Hormones. Hot Flashes. Menopause. Estrogen. You've probably heard these words a lot over the last several years, as women’s midlife health has come to the forefront in major news outlets as well as online (and hopefully in your own conversations with friends and family).
Both lifestyle and prescription therapy can be used for those individuals in mid- and post-menopause, and it is important to acknowledge that medical treatment should not be withheld from patients who are suitable candidates. It is also important to acknowledge that not every patient wants, needs, or is a suitable candidate for menopause hormone therapy (MHT).
Though hormone therapy has its benefits, it is by no means a panacea. It works in tandem with many other non-hormonal approaches, both lifestyle and medical, to help patients achieve their health goals. Below, we address some non-hormonal modalities for three particular components of peri/menopause: vasomotor symptoms, osteoporosis, and cardiometabolic disease.
Vasomotor Symptoms
Night sweats and hot flashes (called vasomotor symptoms or VMS) have long been the typical symptom linked with menopause, and in fact they were the only symptom that most people believed to be what the menopausal experience entailed. Although estrogen therapy (in the form of MHT) has been proven to be the most effective medical treatment for vasomotor symptoms, it by any means is not the only available option. A number of other lifestyle measures and alternative healing methods have been shown to help with vasomotor symptoms:
- Wearing several layers of clothing, setting the thermostat at home and at work to a lower temperature, using fans, reducing alcohol consumption, keeping a healthy balance between body fat and muscle, increasing physical activity, and managing stress all to some extent help with vasomotor symptoms.
- Clinical hypnosis and cognitive behavioral therapy have also proven to be helpful in some patients with menopause related VMS.
Medications
Prescription medications that are non-hormonal and have been shown to help with night sweats include:
- A medication called paroxetine, which is an antidepressant, at a particularly low dose has been shown to help with VMS
- Fezolinetant is a relatively new drug belonging to the class of neuropeptide B antagonists and is designed to affect the way the brain perceives hot flashes; it has proved to be very helpful for people who have had hormone-dependent cancers and are not suitable for estrogen therapy but yet suffer from gastrointestinal symptoms.
- Other pharmaceutical medications, namely gabapentin and oxybutinin, are not approved by the FDA but have been found to provide some benefit in the treatment of VMS without the use of hormones.
Osteoporosis
Osteoporosis, a condition involving the thinning and weakening of the bones, is a major cause of both illness and death associated with aging. Women are more likely than men to suffer from osteoporosis, and it is thought that this may be due to the drop in estrogen levels after menopause. Moreover, there are a number of factors which can lead to low bone density that are unrelated to hormones. As has already been mentioned, aging is one of the most common causes. Other frequent reasons for the development of osteoporosis include being thin or having a low body weight, genetic factors, a history or current habit of smoking, certain diseases, or the use of certain drug groups. Osteoporosis in itself increases the risk of a fracture. Since the thinning of the bones cannot be felt directly (only when a bone breaks), patients often fail to notice it, and for this reason doctors sometimes do not deal with it adequately.
Bone health should be looked after at every stage of a person's life; regarding treatment during the postmenopausal period, although estrogen therapy is very helpful in reducing the chance of developing osteoporosis in cases of osteopenia (mild bone changes), it is not in fact approved by the FDA for the treatment of osteoporosis (more serious bone loss).
Lifestyle factors
There are two important lifestyle factors that everyone—whether or not they are menopausal and whether or not they are female—can control: following a diet adequate in calcium and taking part in regular structured weight-bearing exercise.
Additionally, there are several other classes of medication which can be used to help stabilize the bone, and in certain cases even assist in the regrowth of bone. For many years bisphosphonate therapy has formed the basis of treatment and a great many people have taken it without any problems; it is available in both oral and intravenous forms. The other kinds of drugs used to manage bone health are the RANK ligand inhibitors, salmon calcitonin and PTH receptor agonists. This is a lot of medical jargon, but the point is that there are other medications which work effectively when combined with lifestyle changes to prevent a deterioration of bone health, maybe improve it, and in the end reduce the risk of fracture and the related morbidity and mortality.
Cardiometabolic Disease
The term cardiometabolic disease describes the various illnesses associated with hypertension, or high blood pressure, obesity, prediabetes/insulin resistance, diabetes, and the long-term effects and diseases that result from these conditions. Although progress has been made in the prevention and treatment of cardiometabolic disease so that the overall rate of death from it has decreased, cardiovascular disease is still the leading cause of death among both men and women in the United States and the greatest cause of death for women worldwide—more so than all of cancers, tuberculosis, HIV, and malaria put together!
Several studies have shown that postmenopausal patients see their levels of LDL and VLDL cholesterol rise; even in women who don't already have obesity or heart disease, dietary carbohydrate tolerance changes and there is an increased tendency towards hyperinsulinemia after menopause. Although estrogen was found to be of some benefit to a particular group of people in the Women’s Health Initiative study, it is by no means the only available method for preventing cardiometabolic disease.
Modifiable Risk Factors
Although aging is a risk factor which cannot be altered, cholesterol levels, weight, blood pressure, glucose levels, physical activity, smoking tobacco, sleep quality and diet are generally seen as modifiable ones, either by means of medical treatment and/or through changes in lifestyle.
The biggest change that women can make in order to prevent future cardiovascular disease is to give up tobacco and cigarette smoking. It has been shown that female patients who smoke have between two and six times the chance of having a heart attack than women who do not use cigarettes. When women take up regular physical activity this usually results in a healthy body composition, lower blood pressure, reduced glucose levels, an improved lipid profile and generally leads to better cardiovascular health. It is enough to do ten minutes of light to moderate aerobic exercise several times each week. Repeated studies have proven that consuming sufficient fiber (more than four cups of fruit and vegetables each day), reducing saturated fat and limiting sodium intake produce remarkable long-term benefits for cardiovascular health.
The main points to take away are that the same habits which contribute to overall longevity can also be of help to people going through the age- and hormone-related changes of the menopause transition. It is essential for those patients and their families to recognize that there are tools and resources available, even if hormone therapy is not available or suitable.
If you have any questions about how any of this might affect your own health or that of someone you care about, please arrange a consultation with your provider to talk over the various ways in which we might assist you or refer you to the appropriate specialist who could provide support.
This blog post was written by Liz Frost, PA-C, MSCP and Vice President at Integrative Family Medicine of Asheville. You can read more about Liz in her bio.