I am immersed in the issue of menopause and its impact on different spheres of female life, although the symptoms produced by the decline in estrogen production are the most visible: from hot flashes to mood swings; from loss of libido to increased cardiovascular risk. Faced with so many problems, the question arises: is menopause hormone therapy (THM) – popularly known as hormone replacement therapy – a panacea for all ills?
My guide is the endocrinologist Flavia Barbosa, master and doctor in endocrinology from UFRJ and member of the Brazilian Society of Diabetes and the Brazilian Society of Endocrinology and Metabolism. She says THM with estrogen and progesterone is the most effective treatment for climacteric symptoms and has been shown to prevent bone loss and fractures. “The benefits may outweigh the risks for most symptomatic postmenopausal women who are younger than 60 years or less than ten years since the onset of menopause,” she says, emphasizing that therapy has to be individualized based on clinical and preceded by screening for cardiovascular risk and breast cancer. For hysterectomized patients (who removed the uterus), treatment is done only with estrogen. Periodic revaluations are mandatory for all.
Menopausal women: Approximately 75% of women between the ages of 45 and 55 suffer from symptoms that affect their quality of life — Photo: Andrew Yuan for Pixabay
Hormone therapy can be started in the perimenopause transitional phase, a period during which the irregularity of the menstrual cycle increases. She recalls that, in addition to hot flashes, menstruation can even become frequent and excessive or more spaced out, and the sum of discomfort impacts the quality of life: “approximately 75% of women aged between 45 and 55 years suffer from menopause symptoms , which can lead to low self-esteem, sleep disturbances and a feeling of decreased energy”. Estrogen can be given orally (tablets) and percutaneously (patch or gel). The transdermal route is the safest because it reduces the prothrombotic risk and blood pressure decompensation. Progesterone can be prescribed as an oral tablet or intravaginal egg, or it can be used through the intrauterine delivery system.
Patients with a personal history of breast cancer, various endometrial cancer subtypes, previous coronary heart disease, or prothrombotic mutation should not receive THM. In the case of the presence of risk factors for thrombosis or coronary disease, such as obesity or smoking, hormonal therapy must be chosen in order to minimize such possibilities and monitoring must be intensive. For Dr. Flavia, as long as it is well indicated and within the so-called window of opportunity, in the first years after menopause, it brings additional benefits, such as the reduction of bone mass loss, the risk of colorectal cancer and the prevention of sarcopenia, which tends to worsen with aging.
For those who, despite the symptoms, prefer not to adopt hormonal therapy, there are options such as low-dose vaginal estrogen and ospemifene (a drug indicated for dryness, burning and pain during sexual intercourse), in addition to vaginal moisturizers and lubricants. One of the big fears surrounding replacement is the risk of developing breast cancer after prolonged use. The endocrinologist explains that, based on research findings, it is not possible to provide precise instructions on the duration of use: “there is no need to impose a limit on the duration of therapy, as long as a minimum effective dose is used and patients are aware of the potential benefits and risks of the treatment. The risk of breast cancer incidence is directly related to the type of therapy chosen, with micronized progesterone being the most indicated, preferably with transdermal estrogen. If there is no occurrence of new diseases and clinical follow-up is regular, it is safe to continue THM”.
Regarding testosterone, Dr. Flavia reinforces that it is only indicated for postmenopausal women with Hypoactive Sexual Desire Disorder, when there is persistent absence of lack of desire. Clinical studies report some efficacy and safety in the short term, but there are no studies that detail the consequences of its use beyond 24 months of treatment. As the scientific data are insufficient, she says that, in symptomatic postmenopausal patients with adequate estrogen supplementation, it is possible to use testosterone for a period of three to six months to evaluate the results.