Vaginal dryness is not the only issue
that sabotages your SexAbility
For hundreds of years, women have struggled to find solutions for menopause symptoms such as hot flashes and sleep disturbances that affect not only their SexAbility but also their overall quality of life. In the 1870s, Lydia Pinkham’s Vegetable Compound was a popular remedy for virtually every gynecologic ailment, including menopause-related problems. Roving salesmen (the 1870 equivalent of the health food store clerk) would go house to house selling the stuff. The ads claimed the compound was a “positive cure for all those painful complaints and weaknesses so common to our best female population and is particularly adapted to the change of life.”
No doubt, its 18 percent alcohol content had something to do with its efficacy—even proper ladies could remain happily inebriated while dealing with difficult menopausal hot flashes and sleeplessness. Another key ingredient in Pinkham’s remedy was none other than black cohosh, an extract of dried underground roots derived from a plant used by Native Americans. Today black cohosh remains one of the most widely used alternative therapies for treatment of hot flashes despite research questioning its effectiveness.
Estrogen therapy entered the scene in 1941 when Premarin came on the market. A 1948 Reader’s Digest article proclaimed, “The melancholy sickness that blights the happiness of some women at their change of life [can be] controlled by female hormones; yet most women have gone on suffering. . . . But now at last they are ready to transfigure the stormy afternoon of life . . . into a time of serenity and vigor.” By the 1960s, the estrogen boom was in full swing, in large part thanks to Feminine Forever, a book written by Dr. Robert Wilson (and funded by the company that sold estrogen!). Proclaiming that menopause was a disease that required estrogen as treatment, this best-seller stated on its cover that “every women, regardless of age, can safely live a full sex life, for her entire life.” Sales soared.
A slight bump in the estrogen road appeared in the 1970s when it was discovered that women who took estrogen were at increased risk for developing uterine cancer. The addition of a progesterone pill, to protect the lining of the uterus from a buildup of abnormal tissue, solved that problem, which is why a progestin (a form of progesterone) is now routinely prescribed along with estrogen for anyone who has not had a hysterectomy.
Despite the claims of Feminine Forever, estrogen was originally intended for—and in fact was only FDA-approved for—the treatment of hot flashes and vaginal dryness. But in the 1980s some studies suggested that in addition to helping with bothersome symptoms, postmenopause hormone therapy was also beneficial to prevent heart problems, osteoporosis, and Alzheimer’s disease. As a result, women were advised to routinely take estrogen after menopause, even if they were asymptomatic.
The Women’s Health Initiative: The Flush Heard Round the World
The Women’s Health Initiative (WHI) was a large study initiated in 1997 with the purpose of definitively determining whether long-term hormone therapy could prevent heart disease and prolong life in addition to controlling postmenopausal symptoms. The 27,000 women between the ages of 50 and 79 who enrolled were divided into three groups. One group took estrogen and progesterone, the second group took only estrogen (these were women who did not need a progesterone to protect the lining of the uterus because they’d had a hysterectomy), and the third group was given a placebo pill. The women were not told what they were taking, and they were all monitored for side effects and potential benefits. The study was intended to run for eight years but was abruptly ended prematurely at five years when it appeared that the group taking estrogen and progesterone had a higher incidence of breast cancer, blood clots, and stroke. When the results of the study were released to the media, the news immediately went viral.
On July 22, 2002, women all over the United States woke up to the news that the hormone therapy their doctors had recommended was in fact dangerous, increased the risk of breast cancer, increased the risk of blood clots, increased the risk of stroke, and should be discontinued immediately. Millions of hormone pills were flushed down the toilet in anger and fear. Sales dropped by 70 percent. Most media outlets forgot to emphasize that 97.5 percent of women taking hormone therapy had no problems and that the number of women who had problems was actually quite small.
Breaking news in 2002:
“Red Flag on Hormone Replacement”
—CBS News
“Hormone Replacement Is Riskier than Advertised. What’s a Woman to Do?”
