Updated: Jan 8, 2021
As a functional medicine practitioner, the #menopause transition is viewed by me as a physiologic state, much like pregnancy and puberty, and any symptomology that results in discomfort is thought of as a reflection of one's overall health and wellness. Entering these stages of life in an unhealthy state, with fatigued adrenals or gut dysbiosis for example, will certainly provide a less than optimal experience. Guiding a client back into an optimal state of being would be my primary goal in managing menopausal symptoms and certainly my focus as one begins perimenopause, as to avoid any negative experiences; however, for a variety of reasons, it may be helpful to understand a more conventional approach. Potentially more acute relief is required or the woman's overall state of health is more critical and in need of more aggressive medical management. This post will address those states, more so than review how one might optimize their foundational health from a functional medicine perspective.
The Women's Health Initiative released results of their #hormone therapy research in 2002 and it received tremendous media attention, scaring the hell out of the entire women's health profession. Prempro (combination of estrogen and progesterone) scripts dropped by 66% and Premarin (estrogen) scripts dropped by 33%.
Since this time, there has been some evolution in the mindset of supporting women with hormones through what can be an exceedingly difficult life transition. In 2012, the North American Menopause Society (NAMS) revised its position and stated that the risk-benefit analysis of menopausal hormone treatment should be individualized and that the benefits of hormone therapy may outweigh risks when initiated around the time of menopause and used for three to five years.
Later, in 2015, NAMS released an updated statement saying that for women older than 65 years, hormone therapy should not be discontinued solely on the basis of age, but should instead be individualized based on consideration of risks and symptoms. The American College of Obstetricians and Gynecologists (ACOG) updated its position in 2014 to reflect a more liberal approach to hormone therapy during this menopausal transition.
Midwives & Menopause
The #midwifery profession is often thought of as a speciality limited to catching babies to the point that the scope of practice seems to be even less broad than the entry level registered nurse. More often than is even comical, I had to respond to people who belittled the profession that we are capable of much more than simply boiling water.
Midwives are ideally suited to provide care to women through and beyond the menopausal transition, because we are clinicians who place emphasis on women-centered care, shared decision making, non-biased counseling, and extend incredible priority to detailed informed consent.
Menopause is defined as the last menstrual period which is unknown until that first year passes, which averages at about 51 years of age. Perimenopause is the time prior to that last menses when which women are experiencing symptoms, typically two to eight years prior to menopause, and postmenopause is the time following that last menstrual flow. The menopausal transition is climacteric, referring to both the perimenopausal and early postmenopausal stages when vasomotor symptoms are most likely to occur.
Our ovaries contain a finite number of follicles, and menopause occurs when follicular reserve reaches a critical lower threshold of about 1000 follicles. As the ovarian follicles are unable to respond to the hypothalamic-pituitary stimulation, estrogen and progesterone production decreases in the ovary and pituitary gonadotropin (follicule-stimulating hormone) increases. Progesterone is the first to decline. Generally this happens prior to the onset of one's menses, as progesterone is typically highest at this time. During that perimenopausal transition then, these women will start to see more significant premenstrual syndrome symptoms.
Estrone (E1), Estradiol (E2), and Estriol (E3) are our primary estrogen hormones with estrone being the most dominant of the group after menopause, but it is weaker overall. Estradiol is the dominant estrogen during our childbearing years, offering protection to our cardiac health. Estradiol is the cause of breast development and ovulation. This is also the form of estrogen which essentially disappears with menopause, bringing about our symptoms and inviting increased cardiac risk.
Typical symptoms of menopause include changes in the spacing between each menstrual flow, as well changes in the duration and amount of flow. Night sweats without daytime vasomotor symptoms may occur early in the perimenopausal stages, and then later, menses begins to space to as much as two months apart. Changes in bone metabolism, reproductive function, vasomotory symptoms, atrophy of the smooth triangular area at the base of the bladder between the openings of the ureters and urethra (trigone) are changes that are ominous with loss of reproductive steroids.
