Notes From Dr. Rudio

Hormone Therapy, Honestly

Few topics in women's health come loaded with as much fear and as much outdated information as menopausal hormone therapy. A lot of what people think they know traces back to a single set of headlines from 2002. Here, Dr. Olivia Rudio, our women's health specialist, works through what the evidence shows, what the risks actually are, and where Chinese medicine fits, whether or not hormones end up being right for you.

Q: Let's start at the beginning. What is hormone therapy for menopause, and what is it supposed to do?

Dr. Rudio: When a woman begins the transition toward menopause, the ovaries gradually change the way they produce reproductive hormones, particularly estrogen and progesterone. During perimenopause, these hormones can fluctuate considerably. After menopause, ovarian production of estrogen and progesterone drops dramatically, leaving the body with much lower levels of these hormones.

Because estrogen and other reproductive hormones act throughout the body, these changes can affect many different systems. Some women may experience few to no symptoms, while others experience significant changes in their sleep, temperature, mood, vaginal and urinary tissues, and bone strength. Hormone therapy for menopause is one option used to replace some of the hormones that are declining and, depending on the formulation and the individual, can help relieve hot flashes, vaginal dryness, and recurrent UTIs. But the fact that hormone levels decline during menopause does not mean that menopause itself is a disease or that every woman needs to replace what has been lost.

Hormone therapy has changed over time. One of the best-known early forms was Premarin, a preparation of conjugated equine estrogens made from estrogens collected from the urine of pregnant mares. Menopausal hormone therapy today covers a range of formulations, with different types of estrogen, different ways of administering it, and different doses. The appropriate approach depends on the person's symptoms, goals, age, whether they have a uterus, and their individual medical history and risk factors.

Q: I grew up hearing that hormone therapy causes cancer. Where did that come from?

Dr. Rudio: In the 1960s, estrogen supplementation was strongly encouraged as a way to help women stay young and feminine "forever." Robert A. Wilson, a gynecologist, published a bestselling book called Feminine Forever in 1966, arguing that menopause amounted to a hormone deficiency and that supplementing with estrogen could help women remain feminine and healthy. In the 1970s, however, the pendulum swung when researchers discovered that unopposed estrogen appeared to increase the risk of endometrial cancer. This is why women who still have a uterus are generally given a progestogen alongside systemic estrogen to protect the uterine lining. By the 1980s, hormone therapy was also being promoted for its potential benefits for bone health.

Despite these broader claims, the FDA-approved indication for estrogen therapy was treatment of menopausal symptoms such as hot flashes and urinary problems. Culturally, however, hormone therapy had taken on a much bigger role as a kind of preservation tool, based on the idea that menopause itself was a hormone deficiency. That idea eventually helped lead researchers to ask whether replacing hormones might also protect women against cardiovascular disease. This led to the infamous Women's Health Initiative (WHI), which began in the 1990s. In 2002, one arm of the study was stopped early after researchers reported that women taking a commonly used form of combined hormone therapy had higher rates of breast cancer, stroke, and blood clots.

The part that got lost in the headlines is who was actually in the study. The women were mostly in their sixties and seventies; the average age was around 63, and many were more than a decade past menopause when they started hormones. Since then, we've learned that when a person starts hormone therapy matters a lot, and understanding that has changed how we think about its risks and benefits.

Q: So was the study just wrong? What changed?

Dr. Rudio: First, I think it is important to point out that the goal of this study was to see whether hormone therapy could reduce the risk of diseases that become more common as women age, particularly cardiovascular disease, osteoporosis, and certain cancers. For its established use in treating menopausal symptoms like hot flashes, HRT has long been an effective option for the right candidate.

What a second look at this study generated was something called the "timing hypothesis."

The study was accurate for the women it actually looked at; the results reflected what happened in a population that was mostly older and further from menopause. The mistake was treating those results as the truth for every woman at every age. When researchers looked more closely at age and timing, a different picture began to emerge.

