IS HRT GOOD FOR PERIMENOPAUSE?

Dr Steven R. Goldstein, a Perimenopause Specialist NYC comments on the increasing use of HRT for Perimenopause. Is HRT good for Perimenopause? Simply giving traditional hormone replacement therapy such as estrogen patches and progesterone pills, or progesterone IUDs (as many nurse practitioners, physician assistants, women’s health internists who are new to this field are doing) may relieve hot flashes and night sweats, but can often exacerbate abnormalities in bleeding and does nothing for other perimenopausal symptoms such as brain fog, inability to concentrate, free floating anxiety, mood changes, memory issues, sleep problems, etc.

Let’s attempt to answer the question “Is HRT good for Perimenopause?”

True Menopause versus Perimenopause.

True menopause is defined as no more ovarian function. In menopause, the ovary is not capable of responding to the message that it receives from the pituitary. Thus, estrogen is low and the pituitary’s FSH (follicle stimulating hormone) is high. The value of replacing hormones, previously called HRT, now, in medical circles, referred to as MHT (menopausal hormone therapy), is a very individualized decision that should be made in consultation based on one’s own personal history, family history, symptomatology, etc. It is not one-size-fits-all.

Perimenopause, however, is significantly different. One cannot go from the reproductive phase, where ovulation takes place every twenty-eight days, to menopause without passing through a phase where there is sporadic and then, perhaps, absent ovulation.

A short review of the normal menstrual cycle tells us that for the first two weeks, estrogen is produced, then after ovulation, progesterone causes the estrogen-primed uterus to convert to a different phase known as secretory, thinking it will receive a fertilized egg. Fourteen days after ovulation and the introduction of progesterone, if there is no fertilized egg, the uterine lining breaks up and the bleeding that ensues is a true menses. If no ovulation takes place but estrogen is produced, bleeding can still occur.

Although, to patients, they feel this is “their period,” it is anovulatory bleeding. The prefix “an-“ comes from the Greek meaning without. If one does not ovulate, one does not create secretory lining and when and how much you bleed is a function of erratic changes in estrogen levels. The hallmark of ovulatory cycles is their regularity and predictability. The hallmark of anovulatory cycles is just the opposite – they can be heavy, they can be light; they can be with cramps, they can be without cramps; they can last a long time, or they can last a short time; they can be early, or they can be late.

If a patient in perimenopause is experiencing hot flashes and night sweats, it is often from the change in estrogen (the medical term for this is the “delta” of estrogen), not necessarily the absence of estrogen we see in menopause.

The key to treatment in Perimenopause

The key to treatment in perimenopause is not replacement. The key to treatment is suppression of erratic ovarian function and substitution of a stable amount of estrogen and progesterone all month long. In patients who are healthy with no what we call comorbidities (obesity, hypertension, smoking, diabetes), this is best accomplished with ultra-low-dose birth control pills.

The use of low dose birth control pills for treatment of Perimenopause

There are many misconceptions about birth control pills, which you can see at Misconceptions about Low Dose Birth Control pills . The hormone in these pills is not on top of what a woman makes, by suppressing ovarian function, it becomes instead of what a woman makes. In fact, it is often less than what she made during the reproductive years.

So is HRT good for Perimenopause? Treating women in perimenopause with traditional HRT is a suboptimal approach by practitioners who do not understand the basic pathophysiology. The key to treatment, if there are no contraindications, is suppression of erratic ovarian function and substitution of a low amount of estrogen and progesterone all month long. This not only controls bleeding but will ameliorate any psychosocial symptoms that are hormonally related to perimenopause.

Dr Steven R. Goldstein is a Perimenopause Specialist NYC in private practice for over 30 years. He is a Certified Menopause Practitioner, a past President of the International Menopause Society, past President of The Menopause Society and co author of the book “Could it be….Perimenopause?”. Dr Goldstein is considered one of the nation’s top gynecologists.