Primary Prevention of Cardiovascular Disease With HRT

We've just bookmarked an important new article that we think really brings home the post-Women's Heath Initiative Study (WHI) thinking on the flaws of that study and what we really need to know about the cardiovascular risks of hrt. Why should we care when cancer terrifies us? More of us will die from cardiovascular disease than breast cancer. It lacks the drama and publicity, but that doesn't mean we shouldn't pay very serious attention indeed to this aspect of our health.

Primary Prevention of Cardiovascular Disease With HRT (free signup required to read)
Kate Maclaran; John C Stevenson
01/03/2012; Women's Health. 2012;8(1):63-74

Abstract 

Prevention of cardiovascular disease has increasingly important health implications as our population ages. Menopause is associated with the development of cardiovascular risk factors and there are many plausible biological mechanisms through which estrogen may confer cardiovascular protection. Despite a wealth of observational data to support the use of estrogen, large randomized controlled trials failed to demonstrate a benefit. It is now becoming clearer that the beneficial cardiovascular effects of estrogen are greatest in younger women and those closest to menopause. This has led to the development of the timing hypothesis. Use of age-appropriate estrogen doses is crucial to maximize cardiovascular benefits while minimizing risk of adverse effects such as venous thromboembolism and stroke.

Article summary

The article gives an excellent overview of the current thinking on how hrt use relates to cardiovascular disease, taking into account WHI data, the "critical timing" hypothesis, as well as the combination and route of hrts, both conventional hormones and those that have been modified (SERMs).

It starts out by spending some time going through the various cardioprotective mechanisms of estrogen, including metabolic ones related to lipid levels and fat distribution, insulin resistance, and actions on blood vessels themselves. It then introduces a review of the data from the disastrous Women's Health Initiative Study and looks closely at why this was in such contradiction to a substantial body of sound other evidence.

Crucial differences in the study populations are likely to help explain many of the discordant findings. The observational studies generally involved women who started HRT around the time of the menopause for symptomatic relief. Subjects tended to continue treatment consistently and were followed-up for a long duration, often 10–15 years. By contrast, women in the WHI studies were started on HRT at an advanced age (average 63 years), often with a significant delay following menopause. Furthermore, subjects had elevated BMI, were not using HRT for symptom relief (only 12–17% had moderate-to-severe vasomotor symptoms) and generally had much shorter duration of treatment and follow-up

While research studies cannot assume any reason for observations, the article notes that

The presence or absence of vasomotor symptoms in study populations is important as hot flushes are increasingly being recognized as a determinant of vascular health.

That means, in research terms, that they must now state that hot flashes cause cardiovascular disease. But because we're not researchers, we can read into that the premise that this more likely reflects an underlying commonality, and quite likely demonstrates the difference between women who are not meeting their hormone needs or are fluctuating a lot, vs those who are hormonally adequate and stable. For now, though, this implied causality results in the conclusion that

further evidence is needed to help fully understand the mechanisms by which vasomotor symptoms may influence cardiovascular risk.

One of the important aspects of hrt use and cardiovascular disease is that the payout time is quite long.

This theory is supported by further analysis of the WHI estrogen-only arm, which demonstrated that lower cardiovascular event rates in women receiving estrogen compared with placebo only appeared to emerge from 7 years onwards...Similarly, data from the WHI estrogen plus progestogen arm showed that CVD benefit only appears in younger women after at least 6 years

Why is this important for us? Too many women are given hrt briefly after surgery and told they will be discontinuing it in a few months when their menopause "goes away."

Other women run up against the pretty generally accepted current guidelines that state that

HRT should be used for the shortest possible duration, often interpreted as less than 5 years.

That magical 5-year figure actually is another bit of fallout from WHI, in that it was after five years of study progression that the cancer figures for the combined hrt arm (not for the estrogen-alone arm—and this is a critical difference often missed in the panic) crossed the arbitrary threshold for study cancellation. So, nothing about cardiovascular disease is in that limit, even though it's cardiovascular disease that kills more women than breast cancer.

