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The Basics of Perimenopause – HRT and Your Heart
Posted by: | CommentsWomen with a family history of heart disease may find themselves buffeted by conflicting information about hormone replacement therapy and heart protection. I want to emphasize here that when it comes to protecting your heart, HRT needs to be weighed as one of a range of options you have. A family history of heart disease is one factor to consider in evaluating the benefits of HRT, evidence shows that HRT can reduce the incidence of heart disease by as much as 30 to 50 percent. But in our forties the tools at our disposal to strengthen and protect our hearts certainly aren’t limited to medication. I prefer to aim for the overall goal of good health and resilience and do what we can do now, on our own, to achieve it without medical intervention.
Perimenopause is a time to begin anew, to make a strong commitment to taking better care of ourselves than we ever have before. A very important aspect of your self-care is paying attention to what your heart is telling you. It’s true that men and women who report cardiac symptoms are often treated very differently by the health care system, but it’s also true that women themselves often dismiss signals of heart trouble. If you have any concern about a possible cardiac symptom, you owe it to yourself to be sure that this symptom is fully explored. And you may have to be assertive in insisting that it be checked out, if your health care provider seems reluctant to do so or if he or she wants to attribute it to anxiety without any futher exploration. In other words, you may have to take the lead in educating your health care provider about the risks of heart disease in women.
The American Heart Association lists these warning signs of a heart attack:
- Uncomfortable pressure, fullness, squeezing, or pain is felt in the center of the chest, lasting more than a few minutes.
- The pain may spread to the shoulders, neck, or arms.
- Chest discomfort with lightheadedness, fainting, sweating, nausea, or shortness of breath may also occur.
If you have pain in your chest radiating into your left arm; tightness in your chest accompanied by shortness of breath; or palpitations, contact your health care provider right away. Note that palpitations can also be a symptom of perimenopause. Some perimenopausal women say their heart pounds abnormally hard or fast when they are having a hot flash, while others have palpitations that are not connected to hot flashes. Again, I want to underscore the importance of not making any assumptions about these symptoms. Talk them over with your health care provider and ask to have the appropriate investigation to rule out a heart problem.
Women who are affected by cardiovascular disease have a less favorable prognosis than men, for a host of reasons. In the past, the medical community tended to interpret danger signs differently for men and women, although this is slowly changing. Still, palpitations in women are frequently attributed to anxiety, while in men they are viewed as a more serious sign of potential heart disease. A more complete diagnostic workup will usually be done on a man who reports chest pain than on a comparable woman. The medical community is beginning to pay closer attention to signs of heart disease in women, a long overdue change mat women in our age group can take credit for because we have insisted upon being heard.
If a woman is incorrectly diagnosed as having anxiety, however, when heart disease is the real culprit, her treatment will be delayed or inappropriate. By the time the problem is correctly identified, she will probably have more advanced coronary disease than her male counterpart. Delaying treatment for coronary disease lessens the opportunity for effective intervention. Again, if you experience the warning signs of a heart attack, there are two rules to heed: get medical help immediately, and insist that a heart attack be ruled out. Honoring and respecting yourself means listening to your body when it is talking to you.
The Female Heart cites sobering statistics on women who have heart attacks:
- Thirty-nine percent of all women heart attack victims will die within the first year of the attack, versus 31 percent of all men.
- A woman is twice as likely as a man to die within the first sixty days of a heart attack.
- After a first heart attack, a woman is twice as likely as a man to have a second heart attack.
These statistics can be alarming; especially for those of us whose mothers or fathers have had heart attacks. But you don’t have to feel like you may suddenly be blindsided by a heart attack, there is a lot you can do to keep your heart healthy so you don’t find yourself facing those post-heart attack odds. For example, smoking not only causes lung cancer and emphysema but also increases the risk of heart attack. You can cut your risk of heart disease by stopping smoking, exercising regularly (women who exercise regularly are three times less likely to have hearts disease than those who don’t), minimizing your stress level, and paying attention to your diet.
The Basics of Perimenopause – HRT and Genitourinary Changes
Posted by: | CommentsHormone replacement therapy often relieves vaginal dryness. But if the combination of hormones in the regimen isn’t suitable for an individual woman, vaginal dryness, burning, uncomfortable intercourse, or stress incontinence persist.
