Going Through The Change
Several years ago when I was in my early 50s, I witnessed a curious situation in the Green Tennis Center parking lot. It was a cold winter day, and a friend and I, still in our tennis togs, were chatting outside our cars. I was wearing a jacket. She was not.
“Haven’t you gone through this?” she asked after I inquired why she wasn’t cold. She said her new condition was really cutting down on heating bills.
Not long after, I learned all too well what she meant. I woke in the middle of the night on fire from the neck down. Desperate for evaporative cooling, I kicked off my covers and lay spread-eagle on the bed. Heat surged through me stabbing at my chest. A few minutes later I was drenched and clammy, and it was over–my first full-blown hot flash.
Hot flashes are one of the telltale signs of peri-menopause, a woman’s natural transition toward menopause. They occur with varying degrees of intensity and affect about 75 to 85 percent of women in peri-menopause. Other symptoms include irregular or heavy periods and menopausal disturbances such as headaches, fatigue, hair loss and vaginal dryness. Most women reach peri-menopause in their mid-to-late 40s, but some can notice the symptoms as early as their mid-30s.
Doctors don’t know exactly what causes hot flashes, but it’s likely related to hormonal changes. Decreased levels of estrogen have a direct effect on the brain’s hypothalamus, which controls appetite, sleep cycles, sex hormones and body temperature.
“Most women are not surprised by what is happening,” says Katie Welch, MD, an obstetrician/gynecologist at Women’s Health Associates. “They just want to know how to help modify the symptoms.”
During peri-menopause a woman’s estrogen levels are in flux, which gears the body toward the ceasing of menstruation, Dr. Welch says. Eventually, there’s not enough estrogen released from the ovaries to thicken the uterine lining, and menses stop. Ovulation also stops, and a woman can no longer bear children. She says that peri-menopause can last up to 10 years, and the average age of menopause is 51.
For me, it was 52. By then the hot flashes had ramped up, and I too was saving money on heating bills. My husband invested in a polar fleece vest, which he wore inside while I dressed for summer. I was unfazed by Missouri’s “wintery mix” and joked with friends about how our hot flashes might be causing global warming.
I certainly didn’t miss the hassles of monthly periods or the PMS and cramping that accompanied them. I also found menopause to be a convenient excuse. Any time I forgot something or got confused, I blamed it on “mental pause.”
But for some women, the symptoms of peri-menopause and menopause can be unbearable. Extreme hot flashes and night sweats can disrupt sleep, which results in irritability, fatigue and even depression. Added to that, vaginal dryness, loss of libido and increased urinary infections can take the joy out of sex. For women who might also be facing an empty nest or the loss of their parents, these changes can make them feel like they’re getting old before their time.
“The hardest part for most women is the fear of aging, and menopause is a sure sign of that,” Dr.Welch says. “We live in such a ‘beautiful’ society – staying young forever and the fight to make that happen. For a lot of women, dealing with menopausal symptoms is just the beginning of other things.”
At the root of these other things might be misgivings associated with menopause. Often, a big part of a woman’s identity up until menopause is the ability to have children. When a girl gets her first period, she’s often told she’s become a woman, and in cultures throughout the world, the onset of menarche is cause for celebration. By contrast, menopause can feel like a loss.
“I look at menopause as a reverse puberty,” says William Trumbower, MD, a gynecologist and independent contractor at Pela Cura Anti-Aging and Wellness. “You lose bone and muscle mass, your brain changes, your sleep is different. You lose your sex drive and your sexual function. How women deal with that is really up to them.”
Recently, Dr. Trumbower retired from Women’s Health Associates to become an independent contractor with daughter Elisabeth Trumbower, an RN, licensed esthetician and owner of Pela Cura Anti-Aging and Wellness. “What we’re offering is an integrated approach that will improve a patient’s quality of life for as long as possible,” Elisabeth says. “Bioidentical hormones and BHRT are a huge part of that.”
Over the years, Dr. Trumbower has been involved with bio-identical hormone replacement therapy, or BHRT, to help even out hormonal imbalances and reduce certain health risks. “Bio-identical hormones are an option,” he says. The hormones are created in a lab from yams and soy and have the same chemical and molecular structure as what the human body makes. The hormones he uses are FDA approved, so they’ve been shown in trials to relieve menopausal symptoms and reduce the risk of osteoporosis.
Doctors administering BHRT measure their patients’ hormone levels with saliva tests and develop individualized prescriptions to bring them into balance. (Saliva tests can also indicate whether a woman in her 30s or 40s has entered peri-menopause.) The prescription typically includes progesterone, which women who have had hysterectomies or are menopausal no longer have, and estrogen. It might also include testosterone, DHEA or adrenal hormones.
For those who choose BHRT, their prescriptions can be administered in several ways. Many patients use cream, which bypass the liver and avoid the risks like blood clots. For patients needing higher doses, shots or pellets, which also avoid the liver, are options. Pellets are a compressed form of pure hormones that are inserted under the skin with a local anesthetic.
For some women, the pellets can be a godsend. One of Trumbower’s patients, now in her late 50s, went into menopause at 35, about 17 years earlier than average, due to a hysterectomy. She says that the pellets, which she receives every four months (they dissolve over time), keep her feeling steady, help her sleep and reduce headaches.