The article goes on to note that these kinds of time limitations may need to be re-evaluated in the light of the long pay-out on hrt when measured against cardiovascular disease, and this is likely an important and valid issue for all of us in surgical meno.

Next up: the "timing hypothesis." Succinctly stated, this holds that

there is a window of opportunity where HRT may be beneficial for prevention of CVD in younger women, but that in older women, it does not appear to have the same benefits.

But what about the bad cardiovascular outcomes in WHI? The article reviews the potential negative effects of estrogen, but then brings things into a context that is rarely seen in these discussions: need and dose and combination of hormones.

Although these potentially adverse effects of estrogen have been identified, it has been suggested they are not harmful except when inappropriately high doses of estrogen are used, or in the presence of certain progestogens, particularly MPA, which acts to negate the beneficial effects of estrogen and may cause vasospasm.

Ah, here we have the "new" thinking on hrts and this brings things much much closer to what we as women using hrt have found: dose, combination, and route all make a difference; hrts are not a single monolithic entity in which giving any random one stands for the effects of all. Seriously—please consider standing up and cheering at this point: it's that radical a departure from traditional thinking on hrts.

Is there firm data that these things really make a difference? No, the article notes that this is the direction thinking is going and that studies being conducted now should be clarifying this relationship as they are completed.

The article then looks at specific forms of cardiovascular disease that are worrisome based upon WHI results. In terms of stroke, which is what caused the ending of the estrogen-alone arm with a 32% increased risk, the authors provide supporting data from more recent studies that find that route and dose are critical to these outcomes and, not surprisingly, lower doses and non-oral hrts reduce this rate to "extremely low."

Similar insight is found into the issue of venous thromboembolism (blood clots): route and dose and specific hormones make a big difference.

oral, but not transdermal, therapy was associated with increased risk of VTE and also that the thrombotic risk differed depending on the progestogen used. There was no increased risk with micronized progesterone, pregnane or nortestosterone derivatives, but significantly increased risk with norpregnane derivatives.

Overall, there is still not a good solid body of research evidence that pits one hrt against another for route and dose. It's well enough demonstrated that different hrt types and routes have different specific effects, and it's worthwhile, as we make our own hrt selections, to review these—the article does a decent job of listing them and providing citations for the actual research. At the moment, based upon their overview, their conclusion is that

the dose of estrogen is probably more important than the route of administration on the risk of CHD, whereas both route and estrogen dose can influence stroke and VTE risk.

Estrogen, we've long emphasized here, does not act in a vacuum. While the use of progestogens (progesterone-like hormonal agents) in surgical menopause is probably declining, it remains a critical element for the prevention of endometrial cancer and endometriosis growth and continues to be popularly pitched to women by hormone marketing, especially in the compounding realm. The article takes a look at the existing data on different protestogens, noting that it's "the androgenicity of progestogens [that] influences their metabolic effects." Any woman who requires a progestogen as part of her hrt should read this section as she considers the overall effects she both wants and must avoid.

Tibolone and the selective estrogen receptor modulators (SERMs) are often offered to women as being "safer" than actual hormones while still holding benefits of other types. There's not a lot of data on cardiovascular disease aspects of their use, but this section of the article does summarize what exists. For women without specific risk factors that require these treatments, the lack of good data on their risks should certainly raise a flag that they cannot be taken as completely benign and that simply choosing them in fear of one thing, usually cancer, may raise other risks. As ever, it's all about balancing risks and to do this effectively, we need to set aside our fears of one specific boogeyman and look very specifically about our own personal risk factors in a number of areas. This section begins to lay the groundwork on this category of hrts.

Finally, in conclusion they sum up the situation:

CHD forms a significantly greater burden of disease than breast cancer or stroke, and the menopause is a pivotal time for reducing future cardiovascular risk.

They note the importance of lifestyle and diet in overall risk management, something that we would like emphasize here as well. They go on to note that

Cardiovascular risk is determined by a combination of genetic, lifestyle and environmental factors, but sex steroids can play an important role in modulating risk.

