Revisiting Menopausal Hormone Therapy

When I was a new Nurse Practitioner (NP), the Hormone Replacement Therapy (HRT) evidence-based medicine guidelines scared the sh * t out of many prescribers. I was one of them. HRT went from being the miracle drugs for treating perimenopausal and postmenopausal symptoms to OMG: in treating hot flashes with HRT we are increasing women’s risk of heart attack, stroke and cancers. I think it is important to note that just being post menopausal is a risk factor for vascular disease (cardiac event, stroke, dementia, osteoporosis, joint and muscle pain etc.) The new HRT guidelines cautioned to only prescribe HRT for women with severe symptoms and for the shortest period of time possible. Really, what the hell did I know? At the time I was around 40 years old, a new NP graduate who hadn’t gone through “THE CHANGE.” I didn’t have a hot flash until I was 55 (yes, you who suffer greatly can kill me now).

I religiously prescribed it according to the HRT guidelines. However, that all changed when my perimenopausal and postmenopausal patients and friends were saying HRT saved their lives.  Stopping or reducing their HTR dose resulted in them having: 1. feelings like they were going crazy 2. brain fog 3. midline weight gain 4. Urinary frequency/urgency 5. muscle and joint aches 6. intense night sweats and hot flashes. So, I got curious and started to have more nuanced conversations (I was scared out of my mind because I didn’t want to do any harm) with my patients. Together we reviewed their risk factors and created personalized HRT plans. The outcomes were very positive in decreasing or ending women’s suffering.

Now 20 years later, at the age of 61, HRT is called Menopause Hormone Therapy (MHT).  I read Haver MD’s new book, The New Menopause and I think, shit, I may have missed my window for MHT to be helpful to me. Being a person who suffers from migraines with aura I thought I wasn’t a candidate for MHT and it isn’t true. Migraine with aura is not an absolute contraindication to MHT.  However, according to Haver, the optimal time to use MHT to reduce cardiovascular disease & death from all causes, is in women younger than 60 years old who are at or near menopause (that date on the calendar when your periods have stopped for 12 consecutive months) and is no more than 10 years out from menopause. After the 10-year marker, initiating MHT increases risk of cardiovascular disease and 20 years out an even greater risk (p.61).

So why should I give a sh*t?

Well because my chronological age is 61, however, my endocrine(hormone) age is more ambiguous because of my endometrial ablation. Knowing my date of menopause is significant when it comes to initiating MHT and keeping me out of the death/chronic disease zone longer. I am pissed that I may have missed the MHT window.

Upon reflection, I was probably having perimenopausal bladder symptoms (urinary frequency and urgency) in my 40s when I was diagnosed with over active bladder and treated with oxybutynin. It works by relaxing the bladder; however, it wasn’t until I started routine vaginal estrogen, vulva massages, self penetration with lots of lube that my genital-urinary symptoms resolved and no longer needed oxybutynin.

I also wonder if the onset of my cluster headaches and my increasingly not giving a F##$% K attitude in my late 40’s were perimenopause symptoms.  It wasn’t until age 55 that I noticed the morning brain fog and anxiety, hot flashes, night sweats, muscle pain/ stiffness and my new candy apple shape that I figured I was postmenopausal (Aw, geeze).

So, I started to look for ways to combat my symptoms. Cutting my carbohydrates helped decrease the intensity of hot flashes.  I sleep with ice packs under my pillow so when night sweats happen, I pull one out and put it on my chest or head (Yup, for real.) Getting air conditioning was a god send. Also, I used cool max sheets and now I love my bamboo sheets. Even though all the above symptoms were annoying, it is the brain fog, muscle stiffness/ aches, the rolling & morning anxiety that I find most brutal. Yup brutal.

So, I started a deliberate and daily routine including 15-minute cold dunks (I find this helpful to reduce brain fog).  The muscle aches/stiffness are more bearable when I stick with my 3 days a week interval training and I take magnesium daily. Being outside for my daily walk improves my mood and dissipates anxious energy. Lastly, for bone health I take Vitamin D, K2, Calcium and use kettlebells 2x/week. Oh, my goodness no wonder I am tired by the time Friday rolls around. I remember a friend saying that as you age, you need to do more maintenance. Personally, I would like a complete overhaul including some testosterone straight up with a side of estrogen and progesterone please.

Forever having a curious mind, I have booked myself an online MHT assessment. If it is too late for me, then maybe what I learn can help alleviate another woman’s unnecessary suffering.

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