A Visit to the Doctor’s Office Made Me Think of ‘Menopause Confidential’

Also, where do you stand on Hormone Replacement Therapy?

Originally published in Middle-Pause on Medium on July 1, 2024

I don’t know about you, but when I go to a physician, I tend to squeeze them for information. These visits are costly, so I’m always trying to optimize my twenty minutes to get both good answers and solutions for the problem at hand as well as some ideas for other, related solutions.

I recently saw a dermatologist for a recurring skin condition I have that causes small lumps. They usually go away on their own, but when they don’t, and when they get infected, I have to apply local treatment. I’ve now seen this dermatologist twice for this problem, since the first time around I had forgotten to do something very important: take notes of what I discussed with the doctor, including her answers to my initial set of questions.

The last time I was there I asked what causes my skin condition and was told it in the absence of certain factors like smoking and diabetes, it had to do with a weakened immune system.

I am guilty of a weakened immune system in the summer because I don’t cook much, I exercise less, and, as a result, I eat more sweets. (I usually bake a weekly cake to prevent the latter.)

But this time around, with other conversations about perimenopause fresh in my mind, I persisted and asked if the latter couldn’t be involved too. It turns out, it has something to do with hormonal changes as well — something I wasn’t told the first time.

And I Brought Up HRT

So then I asked a related question: what does she think of hormone replacement therapy (HRT)? She hedged, saying it wasn’t really her expertise. But she was a medical doctor, and a very good one at that, so I thought she must have an informed opinion. So I then asked her if she had HRT for herself. She said no. I didn’t want to pry more — it was already a very bold question — but the information was very useful.

Why? Well, here I have to say that I’m very sad to share this. The first time I went to see this doctor, she was a powerfully beautiful woman in her early fifties. I remember her vibrant, expressive face and her healthy, if not luscious, hair.

Now, a couple of years later, she was almost unrecognizable when I stepped into her office. A combination of things struck me all at once, but mostly it was the look of fatigue on her face and her wrinkles. I couldn’t help but think that part of that transformation may have happened because she didn’t benefit from HRT.

Somehow when it came to HRT, I thought I had time, since I still had my period, even if not regular, and I wasn’t experiencing major symptoms. But then I talked to a friend about HRT. She had been studying this through social media for months, and she had also experienced her own health issues because of perimenopause.

Her perspective made me realize that at 45-plus and decidedly perimenopausal I have no time to be on the fence anymore. True, my mother didn’t have hot flashes, so I may not get them either, but menopause is about much more than that.

I decided to make an appointment with my OB/GYN this summer, talk to her about what she recommends, and make a decision soon — since, from what I’ve read, it’s enormously important to start this therapy sooner rather than later. IF I decide to start it. It’s not prescribed if you have certain conditions, and it augments some heart disease risks — while also reducing others — as well as the risk for breast cancer and stroke even if you’re healthy.

Dr. Tara Allmen’s ‘Menopause Confidential’, a Guide to ‘Thriving Through Midlife’

Here’s more about HRT, along with a book review of sorts, from Tara Allmen’s Menopause Confidential.

Dr. Tara Allmen is a gynecologist specializing in women’s health in middle age. While her advice may be dated in parts — the book came out in 2016 — I thought it would be useful to share it for information purposes (and not as medical advice).

It’s important here to clear a few misconceptions before I get started. Once you hit menopause, you are a menopausal woman — I’ll use the term in the larger sense, to include all people assigned female at birth (AFAB) — forever. This can be confusing because these days the term menopausal seems to be preferred to postmenopausal. You’re in menopause when you haven’t had a period for twelve months — or when you’ve had your ovaries removed.

As for perimenopause, it more often than not starts in your forties and lasts between four and eight years. During this time your estrogen production will be all over the place, which may lead to menopausal symptoms, such as hot flashes, sweats, disrupted sleep, brain fog, irritability, and others.

Estrogen helps with ovulation — the release of an egg — and then, along with progesterone, with making a soft monthly uterus lining for a potential pregnancy. Our ovaries also make some of our testosterone and will continue to do so even after menopause for a few years.

Estrogen does far more than only help with the menstrual cycle. Every organ has estrogen receptors, so when this hormone circulates in the blood, it affects the whole body, from the heart and bones and muscles to the brain. Estrogen influences cholesterol and blood sugar levels, bone and muscle mass and physiology, collagen and skin, bladder, vagina, breast, colon, and more. As Allmen says, we’re aware of little of all that before perimenopause and menopause, and then only later, when our period is gone, we realize how much we took for granted.

Allmen takes us on a journey about the major changes our body will experience, such as mood swings, for instance. The latter may start during perimenopause and disappear during menopause, only to be replaced by a lower mood overall. That may be especially true if we also struggle with symptoms such as hot flashes, which, she says, usually last at least seven years, some women experiencing them even in their seventies, after more than twenty years.

She offers various solutions to mood swings, from daily exercise and healthy food to estrogen therapy to feed hungry estrogen receptors in the brain. She cautions, however, that hormone therapy, while it may do the job and shift the mood and relieve hot flashes, is very little compared to what ovaries used to do naturally. And sometimes, hormone therapy fails to fix mood symptoms, as they may spring more from depression and anxiety.