And then for the payoff:

Current evidence points to a window of opportunity, where greatest benefit in preventing atheroma progression is seen when HRT is initiated early after menopause. HRT may cause adverse cardiovascular effects through coagulation activation and abnormal vascular remodeling, although the use of age-appropriate doses and transdermal routes can help minimize these risks.

And that, right there, is where WHI was trying to go but, due to flaws in the study design, went dangerously and disastrously astray.

Important points to take away from this article

First of all, it is a good overview of the whole topic, appropriate for us to read and share with other women but also appropriate to share with our doctors should they still be stuck in the post-WHI "OMG HRT kills!" mentality.

While there is much mention made these days of a woman's "individual choice" there are still many, many women, even in surgical meno, who feel pressured to "do it the natural way" as though there are some merit points to be won in withstanding misery and poor health. We think articles like this are things all women at perimenopause or surgical menopause should read, so that they better understand that against the "all natural" glamor can be stacked the true risks of the situation. This article is good on true risks.

Hot flashes cause cardiovascular disease. As noted above, it's likely that over time and with more research, this will be seen as a profound oversimplification, in which we have a correlation rather than a causation. Never mind; for the moment we can use this to our advantage if we are being denied hrt and feel that we must campaign for its prescription.

Cardiovascular disease prevention is not a case for treating hrts like drugs: this is the antithesis of a quick, dose-related response. Instead, we need to take a longer view of hrt use when we're talking cardiovascular disease, and so while the "least dose required to meet needs" premise of risk management is not at all contradicted here, the arbitrary discontinuation of hrt at some set age or interval is strongly called into question. This is important for us to understand and very important to convey to our doctors if they are not conversant with current thinking on this.

We can, each of us, resist the mindless panic brought on by the post-WHI media frenzy, and it's these sorts of articles that can help us make a more realistic evaluation of our risks with respect to hrt use. Further, by sharing this kind of updated, serious, and medically sound information with other women, we can help them make better, less emotional decisions for themselves. And by bringing this to our doctors, we can help them stay more up to date where they might not otherwise have the time or interest to pursue all the small studies that have, over the past decade, contributed to a much more realistic and accurate picture of hrt actions and options.

Surgical menopause boosts cardiovascular risks

Update note: the study cited below, "Surgical Menopause Boosts Cardiovascular Risks" no longer seems to be available online. Nonetheless, the discussion around it remains valid and we are retaining this post for that reason.

We've known for some time now that overall cardiovascular risk rises at natural menopause to approach men's generally higher rates. This was long assumed to be the result of the shifting of balance away from the heavily estrogen-dominated profile that distinguishes (fertile lifestage) women from men. Indeed, it was cardiovascular risk that was really the underlying focus of the infamous Women's Health Initiative study: women well past menopause who had developed cardiovascular disease were put on hrt to see if it would improve their status. Sadly, no such findings resulted. Nonetheless, the generally better cardiovascular status of women on HRT as compared to women without continues to fuel research on the "critical timing" premise, that proposes that functions supported without interruption by covering hormone needs in menopause without a significant time lag are protective, but that once hormone support lags, women cannot regain that lost protection.

We also know that testosterone may worsen cardiovascular risks as it brings us closer to the male profile of risks. That's part of why the US Food and Drug Administration did not approve the female testosterone patch: it didn't improve the libido in some women (where testosterone deficiency wasn't the problem) and it did boost risks. For women with Polycystic Ovarian Syndrome, that's a special concern, since their disease is often characterized by lifelong elevation of testosterone levels. The literature is not yet clear on this hormone and cardiovascular risk

Cardiovascular risk also relates to elevated progesterone levels. A progesterone-heavy hormone balance tends to make us insulin resistant, raising both the risks of type II diabetes and cardiovascular disease in a special combined disorder called "metabolic syndrome." Metabolic syndrome is considered of the established risks of menopause.

