Hot flashes, middle-of-the-night wake-ups and skin changes are just the start of the big bad change of life. But for decades, symptoms of perimenopause and menopause haven’t had effective treatment. In fact, the best thing we had, hormone replacement therapy (HRT), tanked in reputation in the early 2000s due to safety concerns. But now, some 20 years later, it’s one of the most effective ways to treat symptoms.
So, what changed?
How does HRT work?
“Hormone replacement therapy essentially works by replenishing the estrogen and progesterone levels that naturally decline during menopause,” explains Miami dermatologist Dr. Deborah Longwill. “This can help stabilize hormone levels, relieving many disruptive symptoms like hot flashes and mood swings.”
Why the back and forth on HRT?
“There are two parts to the story,” says New York dermatologist Doris Day, MD. “One is a bad study, and the other is bad journalism.” Back in 2003, the Women’s Health Initiative (WHI) halted a clinical trial and announced a potential link between HRT for menopause to increased health risks. The original study included women over 60, who had not been producing estrogen on their own for upwards of a decade, and did not account for patient-specific risks like breast cancer, diabetes and obesity.
“The reality was just not what was portrayed,” says OBGYN Lynn Westphal, MD, professor emerita in the Department of Gynecology and Obstetrics at Stanford University School of Medicine. “When we looked at the data, we saw that in women under 60, those on HRT had lower mortality, and the estrogen-only group also had a lower incidence of breast cancer.”
And then, reporting surrounding this sudden stop focused attention on the increase in relative risk, not actual risk. “If you buy a lottery ticket, and say your chances are one in a million, are you going to win?” Dr. Day asks. “No, you’re not. But, what about if you buy two tickets? Your chance is now two in a million. Are you going to win? No. But, your chances doubled. That’s the difference between actual and relative risk.”
When it came to breast cancer and HRT, the original study by the WHI reported a change in risk for women taking estrogen and progesterone from a four in 1,000 chance to a five in 1,000 chance. “That was reported as a 20-percent increase in your chance of getting breast cancer if you’re on HRT,” Dr. Day explains. Once that misunderstanding was there, Dr. Westphal says it became entrenched. “It’s always the first thing patients say: ‘I heard this causes cancer.’”
So, is HRT safe?
“More recent research has clarified that for many women, HRT is safe, especially when started within a certain time frame and tailored to the individual,” Dr. Longwill says. “Today, we have a better understanding of who benefits most from HRT and how to monitor it effectively.” That said, we won’t understand the full benefits of HRT until a comprehensive, years-long study is published. Similarly, side effects like weight gain also need to be studied.
We also have a different approach to HRT treatment, which used to consist of a synthetic oral estrogen. “The gold standard of HRT typically includes a combination of estrogen and progesterone for women who have not had a hysterectomy,” says Miami dermatologist Anna Chacon, MD. “For those who have had a hysterectomy, estrogen alone is often used. Bioidentical hormones, which are naturally derived and structurally identical to those the body produces, are becoming increasingly popular. However, they require more research to establish their long-term benefits and risks.”
What’s changing in the world of HRT for menopause?
Dr. Longwill says there’s been exciting progress with bioidentical hormone formulations and delivery methods, like patches and topical gels. “These can be easier on the body than traditional pills,” she notes. Delivery methods, in particular, have garnered attention. “We’ve seen that these new low-dosage, topical, natural estrogen and progesterone treatments are much safer,” adds Dr. Westphal. “They are absorbed directly and don’t have to pass through the GI tract, which reduces the risk of blood clotting.”
Just over a year ago, Musely, an online prescription skin-care company, released a topical estrogen cream. “Then, six months later, we released our first systemic HRT solution,” says Jack Jia, founder and CEO. “This is a topical systemic application that is absorbed into the bloodstream to immediately treat symptoms like hot flashes.”
Who is HRT for?
Dr. Longwill recommends HRT for women whose symptoms significantly affect their quality of life and those who don’t have contraindications like a history of certain cancers or cardiovascular conditions. “HRT is particularly helpful for women who have tried lifestyle changes and supplements, but haven’t seen the relief they need.”
These quality-of-life changes can begin during perimenopause. “As levels of estrogen and progesterone begin to decline, skin, hair and moisture levels are directly impacted,” explains Amy Beckley, CEO of Proov, a wellness company that offers at-home fertility and hormone marker tests to help women identify perimenopause. “These hormones play a crucial role in maintaining collagen production, hydration and hair health, so as they diminish, skin often becomes drier, wrinkles become more pronounced, and hair may thin or fall out.”
Dr. Chacon says HRT can help alleviate a variety of symptoms, including hot flashes, night sweats, vaginal dryness, mood swings and sleep disturbances. “It can also be beneficial in preventing osteoporosis in postmenopausal women.”
What are the alternatives?
HRT isn’t for everyone. “I would advise against it for those with a history of hormone-sensitive cancers, blood clotting disorders or significant cardiovascular risk,” says Dr. Longwill. “For those who can’t or don’t want to take HRT, you’re going to be chasing the symptoms of perimenopause and menopause rather than treating the problem directly,” adds Dr. Day.
The good news is, there are options to treat those symptoms. “Alternatives include lifestyle changes like diet and exercise, non-hormonal medications like SSRIs or SNRIs for hot flashes, and herbal supplements such as black cohosh,” says Dr. Chacon. “Some women may also benefit from other therapies like acupuncture or cognitive behavioral therapy to manage symptoms.”
