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Alternatives to HRT for menopause

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Woman's Health. Paper Uterus and Flowers on Light Blue BackgrounThe physical and mental changes experienced by women in menopause have an ever more significant impact on their daily lives. According to the website North American Menopause Society (NAMS), every day, around six thousand American women will become menopausal. That’s approximately two million women each year. What’s more, the number is growing faster than the overall population. This problem is not unique to the US but is a characteristic of all advanced societies.  The leading cause of the proportionately larger numbers is primarily attributed to the increasingly sedentary lifestyle of most advanced countries. This lifestyle is characterized by prolonged periods of inactivity and minimal physical exercise.  Let’s be clear – it’s not that people are becoming lazy. Many different features of modern society contribute to the trend toward sedentary living, and not all of them are voluntary.  The surge in sedentary behavior can be attributed mainly to social and technical changes. Some of them have been long-term trends, such as the overall shift from manual work on factory and shop floors to office work sitting behind desks for the whole workday. The pervasive use of digital devices, the rise of streaming services, and the proliferation of online activities have also contributed significantly.  Some more radical spikes have come with the push towards work-from-home caused by the pandemic. According to one website, twenty-two million Americans work at least part of the week from home. The number peaked at the height of the pandemic but has retreated only marginally.

Women are living longer with menopause

It’s a matter of simple arithmetic. According to actuarial tables, life expectancy at birth for females born in 1930 was 62. So if (on average) females start puberty at 15 and menopause sets in at 45, it means that in the mid-1900s, women were fertile for roughly 30 years and experienced menopause for about 17 years. In contrast, a woman born in 1970 had a life expectancy of 77. She would be fertile for the same 30 years but could now be in menopause for 32 years – close to double the previous figure, making menopause a more significant period of a woman’s adult life than ever and thereby making the changes experienced by women in menopause more important.

How does menopause affect a woman’s health?

Menopause is primarily a set of symptoms driven by the decrease in the production of estrogen and progesterone in the ovaries triggered by advancing age. Perhaps the most well-known effects of menopause are associated with this transition, often referred to as the “menopausal syndrome.” These include hot flashes, night sweats, mood changes, sleep disturbances, loss of libido, and vaginal dryness. These symptoms can be highly disruptive. They may be transient, but for many women, some symptoms persist, often for the remainder of their lives. Menopause can have more specific health impacts. For instance, the decline in estrogen levels is closely tied to an increased risk of cardiovascular disease, the leading cause of death among postmenopausal women. Before menopause, women tend to have a lower risk of heart disease than men, but this disappears after menopause, underlining the protective role of estrogen on heart health. Another significant health concern brought on by changes experienced by women in menopause is osteoporosis, a condition characterized by weak and brittle bones. Estrogen plays a crucial role in maintaining bone density by balancing the activity of cells that build up and break down bone tissue. After menopause, the sharp decline in estrogen leads to increased lower bone density, raising the risk of easier fractures and other injuries. Additionally, the metabolic changes that occur during menopause, such as the shift in fat storage to the abdominal area and the increase in insulin resistance, can contribute to weight gain and heighten the risk of metabolic syndrome and type II diabetes. Menopause can also impact mental health. Some women may experience depression, anxiety, or cognitive changes, such as memory loss or difficulty concentrating. These issues may directly result from hormonal changes or related to the stress of dealing with other menopausal symptoms. Menopause can impact sexual health. Lowered estrogen levels can lead to changes in the vagina, such as dryness and loss of elasticity, making intercourse uncomfortable. This and decreased libido can lead to challenges in maintaining a satisfying sex life.

What’s wrong with the treatment of women in menopause?

