An integrative approach to hormone therapy for menopause

In a recent statement from The North American Menopause Society (NAMS), the organization announced its updated position on treating symptoms of menopause with hormone therapy, concluding that the treatment’s benefits outweigh the risks for those under age 60 within 10 years of menopause onset.

The statement, published in the journal, Menopause, is an update to NAMS’s previous stance published in 2017, which did not officially endorse the intervention despite identifying many of the same benefits and risks. According to NAMS’s latest statement, hormone therapy has proven to be the most effective treatment for relieving symptoms of menopause, including vasomotor symptoms or hot flashes, and night sweats.

Still, the statement warned that significant risks are associated with the therapy. Several factors, the authors explained, like the type of hormone being used, dosage, and duration of use, can increase the likelihood of the therapy’s risks. In addition, NAMS made clear that for patients over age 60, who are past the 10-year mark of their menopause onset, the therapy may contribute to a higher risk of coronary heart disease, stroke, venous thromboembolism, and dementia. In this case, they said, benefit-risk ratio no longer favors hormone therapy.

Integrative medicine and hormone therapy

For many integrative practitioners already providing hormone therapy to patients experiencing symptoms of menopause, NAMS’ new stance was welcome news. However, according to Tara Scott, MD, although the medical community is becoming more accepting of hormone therapy, many providers remain reluctant to bring it up with patients.

“Probably less than 25 percent of patients are told the risks and benefits of hormone therapy,” said Scott, founder of Forum Health Akron, a functional medicine practice specializing in hormone and wellness issues, in Fairlawn, Ohio. “They're not given that option unless their doctor was personally interested in hormones and did some testing, that kind of thing.”

Menopause is defined as the time in which a woman’s menstrual periods stops permanently, according to the National Center for Complementary and Integrative Health (NCCIH). On average, woman experience menopause at age 51. The years prior to menopause are known as menopausal transition, or perimenopause.

While this article refers mainly to cisgender women, it’s important to note menopause can affect people who were assigned female at birth but who may identify as transgender or nonbinary.

Due to hormone fluctuations associated with menopause, bothersome symptoms are common, said Scott. During the beginning phases of perimenopause estrogen levels increase causing heavier periods, breast tenderness, migraines, irregular periods, cramps, acne, and sometimes an onset of anxiety, Scott explained. Then, Scott said, as a patient nears menopause, estrogen levels drop low, prompting symptoms like hot flashes, fatigue, weight gain, low energy, low libido, and vaginal dryness.

According to Scott, conventional medicine doctors treating women experiencing menopause have a lack of training on hormonal changes during menopause and how to treat them and are therefore hesitant to prescribe hormones. Instead, they often attempt to manage symptoms of menopause with antidepressants and birth control pills, which, Scott said, do not offer the same benefits as bioidentical hormones.

Guidelines for hormone therapy

Melinda Ring, MD, director of the Osher Center for Integrative Health at Northwestern University in Chicago, is also an advocate for bioidentical hormones. Ring, who’s patient practice, among other areas, specializes in helping women navigate changes in their hormones, said that the term “bioidentical” implies that the hormone’s estrogen chemical structure is the same type that the body naturally produces. Ring said not only can these hormones treat the symptoms of menopause, but they are also helpful in preventing disease. According to Ring, research has shown that hormones prevent dementia, lower risk of overall mortality and cancer, and protect the heart.

To lower the risks involved in taking hormones, Ring recommends that women and their doctors follow a list of guidelines, including:

• Using bioidentical hormones
• Finding the right timing: starting hormone therapy on patients within 10 years of menopause who are below the age of 60
• Avoiding oral forms of estrogen unless absolutely necessary: transdermal forms have lower risk of complications like blood clots and stroke
• Consider supporting hormones like testosterone or dehydroepiandrosterone (DHEA)

In terms of personalizing a patient’s hormone regimen, Ring said there are several tests that can help determine what hormones a patient needs as well as what dose might work best for them.  Some tests, Ring explained, can be done through typical clinic and hospital labs. There are also functional medicine tests that have gained popularity such as the Dutch Test, which show a patient’s hormone levels over the course of 24 hours. These tests can provide helpful information both before a patient starts taking hormones, and after, according to Ring.

