The Insider:
Last time we spoke, we talked about low libido in women. You mentioned that many women have trouble talking frankly about that. I’m guessing the same may be true about menopause, our topic today.
Dr. Renee Horowitz:
Menopause has been a taboo topic for so many years and is just now starting to be discussed. It is a medical condition that is common to all women and one of the phases of our reproductive life. It’s time for menopause to come out of the closet.
The problem is that many women are not aware beforehand of the symptoms, when they typically occur, how long they last and the lasting impact of menopause. Unfortunately, many doctors now are not trained in menopausal medicine; many providers do not want to take the time to talk about it and thus they don’t bring it up.
The Insider:
What percentage of your patients would you estimate are currently going through menopause?
Dr. Renee Horowitz:
My practice is skewed because I specialize in menopausal medicine, so I would guess 60 percent. I believe that there are currently over 50 million women in the United States who are going or have gone through menopause. The menopause transition, perimenopause, can start as early as the 40s, while the average age of menopause is 51 years.
The Insider:
Briefly, what is the definition of menopause?
Dr. Renee Horowitz:
Menopause is defined as no menstrual cycle for one year. Symptoms typically start prior to the one-year mark.
The Insider:
Don’t doctors learn about menopause in medical school?
Dr. Renee Horowitz:
They do but during an OB-GYN residency, they get very little exposure to it. They may get one lecture on it. Since the Women’s Health Initiative came out, there are far less women being treated for it so most doctors really don’t understand the treatment and the nuances of the treatment.
The Insider:
What is the Women’s Health Initiative?
Dr. Renee Horowitz:
It was a study that examined the results from the use of estrogen with and without progesterone on the health of menopausal women. They primarily looked at cardiovascular disease, i.e. strokes, thromboembolic disease and breast cancer. The study was ended in 2002, several years earlier than anticipated, because they found that there was an increase in these diseases. Prior to the WHI, most menopausal women were put on hormone replacement therapy (HRT). Unfortunately, not only were there flaws in their conclusions but most people, including practitioners, overstated the risks. To this day I remember where I was when I saw the headlines.
The Insider:
Has there been a rethinking of this?
Dr. Renee Horowitz:
I think that the pendulum is swinging back again for women to be treated for the symptoms of menopause. One of the flaws of the WHI study was that they grouped women who were over 60 and had never been on hormones with newly menopausal women and found that there was an increased risk of heart disease. We have known for a long time that estrogen is cardio-protective and although heart disease is the No. 1 cause of death in women, we don’t often see women with heart disease in their 40s and 50s.
That led to the recommendation that women should not start hormone replacement therapy if they are 10 years from their last menstrual cycle or over the age of 60. When we talk about the risks there is a 50 percent increase in thromboembolic diseases with women on HRT. But when you look at the statistics, 16 out of 10,000 women who are not on HRT will develop a venous thrombosis or pulmonary embolism and 32 out of 10,000 who take HRT will. The increase is 16 out of 10,000 and yes, that is a 50% increase, but the absolute risk is low.
The Insider:
What about the risk of breast cancer from HRT?
The risk of breast cancer out of 10,000 women is 30 who do not take hormones and 38 who do take hormones. It is a little less than a 30 percent increase but again, there is an increase of 8 out 10,000 women.
Another way that thinking has changed is the type of estrogen and progesterone that women were taking during the study. The estrogen was Premarin, which is a combination of the estrogens that we produce and is obtained through a pregnant mare’s urine. It was given orally. The progesterone component was a progestin, which is a synthetic progesterone. We now know that transdermal estrogen, generally estradiol, which is the most of potent of our estrogens, is safer as it bypasses the liver and decreases the risk for thromboembolic disease. We also give progesterone, not progestins.
The Insider:
Do you find your own female patients still gun-shy about using HRT because of its prior bad reputation?
Dr. Renee Horowitz:
Absolutely. Estrogen became a medication that no one wanted. Not all women will take it but it’s up to their practitioners to discuss the reality, the studies, the risks and the benefits and to dispel the myths that surround estrogen replacement. Just because your grandmother had breast cancer in her 70s and there are no genetic connections, does not mean that you cannot take it. It takes time to discuss this with patients and to acknowledge their concerns and to allow them to make an informed decision as to whether they want to use it or not.
The Insider:
Do all women get hot flashes or uncomfortable symptoms during menopause?
Dr. Renee Horowitz:
No, they don’t. Some women sail through the transition; some have hot flashes into their 70s and 80s but typically they are not as frequent or severe.
The Insider:
What advice can you give women who are having troublesome symptoms about getting appropriate medical help?
Dr. Renee Horowitz:
Bring up the topic. Do not let your provider downplay your symptoms. These are real symptoms that affect our lives in profound ways. There are treatments and if your provider is not aware or is not willing to discuss them, find a gynecologist who will.