Estrogen and cardiovascular disease

What kind of cardiovascular disease specifically? All sorts, actually. In addition the the hypertension seen as part of metabolic syndrome, hypertension alone can be a sudden-onset disorder upon oophorectomy. It saddens us to read of doctors withholding hrt from women who spike sudden high pressures when they come out of surgery out of concern for stroke risk. In fact, it can be the loss of estrogen's relaxing effect upon the walls of blood vessels that can cause this, so they're withholding the one thing that can treat the problem out of a mistaken focus on the symptom instead of the cause. Other women, less catastrophically, may find their pressure creeping up when they are advised to abstain from supplementing their hormones back up to more normative, menopausal levels or when their HRT is suboptimal.

We also know that estrogen has a beneficial effect on lipid levels and types, although oral hrts provide a different assortment of effects in this regard than transdermal do.

But today we have another small study, Surgical Menopause Boosts Cardiovascular Risks [no longer available online], that looks more closely at just what goes into that shifting CV profile with estrogen loss. Although this is a rather small study of only 90 participants, what they found was that the carotid blood vessels (major arteries in the neck that supply the brain, which are taken as representative of general vascular condition throughout the body) are narrowed in women who had oophorectomies before natural menopause age and who did not supplement their hormones back up to normative levels.

Now, they were working with living study participants, so they couldn't go slicing into these major arteries to find out precisely what had them gummed up. The assumption is that this is an atherosclerotic process, the plating out of metabolic gunk, mostly fat- and calcium-based (think about the condition of your bathtub drain: atherosclerotic placque is roughly as appealing, only with a bit less hair), on the inside of the vessels that, much like the situation in your bathtub drain, gradually reduces blood flow until it may stop it altogether or a bit breaks off and stops flow someplace else (which is what a stroke represents in mechanical terms).

But that's just an assumption, at this point. There is certainly also an element to do with that reduced vessel size/relaxation as well. Beyond that, we don't exactly know and won't until there's more autopsy/surgical data that analyzes what those vessels actually look like on the inside. Still, this is an important step because it does validate that there is actual pathology in place, and that pathology correlates to a woman's specific hormonal status.

Of note, the article concludes:

Dr. Ozkaya said, "We should think twice and discuss it with the patient, should we consider performing oophorectomy before menopause."

Now, would everyone whose doctor warned them about increased cardiovascular risk with this surgery, especially those advised that hormone deficiency would be therapeutically necessary, please raise their hands? Nope, we didn't expect so. This is the elephant in the room that never really gets discussed pre-operatively or that gets hand-wavy assurances of "you'll take this little pill and everything will be fine." Right? And so this is what women need to be able to find out on their own...or with whatever help they can find.

Should women refuse an oophorectomy on these grounds? Oh, goodness no: there are often much more dire consequences and quality of life issues represented by the pathology for which we choose this surgery. On the other hand, this does add more weight on the side of turning down the "oh while we're in here we'll just take out those healthy ovaries because you don't need them any more" sales pitch. It really all comes down to weighing risks, and that has to be done by each woman for herself.

Managing cardiovascular risk in menopause

Yeah, but most of us here have already been through the surgery. How do we manage those risks now?

First of all, by simply being aware of this, aware of the body of literature we've linked to above, that is all legitimate medical research that you can share with your doctor in discussing this aspect of surgical menopause. We need to be monitoring this risk: we need to keep an eye on our blood pressure, we need to get lipid levels checked as part of our annual checkup, and we need to be prompt in seeking actual treatment if either of these start to rise.

Beyond that, though, we can work to forestall these effects through other means, nonmedical things we can do for ourselves. That's right: we're going to talk about those unpopular topics of good diet and exercise along with weight reduction. 

Right now, proponents of the high-fat/low-carb diets continue to duke it out in research studies with those supporting the so-called "Mediterranean diet." Our bookmarks account has a huge section on research and recommendations about diet: go read and make up your own mind. What you should know, though, is that diet is considered to be a major factor in cardiovascular risk and it's one we can manipulate ourselves. And by that we don't mean a week of good intentions when you give up a bowl of ice cream and really do mean to get more veggies; we mean a serious restructuring of what we eat every day for the rest of our lives. Although the site's main focus is cancer, the American Institute for Cancer Research has a lot of good, applicable material on what constitutes a healthy diet as well as tips on this next topic coming up just below.

