Hot flashes, depression, bone loss: menopause can be accompanied by numerous symptoms that are a great burden for women. However, for fear of breast cancer and other risks, many of them shy away from taking hormones – a fear that, according to experts, may also be based on outdated ideas about the corresponding therapies. For many physicians, various types of hormone replacement treatment are once again the means of choice if there are no risk factors to the contrary.
According to the Federal Center for Health Education (BZgA), about one in three women during menopause feels the same as before. Another third have phases with mild symptoms and a third report really stressful side effects. Symptoms such as hot flashes, mood swings, sleeping problems, bladder weakness and vaginal dryness can vary in severity. According to the German Menopause Society, symptoms can appear up to ten years before the last menstrual period and last for more than a decade.
Several studies from Great Britain and most recently from the USA have already shown how stressful this can be not only for the everyday life of affected women, but also for their professional activities. For example, a Mayo Clinic survey of 4,400 working women released in April found that 13 percent experienced impairments at work due to menopausal symptoms and about 11 percent reported missing a day or more because of these symptoms. “Adding to the complexity of women’s experience of menopause is the fact that the topic is taboo, particularly in the workplace, which may add to the psychological burden of the symptoms,” noted lead author Ekta Kapoor in a note to the Science journal. published study.
What does menopause mean
Many of the symptoms can be effectively alleviated with hormone preparations. Because during menopause, with the end of the terrible phase in a woman’s life, the production of female sex hormones decreases. This can be counteracted, among other things, with monotherapy (oestrogen; only indicated after a hysterectomy) or with a combination therapy (progestin and oestrogen). However, the publication of a study by the Women’s Health Initiative (WHI) in 2002 in particular caused concern for a long time: It had suggested a connection between hormone replacement therapies and an increased risk of breast cancer, which deterred both doctors and patients.
A health report by the Techniker Krankenkasse in 2022 showed that in this country only about six percent of working women between the ages of 45 and 65 take hormone preparations for symptoms associated with menopause – in 2000 it was 37 percent.
The publication also changed the focus of science: After 2002, most research work dealt with the possible risks of hormone therapies and came to sometimes contradictory results, as a literature analysis published in the journal “Frontiers in Medicine” in 2022 showed.
Timing is everything
“Immediately after the WHI study, the situation was catastrophic,” recalls Peyman Hadji, head of the Hormone and Osteoporosis Center in Frankfurt. In the meantime, however, the view of hormone therapies has changed again, not only on the medical side, but also on the patient side: “Today, women are much better informed,” says Hadji, who is also a board member of the German Menopause Society. Nevertheless, there are justified fears about the connection between hormone therapy and breast cancer: “However, estrogens do not cause cancer, otherwise every woman at 50 would have breast cancer. Rather, the hormones can accelerate tumor growth, which explains the slightly increased risk described in the relevant studies,” says the doctor.
In fact, concerns were reignited when a 2019 University of Oxford meta-analysis again pointed to an increased risk of breast cancer. Hadji criticizes that this work not only ignored qualitative deficiencies, but also completely ignored advances in hormone therapy: “Today’s hormone preparations cannot be compared with those of 20 years ago.” the one based on mare urine with a mixture of estrogens and an unfavorable corpus luteum hormone. “Meanwhile, completely different, natural estrogens are used and in a much lower dosage, which is not only available in the tablet form that was common in the past, but also, for example, as gels, sprays or patches,” explains the doctor. Applications via the skin also have the advantage that they can be prescribed much more individually and do not pose a risk of thrombosis.
estrogen deficiency
A large study published in the journal Hypertension recently also suggested that hormones taken as pills are associated with a greater risk of high blood pressure than other dosage forms. The lowest risk for this comes from non-oral preparations with estriol. These are available, for example, in the form of vaginal suppositories, which would have a much lesser effect. They also have no effect on the risk of breast cancer, according to expert Hadji.
With the new forms of therapy, the scientific perspective seems to have shifted back to the advantages of hormone therapy and a clearer classification of possible risks, as some recent research results make clear. A study by Chinese scientists recently showed that hormone therapy could help reduce the risk of lung cancer.
Another study from the USA in the specialist journal “Jama Neurology” addresses the increased risk of Alzheimer’s dementia in women compared to men: this is even more pronounced in women if they are younger when menopause occurs. However, if hormone therapy is started early in such a case, this increase in risk does not show up. “When it comes to hormone therapy, timing is everything,” said co-author JoAnn Manson of Harvard Medical School in a statement. Previous results from the WHI study had suggested that starting hormone treatment early in menopause resulted in better outcomes for heart disease, cognitive function, and all-cause mortality than starting it later.
Cancer: prevention and therapy
Expert Hadji also emphasizes the importance of timing: “Hormone therapy can have protective effects for the cardiovascular system, reduce the risk of type 2 diabetes mellitus by up to 30 percent and prevent arthrosis – but only if it is started as early as possible it is started.” Likewise, an early start is advantageous for the prevention and treatment of osteoporosis. A recent study by Chinese scientists confirmed the benefits of hormone therapies for bone density, with protection against bone loss lasting beyond treatment discontinuation.
Hormone therapy for high levels of suffering
The more differentiated view of the advantages and disadvantages of hormone therapy is also expressed in a new review led by Canadian physicians who advocate a “pragmatic approach to the treatment of menopause”. In the “Canadian Medical Association Journal” they recommend hormone therapy as initial treatment for women without risk factors if they are suffering from it. According to Hadji, the identification of such risk factors is also central when deciding for or against hormone therapy when it comes to a possible risk of stroke: “An obese, smoking patient who is older than 65 years should not be recommended hormones.” It is also forbidden Hormone therapy for women with precancerous stages of breast cancer, as they are usually hormone-sensitive, and for patients with certain previous illnesses.
Ultimately, every woman has to decide for herself whether hormone treatment is right for her, stresses Hadji. “The studies show that the risk of breast cancer only increases slightly after four to five years of hormone therapy, but then decreases again when the treatment is ended.” Patients want it, according to the doctor’s experience: “Some of my patients have been taking the hormones for 20 years and do not want to stop taking them under any circumstances, because they notice that their cognitive abilities and muscle strength then decrease.”
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Pill, Viagra, Testosteron & Co.
However, there could soon be a non-hormonal alternative, at least for the treatment of so-called vasomotor symptoms, i.e. hot flashes and sweating: At the beginning of May, the US drug agency approved fezolinetant, an active ingredient that blocks certain neurotransmitters in the brain. In a “Nature” comment, the approval is seen as a sign that research into the causes and effects of menopausal symptoms is finally being taken seriously. Above all, however, fezolinetant and similar drugs currently in development represent a rethink: “Away from menopause as a disease of the female reproductive organs towards a consideration of the neurological causes and effects.”
The BZgA also emphasizes that there is no one-size-fits-all solution for every woman going through menopause. However, in addition to hormone therapy, she also refers to other methods such as more exercise or more rest and relaxation, lubricants or special care creams and also to advice in women’s health centers.
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