HRT regimens frequently include estradiol and estrone, two types of estrogen. A third type of estrogen, estriol, can often relieve vaginal dryness where other types have failed. Frequently called the “weak” or “forgotten” estrogen, estriol has a good track record in relieving genitourinary symptoms such as vaginal dryness and stress incontinence. Estriol is good for hot flashes too.
Although estriol is commonly used in Europe, it isn’t made in mass quantities in the United States. Many health care providers are unfamiliar with this natural form of estrogen. Each estriol prescription is compounded individually by a pharmacist as an oral capsule, vaginal cream, vaginal suppository, or topical skin cream or gel. Estriol suppositories are dry and need to be moistened before inserting, they aren’t waxy or messy like some vaginal suppositories. Some women prefer to use an estriol skin cream or gel, which is also a prescription medication that must be compounded by a pharmacist.
Dana, a reserved woman with a careful way of speaking, came to see me with this report: “My friends complain about hot flashes, moodiness, and memory lapses. I have none of those problems. What I notice is that lovemaking has become painful, and my friends aren’t talking about that.” She paused for a moment. “Well, I suppose I wouldn’t talk about it even if someone did bring it up.”
“These are deeply personal issues,” I said to Dana. “Many women are uncomfortable talking about their private lives, and besides, it hasn’t exactly been common knowledge that these changes can happen in our forties.”
As we talked more, Dana said that the vaginal discomfort and dryness didn’t happen only during lovemaking. She thought it had started at least a year ago; she is now 47. We talked about her options to manage this symptom, vitamin E or another over-the-counter lubricant and estriol.
After Dana and I discussed her family history and her questions and concerns about HRT, she consulted with her health care provider. Given her symptoms and her overall health profile, neither she nor her healthcare provider thought HRT was necessary for her now. She did, however, decide to try estriol cream, smoothing a very small amount (0.05 mg) on her hands twice a day for thirty consecutive days. She was also going to use vitamin E oil, which can be applied directly to the vagina. As we have discussed, estriol does not affect breast or uterine tissue. Unlike other estrogens, it can be taken without natural progesterone or synthetic progestin, because it does not stimulate the uterine lining. Dana had good results with estriol cream and vitamin E. When I saw her last and asked how she was doing, she said, “There has been a complete turnaround.” I took that to be her circumspect way of saying that her vaginal symptoms had improved and, I hope, that she was much more able to enjoy lovemaking again.
The Basics of Perimenopause – Risks and Benefits Hormone Replacement Therapy
Posted by: | CommentsFor some of us, the risks of HRT may outweigh its benefits. Women who have had these conditions should be carefully evaluated before HRT begins:
- breast, uterine or other cancer stimulated by estrogen
- a family history of estrogen-dependent cancers
- abnormal vaginal bleeding
- chronic liver disease
- blood clots in the legs or lungs
The research on HRT and breast cancer is contradictory. Some studies have shown that HRT is not associated with an increase in the disease, but other data link HRT (both estrogen alone and estrogen and synthetic progestins combined) with a greater risk of breast cancer when taken for five years or more. The Harvard Nurses’ Health Study is often cited as showing that HRT raises breast cancer risk by 30 to 40 percent when taken for five years or more, and presents an even higher risk for older women. For some women, even a slight risk of breast cancer is unacceptable, Sharon felt that way, particularly since her mother-in-law was struggling with breast cancer. While she had no direct family history, seeing her mother-in-law’s situation made her feel very wary of anything that could increase her own risk of developing the disease. Other women decide that HRT’s potential benefits for them today outweigh the risks, particularly when their personal risk of heart disease is much greater than their risk of breast cancer. These women, like all of us, need to take care of their breast health by scheduling regular mammograms and examining their breasts every month.