—Time
“New Study Raises Fears About the Risks for Millions of Women”
—Newsweek
Putting the WHI in Perspective
The WHI showed that for every 10,000 women per year who used estrogen and progesterone (compared to the women who were not taking any hormones or were taking estrogen alone), there were:
Seven additional myocardial infarctions
Eight additional strokes
Eight additional breast cancers
Eighteen additional blood clots
Six fewer colorectal cancers
Five fewer hip fractures
There were no additional deaths.
Despite the fact that the absolute number of women who had problems from hormone therapy was quite small, results from the WHI study have continued to contribute to a great deal of concern and confusion regarding the safety of hormone therapy.
Over 80 percent of women who have breast cancer have never taken hormone replacement of any kind. In addition, the risk of developing breast cancer from hormone therapy is lower than the risk associated with daily alcohol use or obesity.
Why WHI Shouldn’t Be a Source of Panic for Women Who Take Estrogen
Since the initial release of the WHI findings in 2002, the data has been revisited, and it is now clear that both the design of the study and the initial interpretation of the data were problematic. There were three striking issues.
Issue 1: Age Matters
The average age of women in the study was 63, and over 70 percent of the women enrolled were over the age of 60. Since most women go through menopause between the ages of 50 and 55 (representing only 10 percent of the study population), the overall results were not reflective of most women who take hormone therapy. A reevaluation of the study looking only at women in the 50–60-year-old range showed completely different and very reassuring results. There was a decrease in coronary heart disease, fractures, and overall mortality. There was no increase in breast cancer, and in fact there was a slight decrease.
Issue 2: Taking Estrogen Alone Is Not the Same as Taking Estrogen and Progesterone Together
Many women were also unaware that the results released in 2002 applied only to women taking estrogen and progesterone. The study group that included women who took estrogen alone was not discontinued until March 2004 and had strikingly different results. Women in the 50–60-year-old WHI group who took estrogen alone had a 37 percent decrease in heart disease, an 11 percent decrease in stroke, a 12 percent decrease in new-onset diabetes, and a 30 percent decrease in fractures.
There appears to be a “critical window” to start hormone therapy in order to avoid other health problems.
And then there is the breast cancer issue. The news flash that didn’t make it to the media was that in the estrogen-only group there was an 18 percent decrease in breast cancer. There were six fewer cases of breast cancer per 10,000 women per year of estrogen use. It is now clear that the modest increase that is sometimes seen in breast cancer in women who take hormone therapy is due to the progestin, not the estrogen.
In fact, total mortality in the 50–59-year-old age group was a whopping 30 percent lower than in women who did not take hormone therapy. Blood clots were the only remaining concern. Blood clots that form in the veins of the legs can travel through the body and block blood vessels that supply the heart, lungs, or brain. The 50–60-year-old group in WHI did have a 37 percent increase in venous blood clots, which sounds alarming. Keep in mind, though, that since the number of blood clots occurring in that age group is very small, even a small increase translates into a huge percentage increase. In absolute numbers, there were four additional blood clots per 10,000 women per year of estrogen therapy.
In spite of the fact that results for the estrogen-only group were very reassuring, they received essentially no media attention. (And I’d even waxed my eyebrows in preparation for explaining the good news on TV.)
Issue 3: Transdermal vs. Oral Estrogen: There Is a Difference
The third issue with the WHI was that it studied only one kind of hormone therapy, Premarin (conjugated equine estrogen) and Provera (medroxyprogesterone acetate). Many newer types of hormone therapy are metabolized by the body differently and are therefore significantly safer. Specifically, transdermal estrogens do not appear to have the adverse consequences of the oral estrogens.
In the 1980s, transdermal estrogen patches were developed as an alternative means of delivering estrogen. The primary advantage to the patch was that, since the skin absorbed the estrogen, it went directly into the bloodstream and didn’t have to pass through the gastrointestinal system, as oral estrogen does. This was intended to benefit women who had liver or gallbladder disease that was known to be aggravated by oral estrogen. It soon became clear that the benefits of avoiding the trip through the liver were not limited to women with liver or gallbladder problems, but were available to all women. The main benefit was the elimination or lowering of the increased risk of blood clots and stroke. Here’s why.
Blood clots are more likely to occur in the deep veins of the legs of women who have high cholesterol and triglycerides. All estrogens decrease cholesterol, but oral estrogens increase triglycerides, while transdermal estrogens decrease triglycerides.
