Post #36: Hot Flashes & Cold Truths: A Guide to Menopause and HRT for All (Especially Men Who'll Never Experience It)

Today’s post (#36) is on a topic that I can never claim to have ever directly experienced myself or can ever in the future, and that is because it is on the subject of menopause. Given the lack of first hand experience, I was hesitant to write about it, but having seen a few loved ones in my life go through it - some suffering through it while others finding a solution - it felt like something more of us men needed to understand the reality that women have to go through for a significant part of their lives. To understand the implications of menopause in their day to day lives, I spent time speaking to some of my women friends that were willing to talk about it (many are) and a few very accomplished experts, including Dr. Rashida Melinkeri (Lipidologist), Dr. Arati Rao (Oncologist), Dr. Swapna Gadgil Gambhir (Functional Medicine and Anesthetics / Intensive Care) and Dr. Geeta Dharmatti (Clinical Nutritionist). Many of the practical aspects of this post are inputs from these wonderful ladies who contributed to my learning on this topic. Although this topic seems to apply only to women experiencing menopause (it is estimated that more than 47 million women worldwide enter the menopause transition annually), everyone would benefit from reading this as we all have women in our lives who deserve our empathy and understanding of a subject that, if not attended to, can affect entire families.?

I should apologize in advance for anything I have written that does not do justice to this topic or if I have missed out on points that are important. On a separate note, I am continuing with my AI based podcast that I mentioned last time because I saw an increase in the number of you who chose to listen to the audio version.

Defining perimenopause, menopause and postmenopause

In the early and reproductive years for women, there are two hormones that are produced by the ovaries and play an important role: estrogen (called oestrogen in British English) and progesterone. Estrogen promotes the development of reproductive organs and regulates the menstrual cycle while progesterone prepares the uterus for pregnancy and helps stabilize menstrual cycles. Having a regular menstrual cycle is important in these years because it prepares the body for a potential pregnancy each month while also helping to wind it down if pregnancy doesn’t occur. In addition, regular cycles balance the levels of estrogen and progesterone. In addition to playing an important role in regulating the female reproductive system, estrogen and progesterone also play a crucial role in many other aspects of a woman’s physical and emotional wellbeing, including maintaining bone density, balancing cholesterol levels by increasing HDL and decreasing LDL, supporting brain cell growth and protecting against neurodegenerative diseases, promoting skin hydration, elasticity, and thickness, regulating metabolism, body weight, and fat distribution, improving emotional stability and promoting relaxation and reduced anxiety, reducing swelling and inflammation throughout the body.

However, as women enter their forties and fifties (for some starting as early as their thirties), and nature starts winding down the reproductive process, the need for the body to produce estrogen and progesterone drops. This leads to the end of women’s menstrual cycles, with 12 consecutive months without a menstrual period being defined as menopause, and is a milestone in time that marks the end of reproductive ability. The average age of women in the US to hit menopause is 52 although it can be anywhere between 48 and 55. So then what are perimenopause and postmenopause??

Unlike menopause which is a one point in time as defined above, perimenopause is the time span during which the ovaries gradually reduce hormone production, specifically estrogen and progesterone. This phase can last several years.?

Postmenopause is the time duration following menopause and continues for the rest of a woman’s life. Hormone levels remain consistently low, and many menopause-related symptoms gradually decrease over time.?

With the hormonal changes (as you can see in the figure at the top) that a woman’s body goes through, it causes a plethora of issues and it is estimated that there are ~35 symptoms that women experience and these can last for between two to ten years.? These include,? irregular periods, hot flashes, night sweats, mood swings, sleep disturbances, weight changes, recurring urinary tract and yeast infections, brain fog, lack of good quality sleep, change in waist line with an increase in waist circumference and inches which is fairly sudden , unexplainable and stubborn, feeling of shortness of breath or air hunger, where women take deep breaths while talking, difficulty in doing exercises, especially core strengthening, spending longer time completing regular tasks that have always been a part of their lives, a rise in migraine episodes, a reduced appetite and feeling of bloating, an increase in acidity issues and changes in libido. While each of the above symptoms are bad enough, the one that Dr. Gadgil-Gambhir, Dr. Rao and Dr. Melinkeri, all called out, is the effect that perimenopause has on mental health, with a significant increase in depression due to the massive changes the brain and the body are going through in a short period of time.

