While most women do not experience significant incapacity from menopause, some do. For women who are distressed, overly uncomfortable, and even disabled by this transition, there are medical interventions that are available to reduce discomfort. You may be familiar with Estrogen Replacement Therapy (ERT) and Hormone Replacement Therapy (HRT) as a first-line treatment as potentially improving quality of life in menopausal women.
The issue of whether women should be advised to embark upon long term hormonal treatment is controversial, as the main assumption of ERT/HRT proponents is that if declining hormones are replaced, a woman will resume her “natural state”. Of course, the definition of ‘natural’ womanhood and femininity is reliant on social and cultural consensus, as well as any messages individual women have internalized across their own life experiences. While the idea of ERT/HRT as alleviating troublesome symptoms may be potentially compelling, women should consider the benefits and burdens—both financial and physiological—of ERT/HRT, as well as maintain an awareness of the fairly low compliance rate: only 50-70% of prescribed therapies are actually taken (Bartl & Bartl, 2019).
ERT and Health
Among users of ERT, only 20% of women take it for more than five years (Bartl & Bartl, 2019). These non-compliance issues may be related to how ERT is administered, via a patch that requires daily replacement. Past research has documented benefits including relief of menopausal symptoms, decrease in vaginal atrophy, and forestalling of osteoporosis (Jewelewicz, 1997) as well as potentially better cognitive capacities (Lobo, 1995; Schmidt et al., 1996). While one longitudinal study documented a reduced rate of heart disease in women taking ERT over ten years (Stampher et al, 1991), these results must be approached with caution due to methodological issues and inconsistencies found in the research itself. In fact, more recent research on ERT alone is scarce, perhaps due to some of the drawbacks mentioned below.
The Women’s Health Initiative (WHI) was one of the largest research initiatives to explore issues and treatments related to post-menopausal women, including hormone therapy, cardiovascular disease, cancer, and osteoporosis. Over 160, 000 post-menopausal women were enrolled. While the ERT component planned to follow women over nine years, study outcomes indicated an increased risk of breast cancer, coronary heart disease, pulmonary embolism and stroke, causing the study to be discontinued early. , among other issues in menopause, the effects of ERT was conducted beginning in 1991, entitled the Women’s Health Initiative (WHI, 2002).
Ultimately, it is important for potential users to understand that ERT masks the natural evolution of the body therefore, decreasing its natural transitions. Furthermore, with the invention of ERT, women, more so than ever, must rely upon chemicals for their health. The long-term implication for such women is that they must always be under the care of a physician which requires not only frequent monitoring, but potentially prohibitive costs. However, for women concerned about post-menopausal sexual functioning, ERT may be a subject worthy of exploration. As mentioned earlier, ERT directly improves vaginal lubrication and does not interfere with the newly found freedoms from menstruation and fear of pregnancy associated with menopause. Nevertheless, while ERT may ‘cure’ some of the problems associated with menopause, ERT’s side effects, such as cancer of the uterus, may outweigh the benefits. Therefore, it is recommended that women avail themselves of this form of medication for as short of a time span as possible.
HRT and Health
Research suggests that HRT reduces the risk of cancer of the uterus, because of the combination of progesterone and estrogen delivered: however, results vary based on age and last exposure to hormones (Langer, 2017). As in the natural menstrual cycle, progesterone acts as a stimulant to the growth of endometrium, which leads to its eventual removal, or sloughing off during menses. In ERT, there is no progesterone to counterbalance the effects of estrogen, which chronically stimulates the endometrium which has no way of sloughing off, thus leading to endometrial cancer. This imbalance is mitigated with the inclusion of progesterone in HRT.
HRT is primarily recommended to slow the rate of osteoporosis (Bjarnason, Hassager, & Chrisiansen, 1998; Torgen & Bell-Syer, 2001; Cauley et al., 2003), heart disease (American College of Cardiology, 2017), and to decrease frequency of hot flashes and night sweats (Santen, Loprinzi, & Casper, 2019). In one study, it was found that after 15 years use of HRT, the death rate of women was decreased by 40% (Henderson, Paganini-Hill, & Ross, 1991); however, more recent research has revealed less association between HRT and mortality (Holm et al., 2018). It has been hypothesized that HRT reduces mortality due to its impact on cardiovascular disease (American College of Cardiology, 2017), specifically, coronary artery disease. In addition, HRT has been recommended to women who experience surgical menopause due to a hysterectomy / oophorectomy for non-cancerous conditions (Langenber, Kjerulff, & Stolley, 1997). HRT has benefits over ERT, the addition of progesterone to the last ten days of the cycle, eliminates the increase risk of breast cancer (Ross, Paganini-Hill, Wan, & Pike, 2000). While both HRT & ERT decrease certain health risks, they increase others. However, on average, women tend to have more complaints about the side effects of HRT. This includes “spotting” several days each month, which can be a source of frustration for women, though this may remit by six months’ time (Sevenson, 2016).
The estrogen within HRT, like ERT, acts to increase vaginal lubrication, strengthen bones, and decrease blood pressure. Some people even believe that HRT may increase a woman’s sexual desire. One of the primary advantages (and disadvantages, depending) of using both estrogen and progesterone is that it stimulates ovulation. This means that women can prolong the reproductive cycle and, with the use of medical technology, (oocyte donation or frozen eggs) continue to bear children. In fact, it has been reported that a 63-year old woman was able to conceive and bring a healthy child to term. To date, there have been at least 100 children born to postmenopausal women through oocyte donation (Eisenberg & Schenker, 1997). A 10-year review of postmenopausal women who experienced oocyte donation revelaed a live-birth rate of 37.2%, results similar to rates in younger recipients (Grossman, Kort, & Sauer, 2014).
As in the case of ERT, women considering HRT should carefully consider both benefits and burdens before committing to a course of action. It can be useful to consult with an expert at The Center for Sex Therapy who is familiar with the research and outcomes of HRT and can discuss important considerations in-depth to determine if it is right for you.
Written By Dr. Erica Hyatt-Goldblatt & Alex Robboy, MSW, CAS, LCSW