The New York Times in the February 5 edition of The Morning, wrote “Menopause has long been a taboo topic. Talking about it can help women learn more about an overlooked treatment.”
The story noted “But one effective treatment has been overlooked for decades, signaling that women’s suffering is widely regarded as unimportant, according to the cover story in today’s New York Times Magazine. I spoke with Susan Dominus, who wrote the article, about her reporting and the reactions it has received from women.”
The overlooked treatment is a menopausal hormone therapy. CTN ran a story about the importance of this therapy in April 2022 after talking to Dr. Ingrid Rodi.
Importance of Treating Menopausal Symptoms
The importance of estrogen replacement for women undergoing menopause went from a “good idea and a standard” in the late 1960s and through the 1990s, to an almost complete cessation that was not based on factual research.
According to Dr. Ingrid Rodi, a world-renowned reproductive endocrinologist at the Pacific Fertility Center-Los Angeles, the onset of menopause occurs at around age 50, and cardiovascular and metabolic diseases, osteoporosis, cancer and cognitive decline start to emerge 10 years later, which coincides with diminishing estrogen levels.
“There is a window of opportunity between the start of the peri menopause and five years after the last menstrual period to start estrogen therapy,” Rodi said. “If estrogen is started during that time many benefits can result. These include reducing menopausal symptoms, reducing hip fractures, reducing coronary artery disease, and increasing life expectancy.”
Prior to 2002, it was common for doctors to prescribe estrogen, a hormone that helps develop and maintain the reproductive system. Women on estrogen therapy showed a reduction in coronary heart disease, mortality, osteporotic fractures and even a decrease in Alzheimer disease.
Estrogen levels vary among individuals and fluctuate during the menstrual cycle and over a female’s lifetime. As women approach menopause, normal estrogen levels drop.
Produced by the ovaries, estrogen contributes to bone health and the function of the cardiovascular system. The highest death rate for woman is not breast cancer, but rather coronary heart disease (CHD).
As estrogen levels decrease, weight gain may occur, and bone loss may become more common. Estrogen affects vaginal lubrication and dryness may occur, resulting in painful intercourse. Increased urinary tract infections could occur because of the thinning of the tissue in the urethra.
Rodi has long advocated for hormone-replacement therapy for women.
“The primary reason is to treat menopausal symptoms,” Rodi said. “These include: worsening depression, anxiety, insomnia, difficulty sleeping, difficulty concentrating, hot flashes, night sweats, vaginal dryness, pain with intercourse, decreased sexual desire, and fatigue. There are an estimated 27 million women who suffer from sub-optimally treated menopausal symptoms.”
She added, “The second reason is to increase life expectancy and quality of life.”
If hormone replacement can result in fewer fractures in women, reduce cardiac problems and prolong women’s lives, why did most doctors stop prescribing hormone replacement therapy (HRT)?
In 1988, the FDA held an advisory meeting to consider an ‘indication’ for the cardioprotective effects of estrogen and decided that randomized clinical trials were needed.
Since cardiovascular disease is rare in young women, the trials were carried out in women in their 60s, who had established cardiac disease. The results showed that replacement therapy showed no benefit and perhaps increased harm in the first one to two years.
During this time, the Women’s Health Initiative, sponsored by the NIH-National Institute of Health, also conducted hormone studies, but the majority of the women in the trial were over 60 (menopause onset is around 50), and many of those in the trial had established disease.
After five years, the study was presented to the media, with the message that hormone replacement was associated with increased risk of coronary disease and breast cancer.
The media ran with the story (2002) and proclaimed it was true for all ages of women and all kinds of hormone replacement.
In a 2016 report titled “Hormone-Replacement Therapy: Current Thinking,” Dr. Roger A. Lobo wrote: “More alarming for women was the message the media heard, and which was disseminated to the public; that is, a manifold increase in risk of harm was associated with HRT. For example, a borderline significant relative risk of breast cancer (1.24) was portrayed as a 24‑fold increase in risk; absolute numbers of increased risk were never provided.
“Surprisingly, the principal investigators of these NIH-sponsored trials were not involved in the data analyses and did not see the data before it was presented to the media,” Lobo said.
“The acting director of the NIH made the statement that the data were pertinent to all women and for all types of hormone therapy. Following this announcement, almost all women abruptly stopped using HRT.”
A May 2017 MedicalNewsToday story (“What You Need to Know about HRT”) noted that new research had questioned the NIH-sponsored trials.
“Critics point out that the findings were mixed, and since different hormone combinations can have different effects, the results did not really show how hazardous or how safe HRT might be,” said the author.
“In the case of breast cancer, a combination of progesterone and estrogen was linked to one extra case of breast cancer per year for every 1,000 women,” the story noted, though acknowledging there was still some confusion.
Recent studies “suggest that hormone replacement therapy might improve muscle function, reduce the risk of heart failure and heart attack and lower mortality in younger, postmenopausal women and be ‘quite effective’ in preventing skin aging, if used cautiously in some women. . .”
Lobo concluded, “The pendulum has swung widely and, at present, seems to be swinging back closer to where it was prior to various randomized trials in the late 1990s and early 2000s, in which the data were not properly interpreted or communicated.
“Indeed, the benefit for all-cause mortality, which is similar to that reported in observational trials many years ago, makes a strong argument to consider HRT for primary prevention in young women,” Lobo said.
Rodi said, “It is imperative that the word get out to women and physicians that it is time to adequately treat menopausal symptoms.”