This one paragraph of symptoms impacts the health of 50% of the world’s population and should therefore motivate the healthcare systems to invest more into research in this area. If that isn’t enough, it is estimated that 20% of the women in the workforce quit their jobs in their perimenopausal years. However, this topic is still not very well understood and significantly underfunded.

How this translates to women’s health postmenopause

This drop in the natural estrogen and progesterone hormone levels during perimenopause translates to a very clear increase in risk of various diseases postmenopause. Here is a quantification of the increased risk for women postmenopause relative to premenopause, as well as relative to men of a similar age:

Heart Disease: Premenopausal women have a 50-60% lower risk of coronary heart disease than men of similar age. After menopause, however, women’s risk of heart disease accelerates, increasing by 2-3% per year in the decade following menopause. By their 70s, women’s heart disease rates equal or exceed those of men. According to the American Heart Association, heart disease is the leading cause of death in women over 65, and they are twice as likely to die within a year after a heart attack compared to men.

Stroke: Before menopause, women have lower rates of stroke than men, but this shifts post-menopause. For example, in the 10 years post-menopause, stroke risk rises about 30%, with a higher incidence of ischemic stroke. In their later years, women have a higher lifetime risk of stroke than men. By age 75, women are roughly 1.5 times more likely than men to have a stroke. Stroke is the third leading cause of death for women over 65, accounting for a disproportionate share of disability and long-term care needs in this population.

Osteoporosis and Bone Fractures: Post-menopausal women lose bone density at a rate of 1-2% per year, which can accelerate to as much as 3-5% annually in the first few years after menopause. Over time, women can lose up to 20% of their bone density within the first five to seven years after menopause. Women are four times more likely to develop osteoporosis than men. By age 65, 1 in 4 women will suffer a fracture due to osteoporosis compared to about 1 in 20 men. Roughly 50% of women over 50 will experience an osteoporosis-related fracture in their lifetime, a rate about two times higher than for men.

Metabolic Syndrome and Type 2 Diabetes: Women are at greater risk of developing metabolic syndrome postmenopause due to hormonal shifts impacting fat distribution, insulin resistance, and cholesterol levels. After menopause, the risk of developing metabolic syndrome increases by 60-80%. Post-menopausal women develop a central fat distribution pattern (abdominal or belly fat), which is more similar to men’s, contributing to an increased risk for insulin resistance and diabetes. Postmenopause women are estimated to have about a 50% increased risk of developing type 2 diabetes compared to premenopausal women.?

Blood Pressure Changes: Systolic (high) blood pressure increases significantly post-menopause, with studies showing that post-menopausal women are 30-50% more likely to develop hypertension compared to premenopausal women. Men traditionally have higher blood pressure at younger ages, but women’s rates rise post-menopause, with older women eventually surpassing men in hypertension prevalence.

The bottom line is that the changes women’s bodies undergo during menopause are very real as is the negative impact on their health. For women going through it, it’s both physically tough as well as emotionally unnerving for each woman. It isn’t a figment of one’s imagination (as I heard one friend wonder about herself) and it isn’t a case of growing old that one can’t do much about. It is absolutely treatable, as outlined in the next section.

What is Hormone Replacement Therapy (HRT), how does it work, and what are the risks?

The solution to this problem seems clear viz. find a way to supplement the dropped estrogen and progesterone levels. Since the body cannot make it consistently once a woman is in the perimenopause phase and can make very little of it in the postmenopausal phase (through their adrenal glands and fat tissue), these hormones need to be added through external sources. This was the motivator for Hormone Replacement Therapy or HRT.?

Therapy can take the form of an estrogen pill, skin patch, ring, gel, cream, or spray, and it usually includes a second hormone, progestogen, which can be either progesterone or a synthetic version. Without that second hormone, the estrogen can cause a woman’s uterine lining to grow too much and put her at risk for some endometrial cancers. So the progestogen helps keep it in check. Women who’ve had a hysterectomy only need to take estrogen.

