Modern Menopausal Hormone Treatment: Facts and Myths About Sex Hormones

128 Pages·2022·4.056 MB·English

by  Hilde Löfqvist

Modern Menopausal
Hormone Treatment
Facts and Myths About
Sex Hormones
Hilde Löfqvist
123
Modern Menopausal Hormone Treatment
Hilde Löfqvist
Modern Menopausal
Hormone Treatment
Facts and Myths About Sex Hormones
Hilde Löfqvist
Gynaecology and Obstetrics
Specialist outpatient clinic for menopausal disorders
CevitaCare, St Göran’s Hospital
Stockholm, Sweden
Partially based on "Hormonkarusellen : fakta och myter om klimakteriebehandling",
Hildemarias AB, 2019
1th edition: © Hilde Löfqvist 2019
ISBN 978-3-030-92734-9 ISBN 978-3-030-92735-6 (eBook)
https://doi.org/10.1007/978-3-030-92735-6
© Hildemarias AB 2022
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Foreword
Many books have been written on the transition period and the treatment of women
going through the menopause, especially with regard to hormone therapy. The com-
mon theme is hormones and how they (oestrogen and progesterone) are produced in
the ovaries. These hormones may also be chemically engineered and altered, giving
effects, which are similar to but not exactly the same as the natural body-identical
hormones. These hormones are called oestrogens (bio-identical or altered mole-
cules) and progestins (always altered bio-identical progesterone). Books on “hor-
mone replacement therapy” have not been the focus of attention on the market
during the recent years. When the American “Woman’s Health Study” (WHI) was
released, in 2002, the hormone replacement therapy arm showed increased cases of
breast cancer, stroke and venous thrombosis. As the study was very large and scien-
tifically correct, with randomized controlled treatment and placebo groups, the gold
standard method for finding the best treatment, the impact on hormone therapy was
detrimental: hormone treatment was associated with bad outcomes. Both doctors
and their patients were afraid of the increased risk for breast cancer, stroke and
thrombosis. However, the aim of the WHI study was not to find the optimal meno-
pausal treatment. The aim was to prove that female hormone treatment would keep
women young, healthy and prolong life. Earlier observational studies, without ran-
domized placebo groups, pointed in this direction. When the WHI study showed the
opposite, most physicians and patients abandoned hormone treatment, almost over-
night. Since the WHI study, menopausal problems have been treated mainly with
nonhormonal remedies, especially plant derived substances, without having evi-
dence of efficacy or risks.
During the last 3–5 years the discussion about the hormone treatment has re-
emerged. Earlier experiences and the scientific plausibility of hormone efficacy
have encouraged scientists to undertake elaborate new studies. These studies show
different outcomes from the WHI study: when hormone molecules are the same as
or very similar to the molecules produced in the human ovaries, the incidence of
breast cancer, stroke and thrombosis may be reduced. These hormones were not
available at the time of the WHI study, where the oestrogen, available at the time in
tablet form, was extracted from the urine of pregnant mares (conjugated equine
v
vi Foreword
oestrogens, CEE), and tablets of synthetic progestins were used instead of body-
identical progesterone. Reevaluations of the WHI study made progestins responsi-
ble for the increased risks of breast cancer. Additionally, transdermal oestrogens, as
patches or gels instead of tablets, almost eliminated the risks of thrombosis and
stroke shown in the WHI study. In addition, it was noted that the women, participat-
ing in the WHI study, were older with a mean age of 63 years, 50% having risk
factors as overweight, hypertension, diabetes and a history of smoking.
In spite of this new knowledge the “WHI-shock” is still present in medicine and
research, and especially within the media, where it still causes controversies. This is
why this new book on hormone therapy written by a gynaecologist with 40 years of
experience as clinician, treating menopausal women in accordance with modern
international research, is so important and published just at the right time. The pur-
pose of this book is to equip health providers with facts on modern hormone treat-
ment of the transition and menopause of women. Considering that about one-third
of all women suffer menopausal symptoms, which interfere with activities of daily
life, this book has a clear mission. Furthermore, almost all alternative treatments are
not able to show the same results as hormone treatment can achieve, for example,
the prevention of osteoporosis.
