Late last year, the U.S. Department of Health and Human Services (HHS) initiated the removal of broad “black box” warnings from menopausal hormone therapy products. The move comes more than two decades after the labels were added.
The warnings on products commonly called hormone replacement therapy (HRT) were a response to a 2002 Women’s Health Initiative report that broadly linked HRT formulations to an increased risk of breast cancer. The report was later refuted, but in the time since, multiple generations of women have fearfully avoided HRT — which the medical community now often refers to as menopause hormone therapy (MHT) — despite its known benefits.
HHS explained the warnings’ removal in a news release: “Studies have provided evidence that starting HRT within 10 years of the onset of menopause can have numerous benefits which for most women outweigh potential risks. Benefits include a reduced risk of all-cause mortality and fractures. HRT has also been associated with a 50 percent reduction in heart attack risk, a 64 percent reduction in cognitive decline, and 35 percent lower risk of Alzheimer’s.”
The change comes amid a national shift in awareness and open discussion about menopause and perimenopause. Celebrities like Oprah Winfrey, Naomi Watts, and Michelle Obama have broken the traditional silence on the topic. Their efforts — along with those of physicians and social media influencers — have helped to educate people of all ages and remove the societal stigma surrounding the subject.
Still, the rapidly changing landscape around menopause has led to some confusion about proven and effective treatments and what women need to know when considering them. We asked Northern Virginia medical experts for their insight and guidance.
An Unavoidable Life Stage
On average, women in the U.S. experience menopause — the stage following 12 full months without a period — at age 52. Perimenopause, the stage preceding menopause when menstrual cycles become irregular, typically begins for women in their mid-40s. Menopause before age 40 is considered premature, whether it occurs naturally or is induced through surgery or other medical treatments.
Symptoms can vary widely but may include hot flashes, vaginal dryness, decreased libido, insomnia, and brain fog. The decrease in hormones can also silently propel women toward cardiovascular disease, osteoporosis, and diabetes.
Menopause treatments have become a multi-billion-dollar market, but not every product or service has been proven safe or effective. “There’s a lot of great evidence-based information on the internet, but there’s also a lot of content designed to drive clicks and sell things that don’t do what they claim,” says Dr. Amanda Rohn, an OB/GYN with VHC Health Medical Group in Arlington and fellow of the American College of Obstetricians and Gynecologists.
Dr. Eileen West, a concierge internal medicine physician in Fairfax who focuses on women’s health, agrees. “I applaud the focus on women’s health, but I caution women not to be taken advantage of by unproven strategies, tests, or treatments,” says West, who is a Menopause Society Certified Practitioner (MSCP), Certified Clinical Densitometrist (CCD), and fellow of the American College of Physicians. “Look for providers offering evidence-based care.”
Navigating the Change
Ashburn resident Rachel Bonner was in her late 30s when she noticed changes with her body. “I was hot all the time, had night sweats, and was tired, irritable, and anxious,” says Bonner, a family nurse practitioner and mother of three. Having treated menopausal patients professionally for years, Bonner recognized the symptoms as perimenopause.
“I was just shocked it was happening to me so young. I was healthy, and there was no history of that in my family. Yet I was in full menopause by age 45,” Bonner says.
Navigating her own health made Bonner, who worked at a busy primary care practice, want to help other women. “I realized I could not take adequate care of patients in 15-minute visits anymore.”
In 2022, Bonner opened her own holistic nurse practitioner business, Rachel B Well. Like a growing number of professionals who specialize in menopause treatment, she became an MSCP.
Talk With Your Doctor
So what should women do if they’re experiencing symptoms?
“If you already have a relationship with a primary care physician, gynecologist, or endocrinologist, describe your symptoms and ask about their history treating menopause,” says Rohn. “Any of them can be well-versed in menopause, but they’ll be honest if they don’t feel it’s an area where they can best serve you and will probably have names they can recommend.”
Look for credentials and certifications signifying expertise in menopause, such as MSCP or CCD. The Menopause Society maintains an online searchable roster of MSCP professionals.
“Menopause can truly affect quality of life,” says Dr. Patricia Bannon, an OB/GYN with Inova Medical Group in McLean. “I think symptoms sometimes are almost an emergency. When patients call saying they are really suffering, or that hot flashes and night sweats are keeping them from sleeping, we try to fit them in quickly.”
“We now understand the long-term health consequences of spending a third of your life without hormone support, so it’s important to seek help,” West says.
MHT: The Gold Standard
MHT is considered a first-line therapy for treating hot flashes, night sweats, sleep disturbances, and vaginal dryness. It also protects bone density, along with other benefits. “There are a lot of hormone therapy products out there, but I prescribe those that are FDA-approved,” says Rohn. “These are usually covered by insurance and are quite inexpensive.”
There are two main types of MHT: systemic and low-dose. Systemic therapy is absorbed into the bloodstream and delivers hormones throughout the body via pills, patches, gels, sprays, or a vaginal ring. Low-dose therapy, an effective treatment for vaginal dryness and urinary tract discomforts after menopause, is administered directly into the vagina, with very little circulated in the blood.
Patients should discuss their health history with their doctor before starting MHT.
“Treatment is individualized,” says Rohn. “If there’s a history of blood clots, for instance, we may be more comfortable with transdermal estrogen given through a patch, gel, spray, or vaginal ring instead of oral. We can talk about risks and benefits of options and make a shared decision.”
West says she considers “the big picture” rather than jumping straight to hormones. “The first step is making sure something else isn’t causing the symptoms and then look at lifestyle and dietary intake.” Consuming too much sugar leads to inflammation, for instance. And sleep disturbances can be caused by many conditions, including sleep apnea and restless leg syndrome. “Once we get people sleeping well, many other symptoms start to straighten out,” West says.
When symptoms point to menopause, West says MHT is the most obvious treatment. “It’s not for everyone, and it’s not necessarily a cure-all, but it is one of the best ways to accomplish several things at once. It really is quite helpful on multiple levels.”
Bannon recommends that women with vaginal and urinary symptoms use local vaginal estrogen, even if they are already using systemic MHT. “Systemic treatments don’t really get into high enough tissue concentrations in the vagina to really help with those vaginal issues, so they can be used together.”
Not every woman is a candidate for MHT. But Bannon says there are other medications that can help, including certain antidepressants.
The health care providers agree that women shouldn’t have to suffer through menopause symptoms in silence. And they deserve to be heard.
“Women spend about half their life in stages of menopause, so the health toll can be huge,” Bonner says. “Women need better care. They don’t want to be frail and hobbling around in their 70s. They refuse to put up with symptoms when they know effective treatments exist. They are not OK with being told they are just getting older. They want providers who listen to their complaints.”
Feature image, peopleimages.com/adobe.stock.com
This story originally ran in our February issue. For more stories like this, subscribe to Northern Virginia Magazine.