There isn’t a single process to arrive at a decision about HRT, and unfortunately we don’t have neat answers to the question about breast cancer risk. It will probably be many more years before enough rigorously controlled long-term studies on HRT have been done to tell us everything we want to know. Until then, some women will give HRT a wide berth, preferring to rely on no drug remedies to keep their symptoms under control. Others will choose HRT, feel well when they are taking it, and be comfortable that, for them, the advantages outweigh the drawbacks. Each choice is personal ¡ªno blanket decision will apply across the board. Whatever you decide about HRT, you need to feel that you have had an honest dialogue with a health care provider, who knows your situation, and who is willing; to seek out the latest research and information about new HRT products as they become available and provide that information to you. Most of all, your decision needs to be made in the spirit of partnership with a professional who listens to and respects your views about your own health.
The Basics of Perimenopause – Managing HRT Side Effects
Posted by: | CommentsIsabel, who considered stopping HRT a birthday gift to herself, is an example of a woman on HRT for whom the “cure was worse than the disease.” Her situation doesn’t have to be yours. When an HRT regimen isn’t relieving your symptoms or is making you feel worse, it’s clearly not working. Then you and your health care provider will need to do some adjusting: you may have to change medications, switch to a different form of administration, or take less or more of a hormone.
“I’m fat since I started HRT,” Laura stated flatly. “I was never slender to start with, but now I’ve gone from a size ten to a twelve, and I’m barely fitting into those.”
Weight gain can be an unwanted companion of HRT, as the estrogen component of the regimen seems to slow down our ability to burn body fat. Laura’s concerns about her weight echo those of many women who are considering HRT. I explained to her that because our basal metabolic rate decreases during our perimenopausal years, it takes our bodies longer to burn the calories that we ingest, whether or not we’re on HRT.
Because Laura’s uterus was intact, her HRT regimen included a synthetic progestin, to prevent estrogen from stimulating abnormal cells in the uterus. One side effect of the synthetic progestin that Laura was taking can be weight gain. The Physicians’ Desk Reference (PDR), commonly used by physicians as a source of product information about drugs, says that among the potential reactions to Provera are “fluid retention” and “weight change (increase or decrease).”
Taking HRT doesn’t have to mean an automatic weight gain. Laura and I discussed the importance of choosing foods wisely and the benefits of getting enough exercise. Then we identified three options for adjusting her HRT:
- First, we would talk with her health care provider about switching her from synthetic progestin to micronized natural progesterone. If, after two to three weeks on this regimen, her weight gain, bloating, or both were still problematic, we’d go to the next step.
- Step two would be to change the type of estrogen she was taking. Laura was currently taking Premarin, which contains estrone and other estrogens that are unique to horses and that may have had a role in her weight gain. Changing to Estrace, which is estradiol, could help. Again, I recommended evaluating this regimen after two to three weeks.
- If there were still no improvement in the weight problem, the third step would be to lower the dosage of Estrace. Sometimes a smaller dosage of estrogen can provide the protection we want without contributing to weight gain.
The Basics of HRT Issues – Pill, patch, or Cream?
Posted by: | CommentsIf you decide to try HRT to relieve specific perimenopausal symptoms and/or to protect your heart and bones, you can choose from different forms of administration. Women who prefer swallowing a pill have that option for estrogen, synthetic progestins, and oral micronized natural progesterone. “It’s easier for me to remember to take pills,” said Nicki. “I take my estrogen and progesterone in the morning, when I take my vitamin.” If you’re taking HRT in oral form, the time of day you choose is up to you. Morning, noon, or evening is fine, as long as you keep the same routine and don’t vary it by taking HRT one day in the morning, the next in the evening, and so on.
When you are deciding which form of HRT to try, convenience is certainly important, but it’s just one factor to consider. Your decision is best made when it is based on the symptoms you most want to manage, and the level of protection you want to give your heart and bones. After that, convenience and cost may come into consideration.
For instance, estrogen is also available as a skin patch. Some women appreciate the convenience of applying the skin patch and going about their business. The patch also provides the advantage of continuous, even delivery of estrogen. But because the patch releases the hormone into the bloodstream, it bypasses the liver. That means that the patch provides the same bone protection as oral estrogen, but it may not provide as much protection against heart disease.
