hormones rather than constant deficiency. Some call it the hormonal roller coaster. This may need to be treated differently than just adding back hormones with MHT to get symptom control. I think of it as our ovaries ‘sputtering;’ sometimes not working, sometimes working or overworking, leading to big swings in hormone levels and symptoms that come and go.

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There are ultra low-dose oral contraceptive pills that are designed for perimenopause. ‘Suppress and Substitute’: They stop the hormonal roller coaster and then add back in E and P. ‘Hormonal cycle control’ OCPs help control bleeding (which MHT does not).​ Using these treatments can also yield other benefits like providing contraception, which is still needed until you’ve gone 1 year without a menses, and decreasing the risk of endometrial cancer and ovarian cancer.​ Breast cancer risk is very slightly increased with use of oral contraceptive pills at any age. Studies have found that the increased risk of breast cancer on OCPs is very small and only temporary; the risk goes back to baseline after you stop the OCPs. Similar to the increased breast cancer risk with pregnancy and with menopausal hormone therapy use.

Bioidentical hormones is a term invented by marketers and has no clear scientific meaning, but is often used to refer to hormone medications whose molecular structure is similar to or identical to the hormones that your body makes. Bioidentical hormones ARE AVAILABLE as FDA approved, monitored medications, i.e., estradiol and micronized progesterone. Some healthcare providers prescribe custom-mixed (custom-compounded) bioidentical hormones containing one or more natural hormones mixed in differing amounts.

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These products not only contain the active hormone(s) but also other ingredients to create a cream, gel, lozenge, tablet, spray, or skin pellet. Healthcare providers who prescribe bioidentical hormones often claim that these products are more safe and effective than clinically tested and government-approved hormones produced by large pharmaceutical companies. They also may assert that bioidentical hormones slow the aging process. There is no scientific evidence to support any of these claims.

 

Government-approved hormone products are required by law to come with a package insert that describes possible risks and side effects. Custom-compounded hormones are not required to come with this information, but this does not mean they are safer. They contain the same active hormones (such as estradiol and progesterone), so they share the same risks. Custom-compounded hormones allow for individualized doses and mixtures; however, this may result in reduced efficacy or greater risk. These compounds do not have government approval because individually mixed recipes are not tested to verify that the right amount of hormone is absorbed to provide predictable hormone levels in blood and tissue. If you have a uterus, there are no studies showing that the amount of progesterone in these custom-mixed hormones is enough to protect you from developing uterine cancer.

 

There is a long history of pharmacies providing a wide range of compounded products, typically when an equivalent government-approved product is not available. Because preparation methods vary from one pharmacist to another and between pharmacies, you may receive different amounts of active medication every time you fill the prescription. Inactive

ingredients may vary from batch to batch as well. Sterile production technique and freedom from undesired contaminants are additional concerns. Expense is another issue, because most custom-compounded preparations are viewed as experimental drugs and are not covered by insurance plans.

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This response taken from the Menopause Society MenoNote