To Scott, in depth hormone testing like saliva tests and dried urine tests that measure not only female hormones but also cortisol, is what allows functional practitioners like herself to determine the specifics of a woman’s hormone imbalance and personalize their treatment.

“The problem is in the traditional world, they don't even believe in testing hormone level at all, let alone looking at how you're metabolizing it, so there's a huge disconnect,” said Scott.

Improving symptoms of menopause through diet

Ring added that determining the right hormones and dosage for a patient post menopause is much easier than when they are experiencing perimenopause. Rather than starting hormones early in perimenopause when hormone levels are unstable, Ring advised practitioners to first consider diet and lifestyle interventions.

Patients struggling with hot flashes and night sweats should cut spicy foods and alcohol out of their diet, said Ring, because these foods can be “hot liquids” and trigger symptoms of menopause. Sugar, Ring explained, can also exacerbate symptoms associated with menopause. Instead, she said patients should focus on foods with phytoestrogens like non-GMO (genetically modified organisms) soy, which may help decrease menopausal symptoms.

When working with a female with a hormone imbalance, Kellie Blake, RDN, LD, IFNCP, owner of the functional dietitian practice, NurtiSense Nutrition Consulting, based out of Charleston, West Virginia always starts with healing gut protocol.

Blake advises patients looking to balance their hormones to follow a paleo or low FODMAP diet, both of which reduce inflammation and immune system dysfunction by balancing blood sugar. In addition, Blake will add probiotics like lacto-bifido blend or saccharomyces boulardii to the patient’s regimen to target gut inflammation and improve the microbiome.

An adequate healthy fat intake is also important for hormone production, said Blake. Foods like avocados and avocado oil, olives and olive oil, grass-fed butter, ghee, and coconut oil, are healthy fats Blake commonly recommends.

Improving gut function and adding phyto-chemicals through foods like cruciferous vegetables help support the healthy detoxification of estrogen, which can help prevent long-term issues like DNA damage, according to Ring.

Supplements for menopause symptoms

Supplements prescribed to patients experiencing menopause are dependent on what symptoms they’re trying to address, Ring said. For instance, chasteberry can be used to treat hot flashes and perimenopause periods. In addition, herbs like evening primrose oil, maca, passionflower, and St. John’s wort are often used to treat symptoms of menopause, Ring explained.

When symptoms of menopause persist despite diet and lifestyle changes, Blake will recommend herbal preparations to her patients. A combination of licorice root, chasteberry, and white peony, can be helpful, she said, as well as a combination of gamma oryzanol, black cohosh, dong quai, licorice root, and trans-resveratrol.

Lifestyle changes

Exercise and movement are very important while managing symptoms of menopause, according to Scott. Getting adequate sleep is also an important factor to improving symptoms of menopause. Scott recommends seven to eight hours of sleep every night, as well as sleeping in a dark, cool room and limiting screentime before bed.

Stress management can also help balance hormones, explained Blake. Before she prescribes a patient any herbal preparations, Blake said she makes sure to encourage better stress management practices. Ring agreed saying things like yoga, breathing exercises, and acupuncture have been shown to help decrease hot flashes and manage stress.

An integrative approach to menopause involves looking at a patient as a whole, Ring explained. Their diet, stress, and physical activity are all contributors to how symptoms of menopause manifest in the body. Through shared decision making, Ring said, integrative practitioners can help a patient develop a personalized plan that’s right for them.

“We’ll look at all kinds of options ranging from acupuncture, which can help with hot flashes, to hormones to herbs to diet,” said Ring. “Taking into consideration all of the patient’s health issues, their quality-of-life issues, we want to not just manage symptoms, but that we actually want to help them thrive and flourish.”