Some women who suffer from headaches during perimenopause benefit from using a skin patch. Experts believe that perimenopausal headaches are related Jess to the amount of hormones our bodies produce than to the fluctuations in these hormones. It may be that the steady delivery of estrogen through the patch levels out the fluctuations, thus helping to relieve headaches.
Estrogen skin patches are now available in several dosage strengths, another hopeful sign that we are moving away from the notion that “one size fits all” when it comes to HRT. Another reminder about the skin patch: you still need to remember to take your progesterone in whatever form you choose; tablet, suppository, or cream.
Estrogen can also be delivered vaginally, either through a vaginal cream or through a vaginal ring inserted somewhat like a diaphragm and left in for ninety days.
Estradiol, estrone, estriol, and natural progesterone are also available in cream form. There is some suggestion that estriol and natural progesterone may provide perimenopausal symptom relief in significantly lower doses in cream form than in oral forms. What’s still not known is how much hormone cream is needed to provide heart and bone protection. Women who currently do not have to be concerned about bone loss or cardiovascular disease but who want to manage mood swings, vaginal dryness, hot flashes, or stress incontinence may be good candidates for natural hormone creams. These relatively new developments continue to build our knowledge about HRT options and raise questions that need further exploration. Before you try taking any hormone in cream form, though, be sure you know exactly how much of the hormone is in the cream, and exactly how many milligrams of the medication you will receive when you use the cream. It’s best to work with a knowledgeable pharmacist and a reputable supplier of hormone creams.
A natural hormone cream seemed like a good option for Sharon, who had begun six weeks earlier with a self-care program that included increasing the amount of soy in her diet, balancing her exercise routine with yoga to reduce her stress, and taking a vitamin supplement with B6. But her home situation had recently become more complicated, and she felt increasingly anxious. Soon after her husband’s illness, her husband’s mother faced a recurrence of breast cancer. Sharon’s three children also required a steady supply of her time and energy.
“I’m just not sure I can do all of this,” Sharon said, her eyes filling with tears. “I can’t even sleep at night, I’m so nervous.” For Sharon, “all of this” is considerable: supporting her husband as he continues his recovery, caring for her 11-, 9-, and 3-year-old children, and wanting to be able to respond to her mother-in-law’s needs.
For some women with Sharon’s symptoms, I might recommend natural micronized progesterone in oral form. But Sharon had already made it clear in our earlier visits that she preferred not to take medication if at all possible, and she very definitely did not want to be on HRT. I suggested that she consider natural progesterone cream, which she could rub into her hands twice daily. “Progesterone cream is medication, but at a very low dose and taken in the least invasive way,” I pointed out. “If you decide to try it, you could start with 10 mg a day. Many women find that a small amount of natural progesterone helps with anxiety and irritability, and it can be an excellent alternative to other medications that are often prescribed to relieve anxiety.”
We talked about the fact that natural progesterone cream would not be an antidote for the understandable anxiety she was feeling as a result of the very stressful and demanding life events she was facing. “But it just might give you a little extra help, and you need that now,” I suggested.
Sharon did decide to try natural progesterone cream for one month. We contacted her health care provider to obtain the prescription, which she then had compounded by a pharmacist. (A prescription hormone cream can be compounded to meet your specific needs. You know exactly how much hormone you’re getting, and prescription creams often cost less than creams you can buy over the counter. Many insurance plans will cover the cost of prescription hormone creams.)
I talked with Sharon ten days after she started using the cream. “Oh, I still have plenty of anxious moments, but I’m not quite as overwhelmed,” she told me. “Between the yoga class I started, the deep breathing, and the progesterone cream, I can feel a difference.”
The Basics of HRT alternative perimenopause treatment – black cohosh
Posted by: | CommentsBlack cohosh was choice as a first line of treatment for perimenopausal heart palpitations. Other women start taking HRT, then decide they would like to switch to black cohosh to see if it will take care of their symptoms. The transition from HRT to black cohosh should be made gradually over a five-to-eight-week period, following these steps:
1. Evaluate the importance of heart and bone protection with your health care provider. Black cohosh probably does not provide this protection. If your cardiovascular health is not an issue but your goal is to build bone strength, black cohosh can be taken with natural progesterone, which has bone-building properties.
