Starting and stopping hormones

menopause sign, The austin diagnostic clinic menopause center

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Hormones: When to start and when to stop

Menopause is a natural life process and all women experience it differently, both in onset and severity.  The definition of menopause is when a woman goes 1 year without a menses (without the use of hormones).

We often get questions from women about when to start and when to stop the use of menopausal hormone therapy.  This is something that is decided for an individual woman after consultation with her physician.  Not all women need to take hormones and there are, of course, risks and benefits from all medications.  Some women never have symptoms, but most women’s menopausal symptoms are worst prior to and in early menopause and they gradually improve with time.  Only 30% of women are still having symptoms by age 60 and only 10% of women are still having symptoms by age 70.  Non-hormonal options are available for women who cannot or choose not to use hormone therapy.  Most women who have had a hysterectomy only need to take estrogen.  The following are general guidelines only.

Starting hormones

Women who have an early menopause, either natural or surgical, should probably use hormones as soon as the diagnosis has been confirmed.  Premature ovarian failure or surgical removal of the ovaries prior to the age of 40, leads to an increased risk of early onset heart disease and osteoporosis.  It is recommended by the North American Menopause Society that these women take hormones until the natural age of menopause which is 51.  Women with an early menopause should also use higher doses that the standard hormone doses.   Women who have menopause in their 40’s (especially prior to the age of 45) should probably use hormones as well for the same reasons.  The Women’s Health Initiative study (WHI) did not include any patients under the age of 50, so the results cannot be applied to younger women.  The WHI did show a beneficial effect on the heart and bones if hormones are started prior to the age of 60.

Women who have a lot of symptoms prior to the final menstrual period can still benefit from starting hormones, but it is sometimes tricky to prevent irregular bleeding.  For this reason, we often use low dose combination birth control pills or rings or progesterone only pills or IUD.  Low dose oral contraceptives can be used safely in non-smoking women up to the age of 55.  There are also health benefits to low dose oral contraceptives including lower risk of ovarian and uterine cancer.

Women who have menopause at the normal age (early 50’s) should only take menopausal hormone therapy if they have symptoms of menopause.  Although there is a beneficial effect on the heart & the bone, there is a slight increased risk of breast cancer in women who take a pill form of estrogen combined with a synthetic progestin after 4-5 years of use.  FDA-approved bioidentical hormones are available and smaller studies have not shown an increased risk of breast cancer with the bioidentical progesterone.  Women in the WHI who had a hysterectomy took estrogen alone and had a slight decreased risk of breast cancer.

The WHI did show an increased risk of heart disease in women who start hormones after the age of 60 and an increased risk of dementia in women who start hormones after the age of 65.  We suspect that was caused by the fact that only a pill form of hormones was studied.  Oral hormones have to pass through the liver to be metabolized and this has been shown to increase clotting factors, triglycerides, and C-reactive protein.  All three of these are associated with heart disease.  Transdermal hormones (patches, gels, etc.) do not have to pass through the liver to be metabolized and therefore do not cause these issues.  Therefore, it is probably safer to use transdermal hormones in women who have risk factors for heart disease (i.e. high cholesterol, diabetes, age over 60).

Studies have shown that the most rapid bone loss occurs in the first 3 years since the final menstrual period, so women who are at risk for osteoporosis and want to use hormones should start it within 3 years.  Studies have also shown that women who start hormones within 6 years of their final menstrual period have healthier arteries than women who do not take hormones.  A general guideline is that hormones should not be started after the age of 60 or more than 5 years from the final menstrual period.

Stopping hormones

The current recommendation is to use the lowest dose for the shortest length of time possible to meet the patient’s needs.  Unfortunately, we don’t know whether a woman will have symptoms without stopping their hormones & then restarting if symptoms recur.  There is no scientific evidence that it is better to stop abruptly or to gradually decrease the dose.  In my experience, I try not to stop hormones in the spring or summer and I prefer to gradually decrease the dosage every 3-4 years.  If a woman is having symptoms on her current dosage, I do not decrease.  We may not eliminate every hot flash, but we do want women to have a good quality of life.  I do try to switch patients to the bioidentical progesterone after 5 years of use of a synthetic progestin.  I also try to switch women to a transdermal estrogen at age 60.

After age 65, Medicare will not cover any estrogen products.  A small number of women (<10%) do have hot flashes for the remainder of their lives.  It then becomes an issue of quality of life.  The North American Menopause Society does support the use of hormones for women over 65 who still have symptoms as long as they are informed of the risks and benefits.  Vaginal estrogen can be prescribed for women who are past the hot flashes but have urinary or vaginal complaints.

Patricia Gunter, MD is a menopause specialist at The Austin Diagnostic Clinic certified by the North American Menopause Society.   She practices at ADC North and is accepting new patients.  To make an appointment call 512-901-1111.