For generations, menopause was a word that went unspoken among women. It was called simply "the change." The silence around menopause and perimenopause has disappeared in recent years as women talk more openly with their physicians about how to better navigate and manage its symptoms.
Elizabeth R. Lapeyre, MD, recently helped the AMA with one such conversation related to menopause and hormone-replacement therapy (HRT) on the latest episode of the AMA podcast “Health vs. Hype.”
"Health vs. Hype"—produced in partnership with iHeartRadio—takes on medical misinformation, viral health trends, DIY medicine, and common health myths to help listeners understand what’s real, what’s risky, and what’s backed by science. Host Trace Dominguez fact-checks popular health claims, explains how medical misinformation spreads, and reveals the real-world consequences of getting it wrong.
Dr. Lapeyre is a board-certified ob-gyn and medical director for the Menopause and Women's Wellness Center at Ochsner Health in New Orleans.
"Perimenopause is a time of a lot of fluctuations of hormones," Dr. Lapeyre said. "I call it the rollercoaster for hormones, because women, we're born with as many eggs as we're ever going to have, and they deplete in quality and quantity over time. When the ovaries are no longer releasing eggs, that's when we have our last menstrual period, and a year of no bleeding is menopause, and that's when everything flatlines in terms of your hormones. Perimenopause is the up and down. Menopause [means] no more hormones."
Ochsner Health is part of the AMA Health System Member Program that provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Menopause often means more than hot flashes
"Your classic symptoms are hot flashes and night sweats," Dr. Lapeyre said. "That's what everybody thinks of. But there's also sleep disruption, anxiety, mood swings, joint pain, brain fog, cognitive changes, lack of focus, vaginal dryness, pain with intercourse, just a whole host of symptoms that come along with menopause."
"About 75% of women will experience these symptoms," she said. "And for some women, it can last an average of seven years. For some women, it's even longer."
Learn more with the AMA about what doctors want patients to know about menopause.
3 main hormones are affected by menopause
"When we think of hormones, we think of three main ones, and that's estrogen, although estrogen is made up of a family of hormones," Dr. Lapeyre said. "When we're talking about menopause hormone therapy or hormone-replacement therapy, we're really talking about estradiol—what I'm talking about generally is FDA [Food and Drug Administration]-approved products. Progesterone, so the estradiol I'm mentioning and the progesterone are what is chemically similar to what's in your body. That's the bioidentical hormones. And then testosterone, which everyone thinks of as a male hormone, but it's not. Women have five to ten times the amount of testosterone in their body than they do estrogen."
How hormone-replacement therapy is administered
"In terms of estradiol, there's transdermal, which includes patches, gels, rings and mist," she said. "The progesterone, most of the time it's really just an oral medication. And then testosterone—we do not have an FDA-approved product in this country for testosterone."
It is worth noting that there are nonhormonal medications that can be used for menopausal symptoms. A discussion with your doctor can help determine what may be best when someone cannot use hormone-replacement therapy.
A billion-dollar study was communicated poorly
"The Women's Health Initiative [WHI] was a billion-dollar study that was done, and it was halted in 2002," Dr. Lapeyre said. "They had a press conference announcing the halting of the WHI because of increased risk for breast cancer, stroke and heart attack. The purpose of this study was to really show that hormones were going to be preventive of problems. It didn't really show that, because the population that they looked at already had some problems. That was what didn't get really portrayed in the media absolutely correctly, and that's why over time, this has finally evolved and changed.
"In the WHI, the Women's Health Initiative, you had women who on average were 63 years old, so they had been in menopause for probably 10 years or longer," she said. "They already had cardiovascular disease or maybe high blood pressure, hypertension. Some of them were obese. So they already had some underlying problems, and then you gave them a synthetic estrogen and a synthetic progestin orally. That was the only way they did it, with one dose. And then you extrapolated to all women when they saw an increase in some instances of those things I mentioned.
“And that's not accurate,” Dr. Lapeyre. “For most women, if given in the right time, in the right modality, it can be very safe and very effective. So we lost a whole generation of patients who could be treated."
Read more about how physicians are expanding the impact of menopause care.
Hormone-replacement therapy can be positive
"For most women, when used in those first 10 years especially, it can be beneficial for bone health, cardiovascular health and brain health," Dr. Lapeyre said. "We know that it's also preventive for bone health, for osteoporosis, and bone loss."
"There's plenty of data out there about the cost to the workforce when women are undertreated for menopause," she said. "I have women coming in who are highly functioning, and they are starting to doubt themselves. They don't have the confidence anymore. They're not able to focus. They have brain fog, and it's frightening to them. I think if we can get her back on track, everybody wins.”
Notably, many patients obtain HRT from a compounding pharmacy. It is important for patients to understand the distinctions between FDA-approved HRT medications and compounded products, and it is worth asking your doctor about this.
Meanwhile, there have been growing challenges surrounding access to estrogen patches. Increased demand for menopausal hormone therapy, combined with periodic manufacturing and supply-chain disruptions, has led to shortages and difficulty obtaining certain transdermal estrogen products in some regions. These access barriers can result in treatment interruptions, forced product switching, or increased reliance on alternative formulations, all of which may affect patient outcomes and adherence.
Find out more about when HRT makes sense in menopause.