However, HRT took a serious hit in the early 2000s with the results of the Women’s Health Initiative (WHI) study, which suggested that HRT was associated with increased risks of breast cancer, cardiovascular disease and stroke. This dramatically dropped the number of prescriptions by physicians for HRT from 1 in 5 women over the age of 50 taking HRT in 2000, to fewer than 1 in 20 by 2008. Within a year of the study, the FDA had put a “black box” warning on estrogen products used in hormone therapy—the most serious warning the agency places on prescription drugs—about the risk of cardiovascular disease and cancer, and that warning remains today. Many physicians have stopped prescribing the therapy altogether.

Unfortunately, this was an example of a poorly conducted study that was debunked just a few years later. A 2007 update to the same study actually found that women in their 50s who took hormone therapy, actually had a lower risk of coronary heart disease (CHD) if the HRT was taken within 10 years of menopause while those initiating it 20+ years post-menopause did experience higher CHD risk. This breakthrough moment came when researchers realized the old results had included women who began hormone therapy in their 60s and older, when their risk of heart disease and cancer was already higher, thereby skewing the results and consequently made hormone therapy seem more dangerous than it actually was — instead of focusing on women ages 45 to 55 who were just entering menopause. An 18-year follow-up of WHI participants found that HRT had a neutral effect on all-cause mortality, including deaths from cardiovascular causes. The 2012 Danish Osteoporosis Prevention Study (DOPS), a randomized controlled trial, found that HRT initiated soon after menopause was associated with a significantly reduced risk of mortality, heart failure, and myocardial infarction, without an apparent increase in cancer, venous thromboembolism, or stroke. The review article in the prestigious Nature Endocrinology journal demonstrated the risks were generally lower with HRT on most fronts except for breast cancer risk (shown in the figure at the top of this article).?

Dr. Rao had this to add on the risks of breast cancer. “The risk of breast cancer is higher but there are some distinct caveats and the WHI study failed to highlight this, which is why the breast cancer risk became the boogeyman! The risk associated with HRT is greater for estrogen–progesterone combination than for estrogen alone. The risk of breast cancer dissipates within 2 years of cessation of treatment. Cancers associated with HRT tend to be low grade and estrogen receptor positive which have a better prognosis.”

So while there is a risk associated with the timing of when HRT is initiated and on specific aspects, the 2002 study grossly overestimated these risks and didn’t call out the benefits.

The most practical summary of the risk-rewards of HRT was captured by Dr. Stephanie Faubion, the Director of Women’s Health at Mayo Clinic, Medical Director of The Menopause Society and a leading expert in women's health. She emphasizes that the benefits of hormone replacement therapy (HRT) often outweigh the risks for many women, particularly those under 60 or within 10 years of menopause onset. Dr. Faubion acknowledges that while certain forms of HRT, especially combined estrogen-progestogen therapy, may slightly increase the risk of breast cancer, the absolute risk remains low. She advocates for individualized treatment plans, considering each woman's health history and symptom severity and notes that the type, route, and dose of HRT can influence its risk profile.

In spite of this, the number of HRT prescriptions in 2023 weren’t significantly different from 2008. There seem to be many reasons for this, including the unfortunate long lasting impact of the 2002 paper that has not been erased from the memories of many physicians, the fact that the subject of menopause doesn’t seem to be in the curriculum of many medical programs (it is estimated that 80% of ob-gyns do not have any meaningful training in this area), lack of awareness by some younger physicians who haven’t gone through it themselves, and liability concerns because even the limited risks associated with it are enough to scare off some physicians. There could also be some legitimate reasons for physicians not prescribing HRT to women with a history of blood clots, cardiovascular disease, or a strong family history of breast cancer, or those that prefer non-hormonal alternatives.?

So, how do you find the right doctor? First off, seek out a physician who specializes in menopause. In the US, the Menopause Society (previously called the North American Menopause Society) provides a searchable directory of menopause care providers at https://portal.menopause.org/NAMS/NAMS/ Directory/Menopause-Practitioner.aspx. Another excellent resource that seems to be gaining traction in the US is Midi Health, a company that seems to be catering to women in midlife, focusing on menopause and related health concerns (h/t to Sudnya Shroff for this resource). In India and other countries, I am not familiar with any organization that specializes in menopause, so I would love to hear from anyone who is aware of a reliable resource they would recommend.?