Hormone therapy is the administration of systemic or local #estrogen with or without progestogen used to treat the symptoms of menopause. Progestogen is a broad term that includes both natural progesterone and synthetic progestins, and when both are being discussed, the more specific term is typically used. When providing systemic estrogen, a progestogen is used to prevent endometrial hyperplasia and cancer in women who have an intact uterus. Low-dose, topical, vaginal estrogen may be given without a progestogen, but any vaginal bleeding after menopause must be thoroughly investigated if it occurs.
After the WHI study, experts theorized that potentially they were simply prescribing too potent of a regime, so potentially, decreasing estrogen to just 14 days may prove advantageous? Some clients do have the low progesterone though, and may even suffer insomnia due to it, so supplementing progesterone on days that estrogen is withdrawn may be helpful. Medroxyprogesterone acetate (MPA) 2.5-10mg, 2.5mg daily if continuous estrogen, or for 14 days is an option, as is norethindrone acetate 0.1-1mg by mouth daily. Progesterone micronized 100-200mg at bedtime for at least 12 days out of every month as a vaginal suppository can help provide endometrial protect if applied at least 10 days/month at 4% (45mg/day) or every other day at 100mg/day for three to five years. My clients have shared that this does help them sleep when taken prior to bed, but also that it is quite messy. Transdermal micronized progesterone does not provide the endometrial protection. There are providers, particularly those who specialize in bioidentical hormones, who will pack a great deal into these vaginal suppositories, which is super convenient, but this can not protect the uterus. These clients will be at risk of endometrial carcinoma if not offered additional support.
Selective estrogen receptor modulators (SERMs) are emerging as an alternative to progestogens, having the potential to prevent endometrial hyperplasia without increasing breast cancer risk. Bazedoxifene is a great option, at 0.45mg/20mg daily, which is a conjugated equine urine product, but evidence is quite supportive of its use. This product is tissue-selective, providing estrogen without the progestin, without inviting risk to the uterus while reducing breast cancer risk. Osphena (Ospemifene) is another SERM, which is specific to vulvaginal dryness, at 60mg each day, with food. This is estrogen-like, but is not in fact, hormones.
Previously, I shared a bit about E1 and E2, neither of which are FDA-approved for supplementation. E2 is well known for increasing the risk of breast cancer in those who are overexposed, which may mean these women initiated their menses at a really young age or endured those years longer than most, such as beyond the age of 55 years, or they did not undergo pregnancy or #breastfeeding which would have reduced exposure to E2. Estrone or E1 is developed in our adipose or fatty tissue so those with higher adiposity or obesity are at greater risk for breast cancer because of this ongoing exposure.
#Estriol or E3 is the dominant estrogen when we are pregnant, made by our #placenta, and this is really where the controversy comes with regards to supplementation. This is not currently FDA-approved in the United States for supplementation, but it is in Europe and Asia. There are hundreds of research articles available on this particular estrogen, primarily as a vaginal estrogen, but no FDA-approval. It is therefore only available by compound pharmacies, via prescription.
Interestingly, when one is pregnant, they find they have better hair growth, a pregnancy glow, and even increased vaginal discharge, which is likely why there is more research on vaginal estrogen E3. Pregnancy also offers improved immunomodulary responses or pro-inflammatory cytokines. We see that women with autoimmune diseases, such as #Lupus, seem to improve during pregnancy. Soon after pregnancy resolves however, relapse often return abruptly. E3 is not as potent as E2 and so it is not as cardioprotective, nor is it as good for the bones.
There are a number of benefits women may attain from hormone replacement therapy. Therapy can also be pertinent for those with increased cardiovascular risk or with various cancer risks, bone disease, or even diabetes. One meta-analysis found combined hormone therapy reduced type two diabetes almost 40 percent with lower fasting glucose levels and levels of HgbA1c. Weight gain increases by about five pounds upon entering menopause even when eating and exercising the same. This gain was abdominal as well, so the conclusion here is that hormone therapy can improve metabolic syndrome.
