Getting past the ‘hot flash’ cliché: the science of treating menopause

Menopause is the term we use for the time of life at which a woman loses the ability to bear children. It can come with symptoms ranging from uncomfortable to debilitating for many women. Hormone treatments came into popular use in the 1990s. Then, concerns cropped up about the side effects of those treatments.

To find out more about the latest science on treating menopause, KUOW’s Kim Malcolm talked to Dr. Susan Reed, an OB-GYN with the University of Washington School of Medicine, a specialist in treating menopausal symptoms, and the president of the North American Menopause Society.

This interview has been edited for clarity.

Kim Malcolm: First, what is menopause and why do women go through it?

Dr. Susan Reed: Technically, menopause is the day of the final menstrual period. The average age it occurs is around 51 to 52. But patients and providers care most about menopause in the context of life stages. We talk most about the symptoms that occur around the time of the final menstrual period, or mainly around perimenopause. Perimenopause usually starts about two to three years before the final menstrual period and extends one to two years following the final menstrual period, when women have the worst symptoms.

Let's talk about these symptoms. We hear of moodiness, fatigue, and even exhaustion in some women who were previously full of energy. Then there's the stereotype of the hot flash. Tell us about those and how all these symptoms impact a woman's health.

Typically, the physiology of all this happens because hormones start to oscillate and change as the ovaries shut down around the time of the final menstrual period. As the hormones oscillate, women can have heavy and irregular periods; they get hot flashes; they can have mood changes. I think women typically feel fatigue and low energy because they may not be sleeping well. Also, they can experience brain fog, difficulty concentrating. These are the primary symptoms we see.

Hormone treatments are available. What are they?

The two hormones used for menopausal hormone therapy are estrogen and progesterone. Estrogen is used for women without a uterus, and estrogen and progesterone are recommended for women with a uterus. These formulations can be taken by pill, by a patch, by gels, and mist sprays, and the doses can vary considerably.

And what kind of impact do they have? How do they mitigate the symptoms?

The standard doses for these treatments will decrease hot flashes by around 80%. We did a head-to-head study of a non-hormonal therapy with hormones with a lower dose of estrogen and found that the non-hormonal treatments were pretty much on par with a low-dose hormone treatment, decreasing hot flashes by around 50%.

There is a story that lurks in the background here, the big hormone replacement therapy study that came out in 2002. It landed like a bombshell. The conversation really changed after that about women in menopause and its treatment. Can you tell us what that study found?

The most important thing to know about this study is it was what's called a primary prevention study. It was done in older women, aged 63, the majority of whom had no menopausal symptoms whatsoever. Its goal was to see if there would be prevention of heart disease or risk for breast cancer with hormones. In women who are an average age of 63, we saw a host of problems or risks that were associated with hormones.

Three-fourths of women in the study were over the age that we would see symptoms. We saw strokes, we saw clots that can go to the lungs. Breast cancer was a primary concern. They did an index that looked at overall mortality. For younger women, we did not see increased mortality. So, what happened was that data was extrapolated to women with symptoms. And that's kind of not fair for younger women with symptoms less than age 60.

I remember hearing of people calling their doctor and insisting that they stop their hormone treatments immediately, as soon as that news came out. Can you talk about the impact it had on how physicians were trying to help their patients in menopause?

Oh, it was a nightmare. The biggest thing that we knew at that time—and the data had not been broken down by different age groups—was there were very concerning risks. When we look at the data more carefully for women aged 50 to 59, we don't see an increased risk for estrogen alone. And for women who are 50 to 59 who are taking estrogen and progesterone, which is recommended for women with a uterus, we do see a slightly increased risk for predominantly breast cancer for women taking it for more than five years. And still, these are still quite low risks. So, specialists in this area, it's so important that we have shared decision-making with our patients and discuss all the risks and all the benefits so women can make choices that are best for their quality of life during this period of time.

And what courses of treatment are common now?

If a woman came into my office and decided she wanted to take hormonal therapies, typically, a transdermal gel, patch, or mist may be given for estrogen. And if she has a uterus, there is progesterone in a patch form, or in an oral form.

There are tens of millions of American women going through this stage right now in their lives or have gone through it. And it's hard to find information out there on this. What would you say to women who are trying to find out what's going on?

I think this is a really important point. In today's world, we have information swirling all around us. And as we all know, it's hard to sort out. I have two websites that I would recommend. The first is mymenoplan.org. This website was developed by researchers and clinicians with funding from the National Institutes of Health to help patients and providers with evidence-based information regarding menopausal symptoms, where to find help, and whether or not they might need treatment.

The second site is called menopause.org. This is the website for the North American Menopause Society. It has information for both providers and patients that need more information regarding menopause and its symptoms.

Listen to the interview by clicking the play button above.