Also increasing the chance that blood will form into dangerous clots is the presence of high levels of clotting factors such as fibrinogen and factor 7. Transdermal estrogens decrease fibrinogen and factor 7. In addition, a protein produced in the liver called C reactive protein causes blood clots to grow larger and more prone to breaking away and traveling to distant blood vessels. Oral estrogens increase C reactive protein. Transdermal estrogens do not.
At this point, hormone therapy is not recommended to treat or prevent cardiovascular disease. But since a transdermal product decreases the likelihood of developing a clot, transdermal estrogen therapy is unlikely to increase and may actually decrease a woman’s risk for heart disease, stroke, or heart attack.
It’s also important to keep in mind that anyone can get a blood clot or develop heart disease even if they are not using hormone therapy. Every postmenopausal woman should minimize her risk by maintaining a healthy body weight and sticking to a heart-healthy diet.
Transdermal estrogen is now available in a variety of forms other than patches, including spray, lotions, and gels. The active ingredient, a plant-based beta estradiol, is found in all transdermal products.
Unlike pills, which must be taken daily, patches offer the advantage of only needing to be used once or twice a week. The disadvantage is that many women don’t like to wear a patch; it can irritate sensitive skin, and while it generally does not come off in the shower or the pool, sometimes it does. You also can’t alter the dose on your own since it is not recommended to cut the patch. Sometimes the patch leaves behind a sticky residue and faint marks on your skin.
Estrogen sprays, gels, and lotions are applied to the arm or thigh on a daily basis. The major disadvantage to these products, compared to orally taken pills, is that they tend to be more expensive. They are also alcohol-based, and there is a chance that you will burst into flame if you light a cigarette—yet another reason to quit smoking.
Despite the Media Hysteria, Estrogen Is Not Poison
While subsequent reinterpretation of the WHI results has been very reassuring, most women (and sadly many doctors) are not aware that low-dose postmenopause estrogen therapy is appropriate and safe for most, if not all, women. The FDA label still inexplicably reflects the original concerns. Which is why, 12 years later, most menopausal women are suffering from hot flashes, insomnia, and sexual problems under the misconception that taking estrogen will cause breast cancer, strokes, heart disease, and ultimately death. A Yale study published in July 2013 suggested that continued sensationalism in the media about the WHI study and concerns about estrogen have caused thousands of needless deaths. The authors estimated that up to 48,835 fewer women would have died between 2002 and 2012 if they had not avoided estrogen. Fortunately, the estrogen pendulum is swinging again, and many women can feel a lot more comfortable about taking systemic estrogen to not only relieve symptoms but maybe even to prolong life.
It’s always interesting to me when I have a patient who is sailing through perimenopause on her birth control pill but will balk when I tell her it is time to stop the pill and start hormone therapy. When I point out that the pill she has been happily taking for the last 20 years has a far higher level of estrogen than standard postmenopausal hormone therapy, she is usually shocked. She is also shocked when I discuss the results of the Women’s Health Initiative study in detail and is relieved to hear that taking hormone therapy for relief of menopause symptoms is a safe, viable option.
It’s also important to note that the WHI studied only hormone extension, that is, giving hormones to women who were in the typical postmenopausal age range. Hormone replacement in young women who have gone through a premature menopause is an entirely different matter. Unfortunately, the two are usually lumped together. As a result, the 36-year-old who takes estrogen feels she is putting herself at the same risk, and has the same issues, as the 52-year-old who takes estrogen supplements. No one worries about a 36-year-old woman taking birth control pills, but if the same woman goes through menopause, many erroneously believe that taking estrogen therapy (which provides dramatically less hormone than in a typical pill) is dangerous.
The Progestin Problem
If a woman is using systemic estrogen and has a uterus, it has been well established that a progestin is needed too, since there is an increased risk of uterine cancer if estrogen is taken alone. If the uterus has been removed, there is no reason to take a progestin. But now that it appears that there is no increase in breast cancer in women who take estrogen unless there is a progestin in the picture, this presents a real dilemma for many women.