We published “Menopause is not a disease” in 2022, defining the most important aspects of menopause today. Our closing sentence was, “Now, hopefully, women will feel empowered to take control of their bodies and their minds and approach menopause not as a disease that needs treatment but as a normal state to be managed.” We stand behind that statement.  According to an analysis published in, there is a ‘massive care gap’ in the US due to the shortage of ob-gyn healthcare personnel who specialize in menopause. Of the two million US women who enter menopause each year, fewer than twenty percent are diagnosed. The article explores a survey of ob-gyn residents in the US published in Menopause, the journal by NAMS, in 2013; more than 60% of those surveyed reported having limited knowledge of fundamental aspects of menopause medicine.

Consider the options for handling any adverse effects of menopause

Hormone Replacement Therapy (HRT) is currently the most common line of treatment. You can read more about it here. The logic is relatively simple. The steep decline in the female hormones estrogen and progesterone levels brings menopause. HRT replaces the missing estrogen. It is also usually combined with progesterone to mitigate the possibility of cancer in the womb from estrogen alone. The main benefit of HRT is that it can reduce, to some degree, all of the symptoms we listed above. Dozens of choices will deliver the required estrogen or progesterone dose via oral medication, skin gels or ointments, and vaginal suppositories or creams. Some of the treatments we have written more about include Estrogel Topical Gel, Prometrium (progesterone), Eviana or Estrace (with estradiol), Minesse (synthetic estrogen), and Premarin (with conjugated estrogens) oral meds, Climara and Estradot (with estradiol) skin patches, and Ovestin and Premarin Vaginal Cream vaginal creams. However, there are some risks associated with long-term HRT. These fears primarily come from surveys showing an increased incidence of breast and uterine cancer (especially when pure estrogen supplements aren’t taken along with progesterone), cardiovascular disease, and stroke for women over 60. The risks can depend on the dose level of HRT and how it is delivered. Overall, there is a growing feeling that the negatives of HRT are starting to outweigh the benefits, mainly because of the need for longer treatments with the therapy as women live longer.

HRT alternatives for menopause symptom relief

Changes in the lining of the vagina can have profound effects on comfort, sleep, and sex life. The NAMS website explains that a condition known as “vulvovaginal atrophy” can develop. “Shifting levels of .. estrogen during the menopause transition produce changes in a woman’s body…. Both the vagina and the external female genitals (vulva) are affected.… After menopause, when estrogen levels are low, the vaginal lining is thinner and has fewer folds, making it less flexible. Dry, fragile vulvovaginal tissues are susceptible to injury, tearing, and bleeding during intercourse.” If oral medications that boost estrogen levels are not appropriate (generally due to side effects or increased risk of breast or uterine cancer), the alternatives may come down to creams that deliver lower doses of estrogen but that have the benefit of relieving the symptoms coming from vaginal dryness. One example is Premarin Vaginal Cream. Read more here about what this hormone replacement alternative treatment can do to alleviate the problems coming from changes to the vagina. The bottom line is that using the appropriate therapy can keep sex life active and pleasurable at any stage during a woman’s life cycle; for a more detailed explanation of what, where, and how menopause impacts a woman’s sex life, read here


Who should avoid HRT?

Hormone Replacement Therapy may be contraindicated for women with a history of breast, ovarian or uterine cancer, who have blood clots, untreated high blood pressure, or liver disease.

What are the risks of taking HRT long-term?

Hormone replacement therapy can be prescribed to ease some of the symptoms of menopause, but it is associated with many serious risks when used over the long term. The benefits include lowering the risk of bone fractures, avoiding hot flashes and changes to the lining of the vagina, it increases the risk of heart and vascular problems, and breast and uterine cancer.

Does HRT outweigh the risks?

For most women, the benefits of HRT usually outweigh the risks. However, the risks depend on the type of HRT, how long it is taken, and a woman’s health status. Speak to a doctor before starting HRT, or it’s already being used, and there are any signs of unexpected side effects.

Where is the best place to apply estrogen cream?

Be sure to follow the instructions that come with any prescribed medications. If there are any questions, be sure to consult with a physician or pharmacist. For most vaginal creams, it’s necessary to cover the estrogen receptors near the opening and inside the vagina. It may not be necessary to push the cream high into the vagina.
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