“Menopause has the worst P.R. campaign in the history of the universe, because it’s not just hot flashes and night sweats,” says Rachel Rubin, a sexual-health expert and assistant clinical professor in urology at Georgetown University. Menopausal symptoms are more varied, and can be more debilitating, than many people know. During the transition to menopause, women may also experience sleeplessness, mood changes, depression, weight gain, joint pain, vaginal dryness and pain during sex, among other symptoms. Bone loss accelerates. In women who have a genetic risk for Alzheimer’s disease, the first plaques are thought to form in the brain around this time.
There has long been an effective, F.D.A.-approved treatment for several of these symptoms, known as menopausal hormone therapy, but because of fear and misinformation, too few women have a clear picture of its risks and benefits. The New York Times Magazine’s cover story this week examines hormone therapy and menopause, unpacking what the research really tells us.
Hormone therapy eases several menopausal symptoms and has some additional health benefits.
Hormone therapy has been shown to ease hot flashes and sleep disruption, and there is some evidence that it helps with depression and aching joints. It also helps prevent and treat menopausal genitourinary syndrome, a collection of symptoms, including urinary-tract infections and pain during sex, that affect nearly half of postmenopausal women. It decreases the risk of diabetes and protects against osteoporosis. Because of the health risks associated with hormone therapy, it is recommended for women who have “bothersome” hot flashes and certain other menopausal symptoms, not for preventive care.
Hormone therapy carries health risks that vary by age.
The age at which a woman begins hormone therapy is important for assessing her increased risk of heart disease, stroke and dementia.
Your Questions About Menopause, Answered
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What are the symptoms of menopause? The symptoms of menopause can begin during perimenopause and continue for years. Among the most common are hot flashes, depression and anxiety, genital and urinary symptoms, brain fog, and skin and hair issues.
How can I find some relief from these symptoms? A low-dose birth control pill can control bleeding issues and ease night sweats during perimenopause. Avoiding alcohol and caffeine can reduce hot flashes, while cognitive behavioral therapy and meditation can make them more tolerable. Menopausal hormone therapy and the selective serotonin reuptake inhibitor paroxetine can also ease some symptoms.
How long does perimenopause last? Perimenopause usually begins in a woman’s 40s and can last for four to eight years. The average age of menopause is 51, but for some it starts a few years before or later. The symptoms can last for a decade or more, and at least one symptom — vaginal dryness — may never get better.
What can I do about vaginal dryness? There are several things to try to help mitigate the discomfort: lubricants, to apply just before sexual intercourse; moisturizers, used about three times a week; and/or estrogen, which can plump the vaginal wall lining. Unfortunately, most women will not get 100 percent relief from these treatments.
For women who go through early menopause, before age 45, hormone therapy is recommended because they’re at greater risk for osteoporosis if they don’t receive hormones up to the typical age of menopause. For healthy women in their 50s, the increased risks from hormone therapy are considered low. There are greater risks for women who start hormone therapy after age 60. No definitive research has yet followed women who start in their 50s and stay on continuously into their 60s.
Women of all ages have an increased risk of breast cancer after about five years of taking hormones.
At highest risk from hormone use are women who have had a heart attack, breast cancer or a stroke or clot, or women with a cluster of significant health problems.
“For everyone else,” says Stephanie Faubion, the director of the Center for Women’s Health at the Mayo Clinic, “the decision has to do with the severity of symptoms as well as personal preferences and level of risk tolerance.”
Fears of hormone therapy are mostly rooted in an important but imperfect study from 2002.
Hormone therapy was once the most commonly prescribed treatment in the United States, but in 2002, a major study raised serious concerns about its health risks, causing many doctors and patients to abandon it. New analyses of the data from that study, known as the Women’s Health Initiative, along with many others, have since provided reassurance that the risks of hormone therapy are low for healthy women under 60. But the treatment’s reputation has still not recovered.
Menopause is understudied and undertaught.
If many doctors aren’t discussing hormone therapy with their patients, it may be because of gaps in their own knowledge. A 2017 survey sent to medical residents across the country found that 20 percent of them had not heard a single lecture on the subject of menopause. Rebecca Thurston, a professor of psychiatry at the University of Pittsburgh who studies menopause, believes that, in general, menopausal women have been underserved — an oversight that she considers one of the great blind spots of medicine. “It suggests that we have a high cultural tolerance for women’s suffering,” Thurston says. “It’s not regarded as important.”
Hormone therapy is not the only option.
For high-risk women, other sources of relief exist: The selective serotonin reuptake inhibitor (S.S.R.I.) paroxetine is approved for the relief of hot flashes, although it is not as effective as hormone therapy. Cognitive-behavioral therapy has also been shown to help women manage how much hot flashes bother them. Doctors who treat menopause are waiting for the F.D.A.’s review of a drug up for approval this month: a nonhormonal drug that would target the complex of neurons thought to be involved in triggering hot flashes.
Women should talk to their doctors about their symptoms and treatment options. The North American Menopause Society, an association of menopause specialists, offers a resource that allows users to search by ZIP code for health care professionals who have received a NAMS certification in menopause care.