Ever since 2002 when several large-scale studies called into question the safety of long-term hormone replacement therapy (HRT), there has been confusion and conflicting opinions regarding the management of menopausal symptoms. Initially there was a movement to avoid HRT altogether; now it is becoming clearer that certain women may safely use and benefit from hormonal interventions.
More than half of all women initiating treatment with hormone therapy will stop within the first year of treatment, most often because of side effects. Mood disturbance is a relatively common side effect that occurs with hormone therapy, and previous studies have suggested that progestins in the combined hormone preparations are responsible for these negative mood effects.
Menstrual problems are common among premenopausal women and become more frequent with increasing reproductive age, especially just before and during perimenopause. In the Study of Women's Health Across the Nation, a multisite study of menopause and aging, information regarding menstrual history was collected in a total of 934 premenopausal and early perimenopausal women between the ages of 42 and 52. History of major depression was associated with an increased likelihood of heavy bleeding (odds ratio, 1.89), adjusting for recent major depression, menopause status, and other confounding factors. History of depression was not associated with other abnormal bleeding or premenstrual symptoms. Future longitudinal studies are needed to explore why past depression increases the likelihood of subsequent heavy menstrual bleeding in midlife women. One possibility is that irregular fluctuations in estrogen levels may be responsible for both abnormal menstrual bleeding, as well as the dysregulation of neurotransmitter systems that mediate depressive symptoms.
The North American Menopause Society (NAMS) has updated its 2010 recommendations regarding the use of postmenopausal hormone therapy (HT) based on evidence accumulated subsequent to the previous report. In the decade since the first publication of the results from the Women's Health Initiative, we have accumulated evidence to indicate that multiple factors influence the effects of hormone therapy, including the type of estrogen used, the way the hormones are given, and the age and recency of menopause of the woman taking the medication. These factors also determine the risks associated with hormone therapy.
A few years ago on our blog, we reviewed a paper suggesting that estrogen may be a beneficial treatment for women with schizophrenia. In this study patients with schizophrenia receiving estrogen showed significant improvement in their positive symptoms (hallucinations, delusions), but no difference in negative symptoms (reduction in range of emotional expression, poverty of speech, lack of motivation).1, 2 Additional studies have also found estrogen to be effective in improving positive and general symptoms in patients with schizophrenia. 3, 4
In increasing numbers, women who are candidates for hormonal replacement therapy are requesting “bioidentical” rather than synthetic hormones. Although there is a tendency to think of bioidentical hormones as “all-natural”, they, like synthetic hormones, are manufactured in the laboratory. In contrast to synthetic hormones, they are chemically identical to the hormones produced by the human body; synthetic hormones are structurally different yet are designed to have similar biological effects as naturally produced hormones.
There is cumulative evidence suggesting that estrogen might play a role in the development of schizophrenia and therefore may be useful in the treatment of this illness. On average, the first signs of schizophrenia appear 3 to 4 years later in women than in men, with a second peak in women around menopause. Interestingly, men suffering from schizophrenia exacerbation demonstrate low serum estrogen and androgen levels. Estrogen has been demonstrated to have beneficial effects in treating hormonally mediated affective disorders such as postnatal depression or perimenopausal depression. A recent study published in the Archives of General Psychiatry suggests that estrogen may also be beneficial for the treatment of patients with schizophrenia.
Up to 25% of women experience migraine headaches during their reproductive years; often migraine headaches may be triggered or exacerbated by hormonal changes. It has been estimated that 7-14% of women experience migraines only during the premenstrual or menstrual phase of their cycles. Another 52-70% experience headaches throughout the month but note increased headache activity before or during menses.
Many women report vasomotor symptoms, including hot flushes and night sweats, during the menopausal transition. While estrogen is clearly one of the most effective treatments for vasomotor symptoms, recent concerns regarding the use of hormone replacement therapy (HRT) have made treaters much more reluctant to recommend HRT, even for short-term management of vasomotor symptoms. A recent study has demonstrated that acupuncture may be an effective non-hormonal treatment for vasomotor symptoms.
As a result of dramatically increased life expectancies in industrialized countries, healthy women today expect to spend nearly 40% of their lives after menopause. For these postmenopausal women, lack of estrogen may contribute to long-term adverse effects, including cardiovascular disease and osteoporosis. Many postmenopausal women might benefit from hormone replacement therapy (HRT) with estrogens and progestins; however, a number of recent studies in the USA and Europe suggest that the potential risks of hormonal replacement therapy may sometime exceed the expected benefits. Thus, many treaters now avoid the use of hormone replacement therapy in peri- and postmenopausal women.
