What is perimenopause?

 

Although menopause is strictly defined as exactly one year after menstrual periods stop, for many women, problems related to shifts in sex hormones happen many years before this, and continue through the menopausal transition for many years afterwards.

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These different stages often have different issues that arise; early perimenopause may be characterized by insomnia, heavy or frequent bleeding, or anxiety. Later in perimenopause, hot flashes/night sweats, brain fog, mood changes (low moods or rage) new joint pain, or libido issues are common.  During and after menopause itself, new pelvic symptoms (including bladder or localized pain or sexual issues) may start to show up, and new disease risks (heart disease, diabetes, osteoporosis) emerge. 

 

The good news  is that none of this is inevitable, and science is increasingly showing us that lifestyle and preventative care can help modify these risk factors substantially and for the long term.  But it's also true that for both women and non-binary people who menstruate, menopausal hormone therapy can improve quality of life substantially over the decade or more that this transition lasets. 

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Is hormone therapy safe?

 

After the publication of the US Women's Health Initiative trial in 2002, many providers in GYN and primary care in North America were afraid to prescribe what was then known commonly as 'hormone replacement therapy' or HRT for several years due to concerns raised about increased risk of breast cancer, heart attacks, and stroke. But the way the study was understood broadly had little to do with whether hormone therapies (now known as MHT or menopausal hormone therapy) are helpful to manage symptoms within menopause, or for the years surrounding menopause. Currently, systemic topical estrogen therapy (patches, gels, creams or rings) is supported by Health Canada for the indications of hot flashes and night sweats (collectively known as vasomotor symptoms), and for the prevention of osteoporosis. Systemic progesterone (the body-identical form) or progestins (similar synthetic medications including the progestin-containing IUD) are given with estrogen for endometrial protection in people who have an intact uterus (also a Health Canada indication), although many providers also use progesterone alone or in combination with estradiol off label to improve sleep or decrease anxiety in patients in perimenopause or menopause. ​

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What about vaginal estrogen? 

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Pelvic estrogens should be considered in a category of their own, separate from standard menopausal hormone therapy.  They are prescribed and used locally either applied to the vulva or inserted into the vagina, and the doses of hormones (estradiol or estriol) used are much lower. They also come in suppository, ovule or cream format and are prescribed to alleviate local symptoms of dryness, pain or irritability that can affect any of the tissues in this region. They are also safe to take for a larger majority of patients, even when systemic hormone therapy may be problematic or not needed.  These therapies can be life changing for many patients, as they can help prevent repeated urinary tract infections or painful intimacy in mature women. 

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Ultimately, the decision to try hormone therapy (whole body or pelvic applications) should come down to an individualized discussion with a provider who knows your history well, and based on the best current evidence for safety, as well as what studies tell us work in general for a specific symptom picture, or a given set of hormone related problems.  My goal with patients is always to make sure that they are well informed about what therapies are most likely to help, as well as taking into account a patient's menstrual and reproductive history, family history, current lifestyle, and preferences for care.  

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What is a Menopause Society Certified Provider (MSCP)? 

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A: Menopause Society Certified providers are licensed healthcare professionals who have demonstrated expertise in menopausal management by passing a comprehensive exam covering a wide variety of topics related to menopausal care. These topics range from managing heart disease and cancer risk, to maintaining bone and muscle health, as well as how to safely manage menopausal symptoms with hormone therapies, and understanding when to refer to more advanced diagnostics or therapies.  We have to keep up with continuing education to maintain this certification. There is a database of MSCP providers here.​​​​

 

But you're a Naturopathic Doctor (ND). Can you actually prescribe standard menopausal hormone therapy in Ontario? 

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A: The short answer is yes, although there are some restrictions on the items NDs can prescribe here.  Currently, we can prescribe estrogens (estradiol, estriol or estrone) in topical patch, gel or cream form, but not as oral hormone therapy, including contraceptives. For most menopausal applications, as well as for pretty much all pelvic applications, these work fine to manage symptoms, and are safe and effective. 

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With progesterone, we are similarly limited at present to topical or suppository progesterone (not progestins). For solo applications, these also often work fine to manage minor symptoms

 

However, when used for menopausal hormone therapy in patients with an intact uterus, oral progesterone or a progestin-secreting IUD is considered best practice for protection of the uterine lining when prescribed with estrogens, or for heavy bleeding of perimenopause. I agree with this; oral progesterone and all forms of progestins have the strongest evidence from individual as well as combined studies, and are the forms with Health Canada indications for this use. ​ This may be changing in the near future, but ​in the meantime, I frequently refer patients back to their family doctors or family health team or even a women's health clinic if we decide that oral progesterone (or an IUD) is the best choice for that patient with a quick note explaining our discussion and my recommendation.  As I often say, safety first. 

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What does a menopause intake appointment look like with you? 

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A: A initial visit in my office (in person or virtually) is 75 minutes. During that time, we review your symptoms and menstrual/health history, as well as your current diet, sleep, exercise, other conditions, as well are current stressors/mental well being and resources, as well as your health concerns and goals. Issues at menopause are often much broader than the presence or absence of hot flashes/night sweats or dysfunctional bleeding (the most well known symptoms of menopause), and I respect my patients' preferences to stick with either prescriptive or not-prescriptive therapies (supplements, plant medicines, diet or lifestyle interventions) and try to create interventions that are sustainable and realistic to help patients improve their quality of life, as well as prevent chronic health problems such as heart disease, cancer, osteoporosis, chronic joint pain, or dementia. 

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