By Lyba Spring
A friend asked me if I was going to talk about menopause during aworkshop I am offering on sexuality and aging. She is 68 and still getting hot flashes. News “flash”: I’m 66 and still getting them too. It made me wonder what has been going on in the world of menopause since I first started getting hot flashes in my late 40s.
I was lucky. Apart from driving everyone around me insane with my perimenopausal moodiness, I was not disturbed by night sweats. For many women, night sweats are debilitating, because they affect sleep and therefore the ability to function.
Common sense advice is not the approach you are likely to get when you visit your doctor. Big Pharma continues to dominate the discussion, and Big Pharma probably has your doctor’s ear.
Back in the day, I found common sense in every issue of Janine O’Leary Cobb’s newsletter A Friend Indeed and her book Understanding Menopause, reading both from cover to cover. Other books, like Menopause Naturally by Dr. Carolyn Dean, put this natural part of a woman’s life into perspective. But doctors were offering women hormones like they were candy.
The Women’s Health Initiative (WHI), a.k.a. the nurses’ study in the States, made great headway in debunking the dangerous practice of offering HRT to every woman with symptoms (and in many cases those without).
“Consistent with WHI randomized trial findings, estrogen plus progestin use is associated with increased breast cancer incidence. Because prognosis after diagnosis on combined hormone therapy is similar to that of nonusers, increased breast cancer mortality can be expected.” (Estrogen Plus Progestin and Breast Cancer Incidence and Mortality in the Women’s Health Initiative Observational Study, 2013).
The problems with hormone replacement therapy (HRT) are well documented, yet the controversy continues. Women’s health advocates had thought the WHI results represented definitive research that was universally accepted. But in 2013, Anne Rochon Ford, executive director of the Canadian Women’s Health Network and editor of the book The Push to Prescribe, was reported as saying she’d like to see most women abstain from HRT altogether; that the new push to prescribe hormone replacements is being driven in part by the drug manufacturers that make them.
“There is a strong current . . . of concern and skepticism for taking potentially problematic medications for natural life events,” she said.
“Menopause is not a disease. Menopause is a natural life event in every single woman on this planet and the move to medicate it had a tremendous marketing machine behind it going back to the 1940s.”
But hormonal prescriptions were just being refined.
“Menopausal hormone therapy remains the most effective treatment for vasomotor symptoms, which are experienced by more than half of menopausal women and are most likely to be bothersome during late perimenopause and early menopause with mean duration >10 years (NEJM Journal Watch, Women’s Health May 12 2011). This long-term analysis confirms that the risk–benefit ratio of HT is most favorable when initiated in younger menopausal women, and for estrogen-only versus estrogen-progestin therapy. While HT should not be used to prevent cardiovascular disease, use of low-dose HT specifically to prevent osteoporosis is appropriate in selected women at elevated risk for this condition” [my emphasis].
There is a great difference between “bothersome” and debilitating. Moreover, women with an elevated risk for osteoporosis have non-hormonal (and non-pharmaceutical) options. Osteoporosis experts have long recommended weight bearing exercise and adequate intake of calcium and vitamin D to prevent osteoporosis. Other drugs with questionable results are bisphosphonates, which have also been widely prescribed for people with osteoporosis (Read the Therapeutics Initiative Letter 78).
Women were sold a bill of goods in hormone therapy. Hormone replacement therapy (HRT) was portrayed as a panacea, at first touted as relief for menopausal symptoms, and then as prevention for heart disease, osteoporosis, Alzheimer’s - you name it. And, lest we forget, staying young. Feminine Forever was first published nearly 50 years ago. The author, Dr. Robert A. Wilson, warned that a woman’s body “ultimately betrays her. At the very moment when she is most able and eager to enjoy her achievements, her femininity – the very basis of her selfhood – crumbles in ruin. But now, at last, medicine offers a practical escape from this fateful dilemma.”
Have attitudes towards support for perimenopausal women changed at all? I recently posted a Medscape article on my professional Facebook page about “treating menopause” [sic]. I was hoping that the discussion had evolved. But no. Even though it wasn’t all hormones all the time, treatment of menopausal symptoms still translated into drug prescriptions.
Sadly, even the North American Menopause Society has chimed in regarding support for the prescription of hormone therapy (HT) be it estrogen therapy (ET) or estrogen and progestin therapy (EPT). Their position paper concludes:
“Recent data support the initiation of HT around the time of menopause to treat menopause-related symptoms and to prevent osteoporosis in women at high risk of fracture. The more favorable benefit-risk ratio for ET allows more flexibility in extending the duration of use compared with EPT, where the earlier appearance of increased breast cancer risk precludes a recommendation for use beyond 3 to 5 years.”
Drug companies are aware that women have become more wary of hormonal treatments and have developed new drugs to maintain their market share. Since some women’s menopausal symptoms include extreme vaginal dryness and a loss of vaginal elasticity, a drug company in the United States developed Osphena, a drug that does not contain estrogen to treat painful intercourse, vulvar and vaginal atrophy. It acts on estrogen receptors without actually being an estrogen. Osphena is a selective estrogen receptor modulator (SERM), like tamoxifen. It has been approved for use in the US. Like any medication, it is not risk free. American women would be well advised to read the boxed warning about the possible serious adverse effects, including stroke, blood clots, as well as common side effects including hot flashes.
The advice to “use it or lose it” as well as lubricants and rehydration products are a reasonable and safe starting point for dealing with vaginal dryness. This is the first line of advice one would hope to hear from a health-care provider.
I recognize that some women will choose the big hormonal guns for a limited period of time having tried other less risky remedies with no relief. As for me, I’ll throw off the covers when I feel hot at night; I’ll stick my head out the window during the day; I’ll drink my coffee and eat my spicy food because I love them even if they trigger a hot flash. I’ll continue to go to the Y and pretend to work out to maintain bone health. And one way or another I’ll ensure that my vagina continues to function.
But I do wonder what my 70s will hold?
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Network article on Older women and sexuality