And then there's exercise. Exercise does so very many good things for our bodies. It doesn't need to be crushing, but it does need to be regular and it does need to be at least brisk. Current recommendations from the US Centers for Disease Control and the American Heart Association are a place to start, although of course this needs to be discussed with your doctor if you have any issues that might complicate the situation. And yeah, it takes time and oh dear how do I fit that in my already busy life and maybe I'll start tomorrow yeah tomorrow for sure...we understand that whole argument because we struggle with it ourselves. The bottom line, however, is that that heart attack is going to be a whole lot more disruptive of our lives when we're spending a week in intensive care, if we happen to survive it. And, unless we get serious about prevention, that heart attack, statistically speaking, is in our future. Isn't that worth a little work to push back?

Last of all, we can't neglect the role of hormone balance in all of this. Imbalanced hormones, whether an excess of testosterone or progesterone, are likely to edge us higher in cardiovascular risk. Normative estrogen levels look as though they edge us a bit away from that risk.

That means that we need to look carefully when we're offered testosterone to make sure it's truly a situation of testosterone deficiency and we've exhausted other efforts to restore libido before we reach for this option. Using testosterone as a bandaid to cover up for poor estrogen HRT delivery: just raising our risks.

This also means we need to be cautious in supplementing progesterone. The "just because" premise of taking it, without regard for actual demonstrated need, looks less appealing with insulin resistance and metabolic syndrome keeping it company. Using progesterone as an hormonal hammer to bludgeon us into sleeping more in the face of estrogen excess: also less appealing when accompanied by cardiovascular risks.

But what about people who must deliberately induce a progesterone-heavy imbalance for therapeutic purposes? Those with endometriosis or who have a uterus are facing increased risk of endo growth and cancer if they skimp on progestogens in their HRT. Does that mean they are doomed? Certainly not, although they possibly do experience a raised level of risk and should therefor also be more vigilant about protective measures and monitoring. And they can consider, especially if they have other familial cardiovascular risks, whether they might prefer to use a vaginal progestogen to enhance pelvic circulation of that hormone without such high systemic exposure.

So does that mean if we take our HRT, we're safe? That's hard to say, but it looks as though the answer is not that clearcut. Even individuals in natural menopause experience increasing risk as their hormone levels decline, even though they are notionally still producing enough to meet their post-fertile needs. And since the level of hormonal coverage individuals with their ovaries produce in natural menopause is the situation we are seeking to emulate with HRT in surgical meno, we can assume that even if we've started taking HRT from the time of surgery and have had few disruptions in it, we still share roughly that level of risk.

And in case the question occurs to you, no, we're not advocating achieving higher-than-natural-meno estrogen levels as cardiovascular disease prevention. In that direction seem to lie increased hormone-mediated cancer risks, an equally unsavory option. So as with so many things hormonal, the middle ground of normative hormone levels and no more, along with a healthy lifestyle, seems to provide an undramatic but undeniably healthier plan.

Special situations: no HRT

There are a number of reasons why some women are unable to take hormones in surgical menopause. A blood clotting disorder or cancer are the most common reasons for this, but occasionally we hear of doctors recommending against hormones for other reasons such as blood pressure, smoking, or fear of the other risks they can carry. Whatever the reasoning, this is a difficult road to follow. While women in natural menopause can often get by with symptomatic relief to augment their own lingering ovarian output, a woman in surgical menopause is most likely going to have to face life in some degree of hormonal deficiency.

Of course there are also women who wish to refrain from taking HRTs or supplementing their hormones (these may not be considered the same thing by some women). We've read comments from many women who are afraid of hormones or HRTs because of some family history of cancer or because they had their hysts for cancer. But not all cancers are the same in the effects hormones may have on them, and if you don't know, for sure and in detail, that your specific cancer or family risk is specifically estrogen-mediated, you may want to discuss your own particular risk factors with an oncologist. Just because cousin Mabel thinks she recalls that Great-aunt Violet died of some sort of cancer doesn't mean that HRT may pose an unacceptable level of risk for you.