In addition, some women don’t tolerate taking a progestin and experience bloating, depression, and bleeding no matter what kind of progestin they use. It’s really tempting to skip taking a progestin altogether, but it’s not a good idea. Uterine cancer is the most common gynecologic cancer in this country and is significantly increased in women who take estrogen without a progestin.
Progestin Alternatives
Some gynecologists place a progestin IUD in the uterus instead of prescribing an oral progestin. While standard in Europe, this is not yet FDA-approved in the States and is therefore an off-label practice.
The vaginal progestins used in the fertility world to stabilize the uterine lining in early pregnancy have not been tested in postmenopausal women, and it is unknown whether they provide adequate uterine protection.
Progestins are generally given in pill form, since the molecule is too large to be absorbed through the skin. Although a couple of FDA-approved patches that have both estrogen and progestin are available, many women don’t like those products because the patch is on the large side and comes with a higher rate of breakthrough bleeding.
While compounding pharmacies offer transdermal progestin creams, to date no scientific studies have demonstrated that they protect the uterine lining. In fact, there is data to support just the opposite. Using a compounded progestin cream is essentially the equivalent of using nothing. The same goes for over-the-counter products synthesized from yams that claim to offer protection.
While it sounds drastic, some of my patients have opted to have their uterus removed and take estrogen alone rather than deal with the risks and side effects of progestin.
Some women skip the progestin and monitor the uterine lining to make sure there is no abnormal buildup. While this approach is not currently recommended, in the future it may be a reasonable alternative for women at low risk of uterine cancer who are taking very small doses of systemic estrogen.
A new product, Duavee, may be the best bet for the woman with a uterus. Duavee is an oral estrogen pill that is combined with a unique SERM, bazedoxefene, which blocks estrogen pathways in the uterine lining. As a bonus, it also builds bone! Women who choose Duavee get the benefit of estrogen without the risk of taking a progestin.
Is a Progestin Needed with Local Vaginal Estrogens?
Since only systemic estrogens increase the risk of uterine cancer, there is no need to take a progestin if the only estrogen you are using is a vaginal product. Not one study shows the same is with local estrogen, which is why the North American Menopause Society made the position statement in 2007 that a progestogen is not necessary, in spite of the FDA warning label that says otherwise.
Why Take Estrogen?
To Put Out the Fire
The number-one reason most women start systemic estrogen is to treat hot flashes once they realize that taking yoga, carrying a portable fan, and dressing in layers are not real solutions. Toughing it out works for some women (like the ones who live in Alaska), but others who have severe hot flashes throughout the day and night are totally blindsided by just how debilitating hot flashes can be. While hot flashes last for two to four years in most women, some will experience them for up to 10 years. Almost 10 percent of a lifetime!
Every once in a while, someone will say, “My grandmother didn’t take anything for hot flashes, why should I?” Well, Grandma was more likely to be home baking cookies than doing a job that required a good night’s sleep and the ability to think clearly. Grandma may have been having occasional sex with Grandpa (there’s a visual I didn’t need to give you!) but was unlikely to be starting a second marriage or a new relationship in her fifties. And Grandma probably did not live nearly as long as you will.
Hot flashes occur in 75 percent of menopausal women and typically begin as a sudden sensation of heat on the face and upper chest that becomes generalized. A severe flash can be pretty intense (I call it “the furnace inside you”), lasting between two and four minutes with profuse sweating, followed by chills and shivering.
Physiologically, a hot flash happens for the same reason you sweat in a sauna: the body is trying to cool down. The difference is that you don’t really need to cool down, but your menopausal brain thinks you do. Let me explain.
The human body is meant to be roughly 98.6 degrees. If you go outside in the winter without your coat, you’re going to shiver to generate heat. You sweat when you exercise to cool the body down. The part of the brain that keeps your body at the right temperature is known as the thermoregulatory zone. During menopause the thermoregulatory zone gets too sensitive, resulting in a hot flash even when the body doesn’t really need to cool down.