2. Begin adding soy to your diet, and be certain you are getting adequate amounts of calcium daily (1500 mg). Boosting your soy and calcium intake is a gentle and natural way to protect your heart and bones.
3. Begin taking black cohosh (40 mg daily to begin) while you are still taking HRT.
4. For the first three to four weeks of the combined HRT/black cohosh regimen, gradually taper your dosage of estrogen. For instance, if you have been taking 1 mg of estrogen daily, take 1 mg one day and 0.5 mg every other day. Remember that you must continue to take a form of progesterone even as you taper down your estrogen, and that you are still taking black cohosh daily. Continue to take progesterone at your regular dosage; do not taper down the dosage of this hormone.
5. After three to four weeks, reduce your estrogen again, taking half your normal dosage every day. Follow this reduced estrogen dosage for two to three weeks, continuing with the black cohosh.
6. Then for one week, take half of your normal dosage of estrogen every other day. You may then discontinue the estrogen and take black cohosh along with progesterone if you choose. Black cohosh does not have to be opposed by progesterone the way estrogen does, but some women choose to take the combination of black cohosh with progesterone.
The literature on black cohosh states that its side effects are minimal, a very few patients will report stomach upset. But I have heard a few women report that the maximum dosage of 160 mg per day made them feel like their breasts were engorged. If this occurs, lowering the dose to 80 mg per day should take care of the side effect. Although no toxic effects are associated with black cohosh, you may want to use it to provide short-term relief from specific symptoms.
The Basics of Hormone Replacement Therapy For Perimenopause – Not Cast in Stone
Posted by: | CommentsYour decision about hormone replacement therapy is a very personal one. Whatever you decide, nothing is cast in stone. If your choice is to try HRT to relieve night sweats, hot flashes, urinary incontinence or mood swings, you can follow up with your health care provider regularly (three months after starting HRT, sooner if any problem occurs). During this follow-up visit, you can evaluate how you are feeling and judge whether your symptoms are adequately relieved. The same holds true if your decision is that HRT is not for you right now. At any time, you can always reevaluate, which is why I stress the importance of making a date every three months to check in with yourself and assess how you feel.
One of my patients, Sylvia, found it helpful to take HRT one day at a time. This mentality gave her the open-mindedness she needed to work with her health care provider to decide if she would continue HRT, and to select the best regimen for her.
Obviously, if you feel worse after starring HRT, you don’t need to wait for months before you take action. Most women feel the impact of starting, stopping, or adjusting HRT very soon. After starting HRT, symptom relief usually happens within three to four days, and side effects, if they are going to appear, usually show up within three to four days as well. Discontinuing HRT has the same rapid impact: the side effects will go away within a few days, and if HRT has alleviated symptoms such as mood swings or sleeplessness, they often return three to four days after HRT is stopped.
I encounter so many women like Terri who approach the decision about HRT as if it were irrevocable. They fear that they are risking great harm to themselves if they don’t make the right decision, or they think that the decision they make today has to stand for the “rest of their lives.” I want to emphasize that there is no single “right” decision about HRT, so take that pressure off yourself. What’s right for you today may change in the future. The important first steps are to review your history and get all the information you can about HRT. Then talk your options over with a health care provider you trust and who is willing to answer your questions. Most of all have faith in your own wisdom¡ªthe choice you make will be the right one for you.
The Basics of Hormone Replacement Therapy For Perimenopause – Facts about Your Choices
Posted by: | CommentsNot long ago I stood in line at the grocery store reading magazine covers. One said, “Estrogen, the hormone of youth!” while the cover directly below it said, “Breast cancer: Is estrogen the villain?” No wonder the issue of hormone replacement therapy seems scary, and even a little crazy, at times.
Newspapers and magazines are filled with articles on the risks of breast and uterine cancer, heart disease, and osteoporosis and how they may be related to HRT. These articles often spell out breaking developments, and provide conflicting information. One article presents HRT as a cause of disease, while another sees it as a preventive measure. Many women tell me they’ve simply stopped reading these articles. These are intelligent women who are committed to taking care of themselves, but the contradictions in the news stories about HRT leave them feeling confused or frightened or both.