By the same token, if you cannot safely take HRTs, please understand that alternative HRTs like nutraceuticals and high-phytoestrogen foods do contain functional hormones and carry those same risks you're avoiding with prescription HRTs. And consider further that if you deem a family or personal cancer risk too high to supplement your hormones, you may want to discuss with an oncologist whether your own hormones also present that level of risk. Remember: your body doesn't stop producing hormones entirely when you lose your ovaries: you are still producing enough for the majority of your needs via body fat and adrenal conversion. If the small increment that HRT use adds is too dangerous, so too might your own production pose an unacceptable risk. An oncologist can help you explore whether you need to take drugs to block all hormone production or use in the body, and this may be every bit as important for you as not adding more to your system.

We also hear from many women who don't want to take "artificial medicines" that "make menopause a disease." Well, neither do we. Alas but HRT has been demonized plenty, both in the popular media and by crusaders who view it as nothing more than an evil plot by doctors/pharmaceutical companies/aliens to enslave women. That ignores, sadly, the real situation of surgical menopause as characterised by a shortage of something normal to the body's functioning and replaceable with equivalent chemically-structured supplements. We're not proselytizing for the use of HRT, but we are, strongly, urging women to research and understand the physiology behind their hormone needs and how they can be met. It's not a case where taking HRT is the only side of the question that has potentially negative impacts on health: not taking it can be just as devastating, can raise mortality risks just as high. And sadder yet are those who try to meet their hormone needs with alternative HRTs all the while denying that they are taking HRT and failing to monitor for those hormone risks. Whatever you do, please understand both the risks and benefits; don't just be swayed by fearmongers and salesmen.

For those, then, who cannot or choose not to supplement their hormones beyond what their own body can produce, there are a number of coping strategies that may be of use in dealing, one by one, with the aspects of hormonal deficiency that most plague you. The big question for women in this situation is well, what can I do? We'll do a rundown here of the most common problems.

Bone density

Weight bearing/strength/balance exercise is the biggest component of bone maintenance, whether or not we take HRT. No matter what raw materials we take in, we need to use our bones daily to produce the stimulus for our body to maintain bone strength. All women, irrespective of hormonal status, are recommended to get a hour's weight-bearing exercise daily. Yes, we realize that this is dull and unappealing for many women, but for women not taking hrt, this is akin to a drug that is required to replace it.

In addition to that, we need to provide our bone-building cells with the raw materials to construct those bones. This means about 1200-1500 mg calcium and 600-750 mg of magnesium, 15-30mg of zinc, and 800 mg of folic acid. We also need to make sure our vitamin D intake is adequate; while the US government standard has been raised from 400 IU daily to 600- 800 IU, the latest numbers we're seeing call for 1000 IU daily (free signup required to read) and many physicians, especially in higher latitudes, are recommending 2000 IU to their patients. It is widely believed that caffeine is a bone-robbing culprit, but that has recently been demonstrated not to be the case (it does boost circulating estrone, an estrogen, and for that reason is not something to binge on if you can't use HRT).

Bone scans are even more important for those who cannot use HRT, and getting a baseline density measurement soon after your hyst may be wise to track changes. There are a number of different drugs doctors can prescribe if we develop osteoporosis, but each of them carries fairly significant and not necessarily reversible risks of their own, and they are all rather expensive for lifelong maintenance. For recent articles on these drugs and other aspects of bone density/osteoporosis, check out the relevant collection in our bookmarks account.

Cardiovascular system

Taking a daily aspirin can reduce your CV risk by 33%, achieving your ideal body weight counts as a 45% risk reduction, regular exercise contributes a 45% reduction, you reduce your risk 2% for every mmHg of hypertension (blood pressure above 140/90) you reduce, quitting smoking is another 50% reduction of risk, and you get a 2% reduction for every 1% you reduce an elevated cholesterol. Sources also attribute a 35% risk reduction to "modest use" of alcohol, but because alcohol ingestion boosts circulating estrogens, we can't recommend it as a strategy in those avoiding estrogen exposure. Needless to say, monitoring blood pressure and lipids should be a part of a menopausal woman's annual physical and this is especially true of women raising their CV risks by practicing estrogen deficiency.

