Ask the ND: Managing Menopause

March 3, 2012
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We asked Dr. Tori Hudson, ND, to answer some of the most common questions about menopause symptoms and treatment. Dr. Hudson is a member of Pharmaca’s Integrative Health Advisory Board and Medical Director of A Woman’s Time Clinic in Portland, Ore.

What herbs and supplements should I consider to control my menopause symptoms?

It always depends on your symptoms, but here’s how I approach it. First I have to determine that someone’s symptoms are related to perimenopause or menopause. If she’s 40-something and has a familiar collection of symptoms (e.g. hot flashes, anxiety, irritability) and her periods are starting to change in some fashion, it’s probably related to menopause.

If so, there are some core products I like to use as a foundation: black cohosh extract, Femmenessence MacaPause or Vitanica’s Women’s Phase II. These three products have been well researched for a diverse array of menopause symptoms.

If needed, I would give additional supplements based on other symptoms that need addressing. Really can’t sleep? Add valerian or a sleep formula right before bed. If depression is a more dominant symptom, add St. Johns wort (which has been researched to work especially well with black cohosh).

You also have to make sure you’re addressing the correct symptom. If your hot flashes are causing insomnia, you have to quell the hot flashes before you can address any remaining sleep issues.

Are there lifestyle changes or other modifications I can make to help alleviate symptoms?

There are definitely some lifestyle changes that have research behind them. Research has shown that relaxation techniques like yoga and meditation can ease sleep problems and hot flashes. On the other hand, hot and spicy foods have been shown to trigger hot flashes, as have alcohol, caffeinated beverages and smoking.

At what point should I consider hormone replacement therapy?

The primary indication for HRT is hot flashes and/or night sweats and/or vaginal dryness–these are the primary approved symptoms for estrogen administration. But doctors use hormones in this population to help all kinds of symptoms, not just what the FDA has approved it for.

In addition, there’s some compelling new evidence that says that estrogen can help prevent Alzheimer’s. Even though it’s not approved for that yet, if a patient has a family history of Alzheimer’s, I would be more prone to prescribe estrogen for her.

Things are complex with each individual patient, so we look at the whole picture before we decide on a course of treatment.

If I choose to use hormone therapy, what are the advantages and disadvantages of the various routes of administration?

If a patient has local genital symptoms that we think are estrogen related (dryness, itching, pain), then the best solution is a topical estrogen that’s applied in or outside of the vagina. We always try to address a symptom as locally as possible before pumping a medication through the rest of the body.

In terms of oral pills, the main advantage is they’re easier, generally cheaper, and if we’re doing compounding, we can blend all different hormones and doses into one pill. And in general, we get more predictable results from pills.

On the other hand, transdermal patches, creams or gels have the advantage that they avoid passing through the liver, the route that oral hormones go. Experts believe this interaction with the liver can increase tryglicerides, blood clotting, liver enzymes and c-reactive proteins (a marker for inflammation). These increases don’t necessarily happen, but they can. So if someone already has elevated liver enzymes–from obesity or high alcohol consumption–I would opt for a transdermal delivery so we don’t add to the burden of the liver.

The drawback to transdermal hormones is that people can be allergic to the adhesives, they can be more expensive, and most of the patches are estrogen only, so you would have to supplement with an oral progesterone.

What is bio-identical hormone therapy? Is it safer than the standard hormone therapy?

These hormones are made in a manufacturing facility–an ingredient is extracted out of a plant, either soy or Mexican wild yam, then converted into a hormone that is biochemically identical to human hormones. (The word “plant” can be confusing to some, but the finished product is not a plant hormone, it’s a human hormone.)

Is it safer? Bioidentical estrogen has not been proven to be safer, but progesterone does have some potential safety advantages. Fewer women have side effects with it, and it seems to have a friendlier effect on the coronary arteries since bioidentical progesterone doesn’t lower good cholesterol (though synthetic progestin does). Additionally, there are two French studies that have shown that when you give any kind of estrogen along with a synthetic progestin, you get a slightly increased risk of breast cancer. But when you give any estrogen with bioidentical progesterone, the risk is not there.

Some bioidentical hormones are available through commercial drug companies (such as Estradiol, Estrace and Prometrium), and are often less expensive than compounded versions. But the advantage to compounded hormone replacement therapy is that we can offer specialized doses, create infinite combinations of different hormones and customize the delivery system. You can’t get a cream or pill with both bioidentical estrogen and progesterone from a drug company. Compounding also allows us to address sensitive patients who are allergic to a certain filler in the brand name drug, or to the patch adhesive.

I recommend compounded hormones most often, but when people’s budgets are involved, sometimes the commercially available bioidenticals are the best bet.

Are there side effects of hormone therapy? How does my individual health/family history affect my decision to take hormone therapy?

If a patient starts hormone therapy within the first 10 years of menopause, we don’t think it will increase your risk of heart disease or Alzheimer’s. But waiting longer than that may increase that risk.

Here are some other side effects we know about:
If you take a combination of estrogen and progesterone for longer than four years it can slightly increase the risk of breast cancer, though studies show combining any estrogen and bioidentical progesterone won’t.
If you take estrogen only (which is the approach if you do not have a uterus), then your risk for breast cancer slightly increases after seven years.

In the first year of taking oral estrogen, there is a slight risk of blood clot or stroke. If a patient has a history of blood clots, I won’t prescribe oral estrogen–I’ll try a lot of other options before I try even transdermal estrogen.

When talking with your doctor about the benefits and risks of HRT, make sure you discuss any family history of breast cancer, heart disease, Alzheimer’s and osteoporosis.

Are there other prescription options if I can’t do HRT?

There is scientific evidence to show that selective serotonin re-uptake inhibitors (SSRIs) can be helpful. Medications like Prozac and Paxil are being used especially with women who can’t take estrogen for another medical reason.

They don’t work as well as estrogen, but can work for hot flashes. We usually only go that route if we’ve worked through all the herbal options and dismissed hormone replacement therapy as an option.

How do I know my symptoms are related to menopause and not another health issue?

Given that there’s a long list of possible symptoms, it’s true that many of them could be caused by something other than menopause. Hot flashes can be caused by hyperthyroidism, for example, and even certain cancers can have heat associated with them.

Irregular bleeding would be the most worrisome thing that could be caused by something else, like polyps, cancer or endometriosis. So it’s prudent to do due diligence with your practitioner to see if your collection of symptoms is indicative of menopause or something else (or both).

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