MHT 7 things to consider
WHY ARE PEOPLE SCARED OF MHT?
1 MOOD & SLEEP Oestrogen and progesterone closely regulate the production of neurochemicals in the brain: GABA (calmness and sleep), serotonin (a sense of synchronicity and wellbeing) and dopamine (pleasure, motivation and drive) can all be impacted when female hormone levels are depleted. Hormonal health colours the way we see ourselves and the world around us, and depression and anxiety are common in women who are going through any hormonal transition, whether after giving birth or during menopause. There are many pharmaceutical and non-pharmaceutical options to help improve mood and sleep, but hormones play an important role and should be discussed as part of a holistic plan to adequately address these issues.
MEMORY Female hormones have been shown to maintain memory, focus and reasoning skills. Starting MHT within 10 years of your last period is associated with a reduced risk of Alzheimer’s disease and dementia, but if you’ve already been diagnosed with Alzheimer’s or have symptoms of dementia, unfortunately MHT doesn’t seem to slow it down.
MOBILITY Oestrogen and progesterone maintain the health of the connective tissues: muscles, ligaments, cartilage and bone. Major hormone shifts have been linked to a higher risk of inflammatory and autoimmune diseases like osteoarthritis and rheumatoid arthritis. Loss of hormones during menopause is also associated with a higher occurrence of joint pain and higher risk of osteoporosis. Maintaining mobility is critical to healthy ageing and longevity.
HOT FLUSHES & NIGHT SWEATS MHT has been shown in randomised controlled studies to relieve hot flushes and
night sweats. For women who don’t want to or can’t use MHT, some studies have shown that plant-based supplements like black cohosh and red clover (that contain high levels of isoflavones) can reduce the severity of hot flushes but the effects might be limited to a six-month period. And while these supplements may help with the symptoms of hot flushes, they don’t perform the same functions as hormones on the rest of your body – they won’t offer the same advantages for your heart and brain as actual hormone therapy. HORMONES & YOUR HEART Female hormones greatly contribute to a healthy heart and blood vessels because they keep the arteries elastic and dilated (reducing blood pressure and hardening), reduce inflammation in the cardiovascular system, improve cholesterol levels and decrease platelet stickiness (which contributes to the risk of clot formation). Several studies have shown that the loss of oestrogens in particular increases the risk of developing coronary heart disease. In the Women’s Ischaemia Syndrome Evaluation (WISE) study, women who experienced premature menopause (before 40) had a sevenfold increased risk of heart disease.
Your age and the timing of MHT is important when it comes to the effects of hormones on the cardiovascular system: women who start MHT more than 10 years after menopause tend to lose the heart protective effects of hormones. In fact, there could be an increased risk of heart disease and stroke. This is largely due to other age-related factors like hardening of the arteries and higher levels of inflammation.
Progesterone may confer different cardiovascular risks: some forms of it reduce the good effects of oestrogen on the heart while others seem to help it along.
If you have a family history of heart disease or several other personal risk factors (you smoke, are overweight and have high cholesterol levels, diabetes or high blood pressure), discuss with your practitioner which combinations of hormones will offer you the best protection for your heart. SEX DRIVE & UROGENITAL HEALTH Vaginal dryness, painful sex and urinary incontinence are common in postmenopausal women. These symptoms often respond very well to a low dose of topical (vaginal) oestrogen which, according to the International Menopause Society, is a generally safe therapy with low systemic (whole body) risk.
Fewer earth-shattering orgasms and loss of libido are also common at this stage – a patient once told me she’d rather clean the floors with a toothbrush than have sex with her husband! Libido is shaped by many physical and emotional factors, but hormones definitely play a role. And it’s not just female hormones that fan the flames of sexual interest; we also need normal levels of testosterone to keep our libidos active.