Dry skin, eyes and hair

Make sure you drink plenty (that's at least a quart and a half) of water every day (this doesn't mean sweetened drinks, which don't hydrate you very well). Put on a good moisturizer while you are still wet from your shower, and don't shower in excessively hot water or more than once a day. You may find that a moisturizer that contains urea will help hold moisture in your skin. Taking evening primrose oil may help with your hair, but you need to eat oily fish (salmon, mackerel, sardines, etc) twice a week to make sure that the whole process works right. Ask your eye doctor for a recommendation of moisturizing eye drops (the single-dose packets are great for avoiding contamination). You may not be able to wear contacts, but if you have your heart set on them, look into some of the newest, high-moisture brands. Limit the number of hours you spend staring at a computer monitor (and remind yourself to blink regularly). If eye dryness begins to damage your eyes, your ophthalmologist can insert tiny plugs in your tear ducts to help maximize the use you get out of what moisture you do produce.

Urinary incontinence

Kegel exercises are the remedy most recommended by physicians for this. Antispasmodics such as oxybutynin or hyoscyamine may help. At night, some women get relief using a low dose of the tricyclic antidepressant imipramine (25 mg). A pessary may help support weak pelvic tissues. Simple tricks like emptying the bladder more often, planning for bathroom availability on long outings, and moderating fluid intake when bathrooms are not convenient can help get you through awkward moments during the day. It may be helpful to consult a physical therapist who is licensed with the Women's Health Physical Therapy branch of the American Physical Therapy Association (the website includes a service locator). Many physicians aren't aware of this specialty service, but trained therapists can do a lot by teaching simple pelvic floor exercises (more specific than Kegels).

Vaginal atrophy

Avoid using scented soaps and rinse thoroughly when washing the genitalia. Avoid the use of antihistamines, decongestants or other drying medications. The use of vitamin E as a vaginal lubricant/moisturizer is well-documented as effective (insert a gel-cap of the regular vitamin into the vagina and let it dissolve and absorb—best done at night). External use of soothing creams made with calendula, comfrey or other soothing herbals may help…if you are not allergic to them (test a tiny bit first, please). Oatmeal baths are a classic for soothing skin complaints of all sorts. Commercial lubricants like K-Y or Replens will help during sex, but may not do as much as vitamin E for general moisturizing. Vaginal tissue health is a use-it-or-lose thing, in which regular intercourse or masturbation can greatly combat atrophy. Zinc and evening primrose oil are said to contribute to vaginal tissue health.

Insomnia

The primary problem with sleep is often being awakened by either hot flashes or their aftermath, soaking sweats. We discussed some measures related to hot flashes at night in our overall discussion of flashing, and there are more under a separate section below. For other sleep help, the use of soothing bedtime drinks is preferable to the use of sedative drugs. Try valerian or chamomile (or both combined in a "sleepytime" tea) or non-chocolate Ovaltine as bedtime relaxers. A traditional remedy is to sleep with a pillow stuffed with dried female hops flowers—which sounds rather nice. Finally, consider what your expectations are. It is better to get up and do something than to flop around in bed being furious that you aren't sleeping. Don't go to bed till you are tired, even if that's not till 4 am, as you'll just train yourself to be frustrated. These tips and many more, both medical and non-medical, are available from the National Sleep Foundation's insomnia portal.

Hot flashes

Black cohosh and red clover are about the only two herbals that have actually tested out as effective, but only in a limited way and with some notable risks. Red clover can affect clotting time, thus impacting those on anticoagulants as well as anyone facing surgery, and some of the recent tests proving its efficacy for hot flashes are now being questioned. Black cohosh, as studied in animal tissue, may stimulate metasteses of existing cancers (not cause new ones). This essentially moves it out of the "herbal-alternative" column and into the "estrogen" column as far as level and type of risks go, although it may retain some utility for those whose objections to pharmaceutical hormone preparations are philosophical rather than health-related. There is also a body of research that suggests that black cohosh does not stimulate new cancers, so its use in women who are convinced they are cancer-free may be less objectionable.