For women who start hormone therapy before about age sixty, or within ten years of menopause, the picture looks different. Research suggests that starting hormone therapy during this window is associated with a more favorable cardiovascular benefit-risk profile, particularly compared with starting it much later. Some studies have even found lower rates of coronary heart disease in women who begin hormone therapy closer to menopause. But this doesn't mean HRT is a treatment for cardiovascular disease or that it is protective for everyone. The timing matters. Starting hormones as an older woman, particularly one who already has significant cardiovascular risk, is a very different situation from treating a recently menopausal woman for symptoms like hot flashes. We had been asking one study to answer a much bigger question than it was designed to answer.

Q: So where does Chinese medicine fit into all this?

Dr. Rudio: I don't see Chinese medicine as being in competition with hormone therapy. If a woman has decided with her medical provider that hormone therapy is right for her, that doesn't change the way I practice.

Remember earlier when I mentioned that the original estrogen used in hormone therapy was derived from pregnant horse urine? I find that symbolically interesting as an acupuncturist and herbalist because, in Chinese cosmology, the Horse has a natural relationship with the Fire phase. Fire is Yáng 陽: warm, active, stimulating, and associated with the Heart, circulation, and the movement of qì 氣 and Blood through the body. The Heart, in turn, has a key relationship with the Blood.

I should be clear that there is no medicinal application of horse urine in any Chinese herbal formulas that I know of or studied in school. What interests me is the symbolism, because it opens up another way of thinking about what happens when the body has a lot of Fire and activity over a long period of time.

Fire has a limitation: it consumes Yīn 陰. Yīn is the more substantive side of the body, the Blood, fluids, tissues, and nourishing substances that give the body something to draw from and that anchor all that activity. When there is a lot of Yáng activity without enough Yīn underneath it, the body can begin to show signs of having been overdrawn: dryness, heat, hot flashes, and difficulty settling down and resting.

Modern life asks a lot of women. We live in a culture that already tends toward Yáng, with constant stimulation, productivity, activity, stress, and very little encouragement to slow down. By the time a woman reaches perimenopause, she may already be living with years of demands on her body and nervous system. Menopause doesn't simply happen in isolation from that history.

This is one reason the Blood is so important to assess in women's health concerns around peri- and post-menopause. Blood in Chinese medicine covers more ground than the blood we see in a lab test or the blood a woman loses during her period. It is part of how we understand nourishment, circulation, sleep, and Shén 神, the consciousness, mental vitality, and emotional presence of a person. Women who have a menstrual history have an advantageous insight into the quality and movement of their Blood based on what their menstruation looked like.

Q: What if I can't take hormones, or don't want to? Or what if I take them and still feel terrible?

Dr. Rudio: This is exactly where Chinese medicine earns its place, and it covers more women than you might think.

If hormones are off the table for you, whether because of a cancer history, a clotting risk, or your own considered choice, you still have options. Well-chosen herbal formulas can take the edge off hot flashes, improve sleep, steady mood, and ease dryness and fatigue, without touching your hormones. Acupuncture can support the transformation started by the herbs. Dialing in a formula takes longer than rubbing on some topical estrogen, and for many women even the modest changes early in treatment are enough to make the difference between coping and struggling. Given a few weeks, many women report a complete retreat of their symptoms.

The other big group who Chinese medicine can help is women who are on hormone therapy and still do not feel right. Maybe the flashes are better, but the sleep is still broken, or the mood is low, or the digestion is off, or there is a fatigue the hormones never reached. Hormones replace estrogen, and that is where their job ends. Tuning the rest of the system, the sleep and the mood and the digestion and the energy, is the work Chinese medicine is built for, and it sits comfortably alongside a prescription. You do not have to choose one team.

The decision about hormone therapy belongs to you and the clinician who knows your history. What the last twenty years have changed is the quality of the conversation you can have about it. The 2002 headlines are not the last word, the risks are smaller and more specific than most people were told, and both the form and the timing matter. Bring your own history into that conversation, including what your periods looked like, because that is information your clinician cannot get anywhere else.