Then women get to face aging brain symptoms at menopause, the so-called brain fog — or, as Allmen calls it, menofog. She says some 60 percent of women complain of impaired focus, forgetfulness, and feeling a bit hazy. She recommends physical and mental exercise, oily fish and other foods rich in omega-3 fatty acids, a healthy diet overall, and, if needed, medication. She says natural supplements do not help with brain fog, but I’ve read elsewhere that omega-3 fatty acids and ginkgo biloba, among others, can have a positive effect on cognitive function even in mild cognitive impairment.

Healthier lifestyle and natural supplements aside, hormone therapy does seem to do the trick when it comes to menofog. Allmen especially recommends it for women with surgical menopause, since they experience stronger brain fog symptoms on account of the abruptness of their transition.

HRT During or After Perimenopause?

Here’s Allmen’s recommendation in the first part of the book: Should you decide to accept your doctor’s advice for HRT, you should do so as early as it’s offered, while you still have lots of neurons thriving on estrogen. If you do it later, the little that HRT can do may not be able to do the trick anymore. Allmen expressly states here, in this first half of the book, that starting hormone therapy a few years before menopause is best.

In the US, according to this book, HRT is approved for symptoms such as hot flashes and night sweats, but you should know and be happy, Allmen says, that it works for brain fog as well. And, according to her, it may even help ward off Alzheimer’s if started a few years before the menopausal transition.

But then, much later in the book, comes the chapter “Potions, Patches, and Pills, Oh My!” and she changes her tune. Now she says that perimenopausal women would have to wait before starting HRT until they’re fifty-five. If they have symptoms, they should make do with a low-dose birth control pill — provided they don’t have certain risk factors which would make this choice unsuitable. At fifty-five they can start considering Systemic Estrogen Therapy, which, according to her table of risks, is clearly not for everyone. (But if you can’t do Systemic Estrogen Therapy, you can easily do local, vaginal, estrogen therapy.) Note that she calls it estrogen therapy, but if you still have your uterus, you would need progesterone as well to balance out some of the effects of estrogen.

It almost sounds as if she wrote this chapter on HRT first and then, by the time she did more research and started writing the rest of the book, she changed her mind!

There’s more in the book, including many useful comments on healthy eating and how to easily get enough aerobic exercise and strength training. Allmen is mindful of her diet and she also uses a treadmill at least thirty minutes a day. She sets it at an incline and works it along with some light weights while watching TV or talking on the phone.

She also discusses colonoscopies, Pap tests, osteoporosis and osteopenia (lesser reduction in bone mass), and how estrogen therapy can both help and damage the heart. Her conclusion on heart matters: if you’re healthy and your heart is young, your HRT benefits will replace the risks in terms of your heart health.

Another important chapter focuses on breast cancers and harm vs. benefit considerations regarding screening and over diagnosing. Allmen says that if you give mammograms to 1900 women between 40 and 49, the tests will save one life while putting a thousand women through the hell of false alarms. Also of note is the question of ductal carcinoma in situ, a diagnosis, Allmen says, that many women get old with rather than die from — and yet they have to make a decision. On top of it all, mammograms can’t detect cancers in breasts with denser tissues — but then most women with this kind of breasts have a low risk for breast cancer.

So what is there to do? Allmen favors less testing but doesn’t dissuade women from having a yearly mammogram if that puts their mind at ease. In her case, she — with dense breasts — has decided to do an ultrasound every two years. She also recommends mammograms two years apart for women over fifty-five, given that past this age breast cancer is less aggressive.

For more comments on women’s health, Allmen includes an overview of five important scientific studies: the NHS (Nurses’ Health Study), from 1976 to the present, started on 121,700 women, the PEPI study on 875 women (the Postmenopausal Estrogen/Progestin Interventions Study), conducted from 1987 to 1990, the SWAN study on over 3,000 American women (the Study of Women’s Health Across the Nation), started in 1996, ongoing, which also accounted for different ethnicities, the HERS study (Heart and Estrogen/Progestin Replacement Study) of 1998 to 2002, involving some 2,800 women with heart disease, and the WHI (Women’s Health Initiative) from the early 1990s to 2007, with over 27,000 women aged 50 to 79 studied for HRT purposes. You can read more about these studies in the book and online. (The Wikipedia pages for the NHS and WHI series of studies are also very informative.)

What about you? Are you taking HRT? If you are, what is your experience with it? If you’re not, what do you think of it?

Disclaimer: I am not a medical or health practitioner, and no part of This Blog, or the articles, websites, and products I mention and link to on This Blog, is intended as professional medical or health advice, and should not be considered as such. Consult with your doctor(s) about starting any course of treatment, taking any supplements, or changing any (dietary, exercise, etc.) routines. Note that natural supplements and even some foods may interfere with certain medications. Also ask your doctor(s) about potential allergies you may have, including cross-reactive allergies. Some allergens can cause anaphylaxis. Here are my Full Terms and Conditions.

To a happier, healthier life,

Mira