This book demonstrates, not only the principles of hormone menopausal treat-
ment, but also the particular situation of the hormonal transition as part of the female
life cycle, starting with the birth of a female baby, through puberty and adolescence,
until menopause (the last natural menstruation). Using the internationally accepted
classification of the transitional stages of the menopause (pre-, peri- and post-
menopause), their typical climacteric symptoms and duration are succinctly shown.
The author describes the consequences of declining hormones and how these are
claimed to be responsible for the complaints and diseases described. After each
chapter the contents are summarized, both for the medical professional and for the
climacteric woman. Alternative treatment options and various recommendations
such as sports, diets and lifestyle adjustments, are briefly discussed. It is empha-
sized that menopausal symptoms arise due to the physiological decline of ovarian
hormone production and should, therefore, not be seen as a disease. This was not
known 120 years ago, at a time when the median age of menopause, at 50, coincided
with a woman’s median life expectancy. Today, however, women may live happily
until at least 80 years of age. This creates a new situation for the postmenopausal
woman, who may suffer from degenerative bone-, cardiovascular or metabolic dis-
eases, directly or indirectly associated with the deficiency of ovarian hormones
(oestrogens and progesterone). The challenge and ambition is to find treatments to
compensate for the loss of ovarian hormonal function and to maintain the woman’s
quality of life.
It may seem like an easy solution to simply compensate for this decline in ovar-
ian hormone production by substituting the falling levels of ovarian hormones. For
this reason, the concept of “Hormone Replacement Therapy” was created. However,
there are many more reasons to be found for the complaints of the climacteric and
postmenopausal woman, such as ageing, changes in lifestyle, social stress at 50,
weight gain, extensive and exaggerated sports activities, and unhealthy and
Foreword vii
one-sided health diets. It is obvious that hormone replacement is not a panacea to
compensate for everything during this difficult period in a woman’s life. These con-
texts are clearly demonstrated and the physiological effects of different hormones,
such as stress hormones, as well as the role of declining androgens during meno-
pause, are fully explained. Moreover, the difficulty in replacing androgens in
women, on the one hand, and the necessity of treating women with androgens on the
other, is an important issue, which is given the attention it deserves.
Of course, hormone menopausal treatment is the principal and central theme of
the book, the historical background is especially useful, charting, as it does the rise
and fall, confusion and come-back of hormone replacement therapy, before and
after the debacle with the aforementioned “WHI study”. Important issues on hor-
mone therapy are clearly presented for the patient as well as for the doctor with the
responsibility of treating the woman. In addition, important topics, such as the
necessity of starting treatment in time (the window of opportunity), the use and
misuse of saliva analysis, recommendations for the primary use of body-identical
hormones, treatment for risk patients and therapy for women who have been treated
for cancer, are fully analysed. The author does not hesitate to confront controversial
scientific issues—especially in her last chapter “Frequently asked questions”. Here,
she highlights common fears and assumptions of the woman concerning the risk of
breast cancer and other related topics, arising from the results of the WHI study. Dr.
Löfqvist answers questions about weight gain, duration of treatment, how to phase
out treatment, and explains clearly the difference between the popular plant-derived
FDA and EMA-approved “bio-identical hormones” and the use of compounded
drugs, which are produced in a pharmacy and prepared according to a doctor’s indi-
vidual prescription. A separate chapter is devoted to the woman’s sexual problems
at menopause. As a gynaecologist, with many years of experience treating women,
especially those suffering from symptoms due to hormonal decline at menopause,
Dr. Löfqvist has expanded this chapter to elucidate different aspects of female sexu-
ality and ageing, problems arising during the menopausal transition and different
therapeutic approaches towards sexual problems, for example, effective local hor-
monal treatments of the vagina to relieve pain at intercourse. One chapter deals with
the Internet, as a source of health information, the use and advantages on the one
hand, and pitfalls on the other, particularly when investigations and treatments are
initiated without professional advice. Additionally, a chapter about therapeutic tools
for managing the complicated menopausal patient, may help the medical student to
learn about what is important in meeting the patient, listening and gaining her trust
in order to be able to start the necessary treatment and why a multidisciplinary
approach sometimes may be necessary. Finally a chapter, with five case histories,
demonstrates the approach and treatment of five very different women, of the same
peri-menopausal age, but with varying problems and possible solutions.