For some women, hot flashes are extremely debilitating. For others, less so. Women who get warm a few times a day don’t understand why some women need help to get through menopause. The woman who flashes twenty to thirty times a day can’t sleep, can’t get through a business meeting fully clothed, and probably coined the bumper-sticker-worthy phrase, “I’m out of estrogen and I’ve got a gun.” Estrogen, even in very small doses, is the most effective treatment of hot flashes and sweats. Period. Estrogen not only works for hot flashes, it works fast. Women who start oral or transdermal systemic estrogen replacement generally experience relief within the first few weeks of treatment.
I am well aware that in spite of the reassurances of menopause experts like me, many women choose not to take estrogen or have been advised by their doctors to steer clear. In fact, only 7 percent of women with hot flashes ultimately accept a prescription for estrogen. For women who prefer not to take estrogen or have been told they should not, there is an FDA-approved alternative.
Brisdelle, the first and only FDA-approved nonhormonal option for hot flash relief, is a low dose (7.5 milligrams) of paroxetine, one of the SSRI antidepressants that years ago was serendipitously found to significantly reduce hot flashes in menopausal women. In the past, like many physicians, I prescribed paroxetine off-label. There are two reasons why I am glad I can now prescribe a low-dose, FDA-approved version as opposed to generic paroxetine.
Paroxetine at higher doses is intended for, studied for, and FDA-approved only for the treatment of depression, not hot flashes. Many of my patients have received a prescription and then also had the experience of their insurance company giving them a diagnosis of depression even though they are not depressed. Just hot. One patient for whom I prescribed Paxil for hot flash relief (as clearly documented on her electronic medical record) was contacted by her insurance company to see if her “depression” was improving and to offer psychotherapy!
Brisdelle is FDA-approved only for the treatment of moderate to severe hot flashes as a result of menopause. It cannot, and should not, be prescribed for the treatment of depression and therefore is not interpreted as a treatment for depression on your medical record.
The doses of generic paroxetine available for the treatment of depression are higher than needed to relieve hot flashes. With higher dosage comes a greater risk of side effects. For example, Paxil and other SSRIs are associated with an increase in sexual problems and an increase in pounds. The last thing a menopausal woman needs is a drug that might sabotage her diet or an already waning sex drive. In clinical trials, Brisdelle, with only 7.5 milligrams of paroxetine, did not demonstrate a decrease in libido or an increase in weight.
If nothing else is working to eliminate your flashes, you may want to check out a new procedure that appears to reduce hot flashes by at least 50 percent called the stellate ganglian block. The stellate ganglion is a bundle of nerves in the cervical spinal column. It appears that if a long-acting local anesthetic is injected into this ganglion, hot flashes are reduced for months. Something about getting a shot in the neck, however, makes all but the truly desperate a little leery.
To Alleviate Vaginal Dryness
Yes, local vaginal estrogens treat vaginal atrophy, but systemic estrogens can often alleviate vaginal dryness too. However, up to 25 percent of women taking systemic hormone therapy still have atrophy and still have problems with dryness and painful intercourse. The reason is simple. Estrogen therapy is not intended to give you the same kinds of estrogen levels you had when you were 20; it is only intended to alleviate symptoms such as hot flashes, and the amount of estrogen that alleviates hot flashes is sometimes not enough to alleviate vaginal atrophy. That’s why it is called estrogen therapy instead of estrogen replacement.
The truth is that many women who use either systemic or local vaginal estrogen assume that they will no longer need a lubricant. That is not the case. Systemic and local estrogens are now so low-dose that their use is not always going to resolve significant vaginal atrophy. And let’s face it—sometimes sex is more exciting or more stimulating than at other times, and you may need a little help to get things going. So, even if you are taking a systemic estrogen or using a local vaginal estrogen product, don’t toss your bottle of lube.
To Get Some Sleep
Menopausal women generally have very little trouble falling asleep. It’s the staying asleep that’s the problem, which is why, when you send an email to 15 menopausal friends at 3:00 AM, you immediately get at least 12 replies. Nighttime awakening happens not only because of hot flashes. Even in the absence of hot flashes, menopausal women are plagued by insomnia because estrogen and progesterone influence multiple factors that control sleep. Hormone therapy is known to improve rapid-eye movement (REM) sleep and sleep quality, even in women who have no problem with flashes. As discussed in chapter 10, a decent night’s sleep is essential not only to avoid getting fired from your job but also to have a decent libido.