Otherwise understood as hot flashes or flushes, vasomotor symptoms involve an abrupt sensation of heat and flushing in the upper body followed by perspiration and chills, occasionally with associated #anxiety and heart palpitations. These might disrupt sleep, work, and overall quality of life. Eight percent of women experience some level of symptoms during their menopausal transition, and half of all women experience these frequently enough to disrupt their daily well-being. When experienced, these symptoms typically endure for an average of 7.4 years, but can last well into the seventh decade for some women.
The gold standard treatment here, is the conventional combination birth control pill, offering the client ethinyl estradiol supplementation. The concern is that this amount and type of estrogen is really quite potent, which might not be optimal for someone in their later childbearing years, who may already have higher cholesterol, maybe even hypertension or pre-diabetes. For this reason, although the current gold standard, this isn't my first choice for women.
Genitourinary Syndrome of Menopause
This is otherwise known as vulvovaginal atrophy or atrophic #vaginitis. GSM is the broader term, which includes vaginal dryness, vulvovaginal atrophy, and the urogenital changes related to the local tissue effects of loss of estrogen on the trigone. These symptoms are chronic and progressive, causing loss of tissue elasticity and decreasing aperture and length of the vagina, which can lead to discomfort, even pain, with intercourse. Many women notice a reduced desire for sex, increased urinary tract infections, and urinary incontinence. While many women do continue regular sexual activity utilizing a water-soluble lubricant, most women without any supplemental vaginal estrogen will find these symptoms worsen with age.
Both systemic hormone therapy and low-dose vaginal estrogen replacement can increase lubrication, blood flow, and sensation of the vaginal tissues. Systemic hormone therapy does not improve sexual function, sexual interest, arousal, or orgasmic response in women without menopause symptoms. If sexual function or libido are concerns in women with menopause symptoms, transdermal estrogen therapy may be preferable over oral estrogen therapy because of less effect on sex hormone binding glubulin (SHBG) and free testosterone levels. Low dose vaginal estrogen therapy improves sexual function in postmenopausal women. For those women who seek to avoid hormone therapy, there are non-estrogen alternatives approved for dyspareunia, including ospemifene and intravaginal DHEA (Intrarosa). Given vaginally, these have had the same effects of estrogen and testosterone. These are synthetic, but the evidence demonstrates that these have not increased systemic levels.
As reproduction steroids decrease with age, bone mineral density declines. Osteoporosis is diagnosed when the T-score is -2.5 (test question), which occurs in twice as many women as men because of the relatively sudden and absolute reproductive hormone loss, rather than gradual loss that men experience. Screening begins at age 50 years in women with risk factors. The US Preventive Task Force and National Osteoporsis Foundation recommends beginning dual-energy x-ray absorptiometry bone density scans at 65 years for those without high risk.
Evaluating for Menopause Clinically
Menopause is generally thought of as a state of diminishing estrogen, but in the transition, women can have elevated estradiol levels during the luteal phase of their menstrual cycle, which could give false reassurance of fertility. During perimenopause, FSH can vary as well, from month to month. Serum results are unreliable diagnostic tools.
Women typically visit their care provider during their menopausal transition for changes in libido, mood, cognition, or due to weight gain. Although these concerns may be secondary to #vasomotor symptoms and subsequent insomnia, they are not necessarily specific to menopause and so, the clinician should be diligent in ruling out other underlying causes. Obesity, coronary vascular disease, venous thrombotic events, reproductive organ cancers, depression, and dementia are other potential causes, independent of menopause. A thorough health evaluation really is necessary, so unfortunately, although many clients do call requesting I recommend labs, this is a very dangerous approach to managing this stage in a woman's life.
When one is initiating menopause and their estrogen is declining, they may experience increased anxiety, arthritis, decreasing breast size, decrease in memory, decrease in sexual interest, depression, elevated cholesterol, more wrinkles, osteoporosis, stress incontinence, and vaginal dryness, whereas, when estrogen is high, women experience bloating, fatigue, elevated risk