The lifestyle approach to dealing with menopause

At the end of the day, opting for HRT is a very personal decision that needs to be taken between the woman going through menopause and a qualified doctor. However, the lifestyle habits that help with reducing the intensity of the menopause symptoms, and promote healthy living in general, are a no-brainer and are beneficial both on their own as well as a complement to HRT.? Dr. Gadgil-Gambhir, one of the contributing doctors to this piece, believes that “lifestyle choices are something we have control over which should be easy to get going on ... and they work beautifully in conjunction with HRT”. While quitting smoking, decreasing alcohol consumption, and improved hydration are universally beneficial for reasons I have described in past posts, here are some more specific lifestyle changes that are helpful from a menopause perspective:

Diet: Foods like soy, flaxseed, and legumes contain plant estrogens, which may help balance hormone levels and alleviate hot flashes. Include dairy and leafy greens for dietary sources of Vitamin D and Calcium for better bone health. Dr. Dharmatti adds “A good practice is to have half your plate at every meal be filled with vegetables as it helps with phytonutrients and antioxidants”. Limit caffeine because it can worsen hot flashes, night sweats, and sleep disturbances. For improved metabolism, and to prevent muscle loss, include lean protein sources like chicken, fish, beans, and nuts.??

Exercise: Dr. Dharmatti mentions that “As a woman transitions from the perimenopause phase to postmenopause and estrogen levels fluctuate to eventually dropping, the fat distribution around the body moves from being stored around the hips and thighs (gynoid fat) to shifting to the upper body and abdomen (android fat)”. It is therefore important to engage in strength training as well as low and high intensity activities, such as walking, cycling or swimming. However it is most important to focus on consistency over intensity to achieve long term benefits.?

Stress Management: Techniques like deep breathing, meditation, and progressive muscle relaxation can reduce stress and improve mood. Yoga, Pilates, and tai chi can reduce stress, improve flexibility, and help with sleep and hot flashes. As one of the contributing doctors to this piece put it, keeping oneself calm plays a major role in managing the symptoms. Even a trivial episode of anxiety will trigger mood changes, hot flushes, acidity, etc. Both Dr. Melinkeri and Dr. Rao both independently emphasized that the single most important piece of advice they share with their patients is “The importance of strong female friendships cannot be underscored enough as bonding with other women who understand and support each other is in itself a stress management tool.”?

Sleep: It is critical to overcome the lack of sleep that one experiences during menopause due to hot flashes or night sweats. Practices like having an early and light dinner, walking for 10 minutes after the meal, and keeping the sleep environment cool and dark is important, leading to better sleep quality, thereby helping to reduce brain fog and improve clarity, focus, and memory.

Supplements: Check your Calcium, Iron and Vitamin D levels regularly and take those supplements if you are not getting enough of them through your diet. Some herbs, like evening primrose oil, are commonly used for menopause symptoms (clinical evidence is mixed with no known side effects but with benefits being inconsistent), but it’s essential to discuss these with a healthcare provider before starting.

Other Resources: There is also an excellent documentary on PBS called The M Factor: Shredding the Silence on Menopause (h/t to Sudnya Shroff). Check it out at https://www.pbs.org/video/the-m-factor-shredding-the-silence-on-menopause-uwesx6/

What can men do to help?

This is the only section I can speak about with first-hand experience. For the sake of my marriage's longevity, I won’t be naming who’s who here—guess at your own risk (a strategy inspired by my survival-savvy friend, Chetan M). Symptoms associated with menopause might show up as:

One of us insists on the heater because it’s a chilly 48°F outside, while the other cranks up the air conditioner, recreating an Arctic blast fit for penguins.

A full conversation held just 15 minutes ago mysteriously vanishes from one spouse’s memory. The other spouse, utterly baffled, wonders if this is an elaborate prank or selective hearing taken to new heights.

The new go-to phrase is now, ‘Want to Netflix and…Not-Chill?’

I am of course being facetious (and it probably isn’t very funny), but the impact of menopause on women is very real and the three pronged-solution I have personally found is to be truly empathetic, take the time to understand the facts around this topic, and make sure to keep both your senses of humor up. Please note that in this type of situation, humor without empathy is a recipe for disaster!?

So that’s my take on a topic I earlier knew very little about and now know a little more about. As always, leave your comments on whether you find this helpful, anything you think I can do better, and any topics that I should be covering. Until next time …

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