To Protect the Heart?
Heart disease is the number-one killer of women. While most women perceive breast cancer as their greatest health threat, an American woman is ten times more likely to die from heart disease than from breast cancer. In addition, women who are overweight, smoke, and don’t exercise or eat right are increasing their risk of heart disease far more than they would by taking estrogen. The WHI was quite clear that women between ages 50 and 60 who take estrogen do not increase their risk of cardiovascular disease and that, in the case of transdermal estrogen, may in fact decrease it.
To Reduce Brain Fog
This is another area that is still controversial. Many studies show an improvement in memory and cognitive function in women who start estrogen during that 5–10-year critical window at the onset of menopause. Estrogen receptors involved in cognition have been identified in many areas of the brain, and increased blood flow to the brain is known to occur in women on estrogen. In addition, sleep disturbances caused by lack of estrogen significantly contribute to an inability to think clearly. What is clear is that if estrogen is going to help cognitive function or decrease the risk of Alzheimer’s, it needs to be started early. Studies consistently show that estrogen initiated more than 10 years after menopause not only doesn’t help but also may actually make cognitive function worse.
To Protect the Bones
Every year 1.3 million women suffer from fractures as a result of osteoporosis, the bone loss that is usually a “silent” disease. There are no symptoms unless you break a bone, which is why bone density screening (a specialized X-ray) is recommended to find out if you are at risk. Any women can have bone loss leading to osteoporosis, but women at particular risk are women who are thin, smoke, take steroids, or have a genetic predisposition. By age 80, 50 percent of women have osteoporosis and are at significant risk of fracture if they fall. Thirty percent of women hospitalized for treatment of a hip fracture die. Osteoporosis is a life-threatening disease with consequences well beyond losing height or suffering the inconvenience of a fracture.
Low-dose systemic estrogen therapy reduces the risk of postmenopausal fractures, including hip, spine, and all nonspine fractures, even in women without osteoporosis! This protection only lasts while you are taking estrogen. Within a few years of discontinuation, the risk of hip fracture is the same as it would be if you had not taken estrogen.
To Decrease Wrinkles?
Women on estrogen have better skin. It’s not your imagination that women on estrogen have fewer, shallower wrinkles. Just as estrogen increases collagen in your vulva, it also increases collagen in your face. Certainly other factors contribute to the skin changes associated with aging, such as sun, smoking, and genetics, but estrogen plays a part as well. This is not to suggest that vanity is a valid reason to take estrogen—it’s just a fact! And one that explains why many women in the 1950s used estrogen-based face cream.
To Alleviate Nasty Mood Swings
Depression is one of the more complicated symptoms of menopause. Are you depressed because low estrogen has changed your chemical balance in such a way that you experience a chemical depression? Or are you depressed when you go through menopause because of sleep deprivation and the sudden lack of libido that has destroyed a formerly terrific sex life? There is also the issue of the extra pounds that have magically appeared on your belly and thighs, despite the fact that your eating and exercise routine is exactly the same as it was ten years ago. Remember too that your last child is probably about to leave for college, you may have been passed over for the promotion, and your husband is going through his own midlife crisis. Good times, right? No wonder you’re depressed.
It’s really not fair that a major hormonal plunge occurs at the same time as a lot of less-than-pleasant life changes. It’s hard to know how much depression is a direct result of estrogen deprivation as opposed to external factors. The change in hormones is certainly a contributing factor, and many women find that estrogen replacement helps. Evidence is mixed about the effect of estrogen on mood. Getting rid of hot flashes and getting a full night’s sleep are definitely going to cheer you up. The question is, if your only symptom is moodiness, will estrogen help? Probably not. It has also not been shown to be useful for the treatment of depression. Go see a therapist or your primary care physician in addition to your gynecologist if depression creeps in with menopause.
To Improve Your SexAbility!
Although many patients tell me otherwise, estrogen therapy has not been proven in scientific studies to improve libido or arousal. However, for women who have vaginal dryness and painful sex and are exhausted from sleep disturbance and hot flashes, relief of those symptoms has been proven to improve desire, arousal, and orgasms.