Testosterone declines with age, stress and menopause. In women, it plays a role in mood, cognitive health and healthy muscle tone. The International Menopause Society advocates evaluation and replacement of testosterone where it affects your quality of life – which low libido certainly does. WEIGHT GAIN & INSULIN RESISTANCE Developing a tyre around your midsection? Hormones help us mobilise fat stores, and regulate and distribute weight. In menopause, most women experience an increase in total body fat and abdominal fat, even lean women. Carrying disproportionate weight around your midsection increases the risk for inflammation, insulin resistance/type 2 diabetes mellitus and heart disease. Hormones wouldn’t be prescribed primarily to reduce tummy fat, but if insulin resistance is a risk, MHT as well as healthier lifestyle choices to achieve a healthy weight can reduce your risk.
Aside from the other health risks associated with being overweight or obese, menopausal women who are overweight have a higher risk of developing breast cancer with a worse prognosis. This is because fat cells can produce oestrogens, in particular oestrone, which may be considered more harmful to breast tissue than other types of oestrogens.
Fewer earthshattering orgasms and loss of libido are also common at this stage – a patient once told me she’d rather clean the floors with a toothbrush than have sex with her husband!
The findings of the Women’s Health Initiative (WHI) study, published in 2002, showed that the use of MHT increased the risk of breast cancer, heart disease and stroke, and created uncertainty, and even fear, around MHT. There are risks to consider with any treatment, but with MHT, it’s important to maintain an accurate perspective of what these risks are. You also need to weigh up the benefits and risks of the treatment for you, from a genetic, environmental and lifestyle point of view.
The WHI study had many flaws. Most participants were older than 65 and already had several risk factors for heart disease and stroke before starting MHT. Many started MHT more than 10 years after the onset of menopause, which we now know is associated with a higher risk of complications. Also, only one type of oestrogen and one type of progesterone were used. Different hormone preparations exhibit different effects and side effects, and so tailoring treatment to suit each woman is critical in light of her treatment goals and personal risks.
WHAT ARE THE RISKS?
Clotting Some MHT preparations have been shown to increase the risk of clotting, and therefore stroke, heart attack or thromboembolic disease. But many studies show that these risks can be reduced if oestrogen is used topically rather than in oral form. Different types of progesterones also confer different risks for clotting; newer studies suggest that micronised (natural) progesterone may be safer. Developing cancer on MHT You need to know your potential risks for developing cancer of the breast or endometrium (lining of the uterus). Oestrogen can cause growth of the endometrium; if this growth isn’t kept in check, it can cause endometrial cancer. Progesterone counteracts the growth effects of oestrogen in the uterus and keeps its lining thin, which is why menopausal women who have an intact uterus must opt for an MHT regime that contains enough progesterone to protect the endometrium. You should also have an annual ultrasound of your uterus to check for abnormal growth of the endometrium.
Things become more complex when it comes to considering the potential risk for developing breast cancer on MHT. The effect of MHT on breast cancer may depend on the type of hormones you use, the dose (higher doses are riskier), duration (longer use may increase risk), how you take it and your risk profile. The risk of breast cancer increases very slightly with the use of oestrogen alone, but studies have shown that the risk may become even higher with the use of oestrogen in combination with certain synthetic progesterones (progestins).
If you have an intact uterus, progesterone therapy is mandatory to protect the endometrium. But does this put you at higher risk for breast cancer? Different forms of progesterones may have different effects on different target organs, including the breast. Different types of progesterones may confer risks in terms of breast cancer, and can even confer certain treatment benefits. For example, micronised progesterone seems to improve mood, sleep and scalp hair growth and reduce inflammation, whereas the more potent progestins can do the opposite, and even trigger sor worsen symptoms such as insomnia, depression and hair loss.
The Radiological Society of South Africa recommends annual mammograms as a preventative and screening tool for breast cancer in women over 40. Speak to your doctor about which forms of hormones will offer you the safest outcomes and will best address your set of symptoms, as well as what your particular risks may be. Menopause can feel like a scary transition, but knowing your body and treatment options can reshape your experience of menopause into a confident, vibrant time in your life. Healthy ageing is absolutely possible – you just need to know how to do it!