“I’ve had trouble with hormonal imbalances since I was 13,” she says. “This is the best I’ve felt in a long time. My husband says I’ve never been more level. I have no intense hot flashes, although I’ll probably flash until the day I die.”
“I do just enough bio-identicals that I do think there’s some benefit to them in the right patient population,” Dr. Welch says. Recently, a patient in her late 50s/early 60s called with a certain problem that was above and beyond what Dr. Welch felt comfortable treating, so she referred the patient to Dr. Trumbower. He helped her with hormonal balance, but Dr. Welch still sees her for annual exams, PAP smears and breast exams.
“I see bioidenticals as much more useful in patients who are peri-menopausal or postmenopausal versus somebody who’s younger and trying to control a cycle,” Dr. Welch says.“The dosage required to control or make a cycle is much higher, so a lot of times we need that birth-control pill dose to regulate a cycle.” Women in peri-or post-menopause have fewer hormones in their bodies than their younger counterparts, so bio-identicals, which are gentler, might be all that’s needed to get things in balance.
Dr. Welch suggests that before considering BHRT, women should be aware of an increased risk of complications, especially if they have cardiovascular disease, diabetes or high blood pressure. She references the Women’s Health Initiative study (WHI), which came out 13 years ago and linked hormone replacement therapy (HRT) to a higher risk of heart attacks, blood clots, strokes and breast cancer.
“Knowing that the WHI study only looked at Premarin and Provera, we can’t say that bio-identical hormone therapy is safer because it’s never been studied,” she says. “Also, cost is a big one with the bio-identicals. Depending on what they’re getting, BHRT may be more expensive than a prescription medication.”
Estradiol and Prometrium are examples of traditional prescription medications that contain natural estrogens and progesterone, she says. Although she doesn’t have solid percentages, she estimates that about 50 to 75 percent of women take some form of hormone replacement during menopausal transition. However, ever since the WHI findings, it is not recommended that women continue traditional HRT for long periods of time.
Dr. Trumbower has a different take on the WHI. “The American medical establishment is basing all of their views on that study,” he says. “Any research on Premarin tells you about Premarin; it doesn’t tell you about estrogen.” Premarin, which is made from the urine of a pregnant mare, contains 26 different horse hormones in one tablet, he says.
“My response is go to France,” Dr. Trumbower says. “The French never got into synthetic hormones by mouth. They have always thought that bioidenticals through the skin were better.”
The French Cohort Study, which is still ongoing after 12 years, has found no increase in heart attack, stroke and blood clots associated with bio-identical hormones, he says. And when the hormones were given in a balanced fashion, it found a decrease in breast cancer.
“The real question is: are you healthier with these hormones?” he asks. “And the answer is I think so because hormone balance makes everything better.” He says it’s important to go to a clinic with a physician who understands the complexity of hormonal balance, which is key in preventing some of the risks associated with HRT.
“I applaud Dr. Trumbower’s individualized approach to women and their hormones,” writes Susan Nagel, PhD, associate professor of Obstetrics and Gynecology and Women’s Health at University of Missouri.“There is a large amount of variability in both estrogen and progesterone levels and the response to the same level of hormone. With any medication, there are risks, and certainly there is a slight increased risk of breast cancer in postmenopausal women taking estrogens of any kind.”
A 2015 study compared levels of hormones in women taking a common formulation of bio-identicals with standard hormone HRT. It found that estrogen levels were generally lower in women on
bio-identicals, which suggests they might not have any additional risks, Dr. Nagel says.
But even with the reduced risk, some women wonder why they should take hormones at all. Rather than thinking of menopause as a deficiency disease requiring medical intervention, why not accept menopausal symptoms as a normal part of aging?
“Many women sail right through menopause,” says Jan Swaney, MD, an internist specializing in women’s health, who recently retired. “They might have some symptoms that they view as nuisances, such as hot flashes, sleep disturbances, dry skin and dry eyes, but they have enough life experience to put them into context.” These women tend not to seek medical intervention for menopausal symptoms, she says.
Recently, Urology Associates of Central Missouri opened Epoch Health, which offers anti-aging treatments for men. With Pela Cura getting into the act, women will have an opportunity to keep up with their partners, Dr. Welch says. “I think Dr. Trumbower’s providing a service that we haven’t had,” she says. “I think he’s going to be busy.”
For me, the onset of menopause was part of an overall re-defining of myself in my 50s. In the beginning it was about fighting the aging process. I had some work done, ramped up my exercise and spent a lot of money on undergarments, all in hopes of recovering my younger self on the outside.
But in recent years I’ve ventured inward, and my anxieties over aging have subsided. I’ve reconnected with a faith community, spent more time outdoors and embraced new experiences. I feel fortunate to have a supportive husband and a number of friends who were going through The Change right along with me.
Hormone therapy aside, there’s something liberating and even empowering about being postmenopausal. With our children launched, my husband and I have more time and money to pursue our own interests and visit our families. Last summer I turned 59, and my father gave me a card that said, “You keep getting better!” He’s 91. I think I’ll take his word for it.