Soy, while considered by many naturally-menopaused women to be useful for hot flashes and other estrogenic effects, is shown (research remains conflicted) to be too estrogenic in the biochemistry of its action to be safe for those avoiding estrogen. Soy isoflavones have not been demonstrated as effective as whole soy, although combination products of the two may be a little more potent (or may not). Soy also is considered inadvisable for those with thyroid issues.

Another potentially-useful agent is an SSRI (selective serotonin reuptake inhibitor) antidepressant. Because this family of drugs boost serotonin, which can occupy estrogen receptors in the brain, SSRIs can be very effective in combating both the hot flashes and the depression that can result from lack of estrogen. They are not totally benign drugs and must be used under a doctor's supervision, but they can be true lifesavers. All SSRIs may not be considered suitable for women taking tamoxifen, but citalopram and venlafaxine are considered safe in that situation.

An older drug that was used to treat hot flashes, bellergal, is a less-attractive choice because of its sedative and drying properties. Clonidine, a blood pressure drug, and Gabapentin, an anti-seizure drug, are other non-hormonal drugs used to treat flashes but also have significant side effects. In 2018, oxybutynin, an anticholinergic drug developed for bladder spasms, was shown to be more effective than citalopram or venlafaxine and safe for women who need to avoid hormone exposure, but it is not without its own side effects. More on this new option in this separate post on oxybutynin.

All of these agents may decrease the frequency and intensity of flashes but probably will not eliminate them entirely.

Depression, mood swings, crying, lethargy

In some ways, this can be one of the most extreme and destructive problems a woman in surgical menopause must wrestle with. While doctors are sometimes too quick to offer the easy fix of antidepressants as a bandaid to cover up hormonal balance problems, we have to endorse the validity of this approach when HRTs cannot be used to correct the underlying chemical disruption lack of estrogen causes in the brain. Depression is a life-sapping disorder and one difficult to admit to or to be effective in combating while in its throes. There are lots of useful non-drug interventions available to help with depression but perhaps the best is exercise. Exercise releases endorphins, a feel-good chemical that can improve your mood for a considerable amount of time. Unfortunately, depression can make it difficult to motivate yourself to exercise or use many of the other useful techniques.

Stepping up in intervention is use of an antidepressant. St. John's Wort continues to be well-regarded by some practitioners as a safe and effective antidepressant. For some women, it's all they need; for others, it's not just strong enough. In those cases, treatment with an SSRI antidepressant would seem to us to be a desirable approach. Some of us who cannot use hormones are now using an SSRI, and the rest of us would like you to know, it's making a vast difference that both they and we can see. An article published by CNN in Dec. 2000 cited a Mayo Clinic researcher, Dr. Charles Loprinzi, who reported that "a four-week trial involving 229 women, most of whom had a history of breast cancer, revealed that venlafaxine was 60 percent effective against hot flashes. The optimum dosage was 75 milligrams daily," Loprinzi said. "And the effects we saw were within a week." The report is the end result of ten years of studies looking for the best solution for breast cancer patients, and finds that venlafaxine (Effexor) to be expensive, but far more effective than any other of the traditional medical, herbal or vitamin remedies. This has been further supported by research since then, and an SSRI is now considered a standard of treatment. As with hormones, different women respond differently to each SSRI, so some experimentation may be necessary to find the best, most effective one for any given woman.

Depression in menopause is both over-dramatized and under-appreciated. Women tend to blame themselves (and doctors may help them do it) for not "getting a grip" and "having a positive attitude." Sure, it's a rough adjustment, especially when we're limited in our choices and the transition is traumatic. But there are also real, physiological issues here. For the best explanation we've seen, we highly recommend the book Women's Moods by Deborah Sichel and Jeanne Watson Driscoll for a scientifically-sound but not incomprehensible discussion of the topic, including a number of self-help steps any woman can take to help cushion her brain from the effects of menopause. The link in the book title above takes you to a more in-depth report on this book here, but you can also check your favorite used book store or library for a copy.

[This post last updated: 12/10/18]