I, myself, have 30 years of experience as a scientist, with 250 original interna-
tional papers and 700 additional publications on the issue of “Endocrinology and
menopause”. For the past 10 years, I have been the Honorary Director of the world’s
largest menopause clinic in Beijing, China. This book displays a high scientific
standard, and although, originally intended to be a book for women going through
viii Foreword
the menopause, it has been expanded in order to address the issue of the menopause
for medical professionals. The author has the ability to illuminate complex scientific
issues in an understandable way, without distorting the content. Her statements and
explanations are verified with the most important scientific references in medical
literature. This is the reason why I believe that this book is eminently suitable as a
textbook for medical professionals as well. I congratulate Dr. Löfqvist on this work,
she has written tirelessly and with much passion, and wish her success in the dis-
semination of this book to a wider audience.
Prof. Dr.med.Dr.rer.nat. Alfred O.Mueck; MD.PharmD.PhD.
University Hospitals of Tuebingen, Tuebingen, Germany
Department of Women’s Health
University Women’s Hospital and Research Center for Women’s Health
Section for Endocrinology and Menopause, Head
and
Capital Medical University, Beijing, China
Beijing OB/GYN Hospital, WHO Centre
Department of Gynecological Endocrinology, Honorary Director

Guest Professor, ZheJiang-University (Hangzhou), China
Honorary President for Life, German Menopause Society, Germany
President, German-Chinese Society for Obstetrics and Gynecology, China
Email: [email protected]
October 12, 2021
Preface
During the hormonal decline at menopause, women experience various symptoms
and complaints with inconvenient hot flushes, sleep disturbances, mood changes,
joint and muscle pain, and bleeding disturbances. After menopause, vaginal and
urogenital problems are the dominant complaints due to hypo-oestrogenic condi-
tions in the female urogenital tract. However, many women do not mention their
problems to their healthcare provider and are, therefore, not adequately treated. The
health professional is not always aware of the association between hormonal defi-
ciency and hormone-related female health problems. Different therapeutic options
just as yoga, acupuncture, herbal medicine and other treatments as well as antide-
pressants are offered. The free market and the Internet make it possible for everyone
to try all kinds of treatments without the prescription and sanction of a health pro-
fessional. Numerous popular publications, on how to optimize health through life-
style adjustments, have been published, but the most efficient therapy for the
menopausal woman with severe symptoms—hormone menopausal treatment, has
for a long time been underestimated. Why has this very effective medical hormone
therapy for menopausal complaints become so controversial for the woman as well
as for the medical professional?
The explanation can be found in this book. The rise and fall of hormone therapy
before and after the publication of the results of the American WHI (Women’s
Health Initiative) study, is the reason for myths and misinterpretations worldwide.
Confusing interpretations of scientific studies during the last two decades have
made women and their health providers insecure about trying hormonal therapy for
climacteric complaints. This book is structured to give the reader a comprehensive
view in order to understand the symptoms arising during the menopausal transition,
the association with other hormones and diseases, and the benefits of evidence
based modern hormonal treatment. Originally intended for women searching for
correct information and answers about hormone treatment, this English textbook on
modern menopausal hormone treatment also provides the medical professional with
scientific facts and practical recommendations about what the doctor should con-
sider in the choice of investigations and treatment. It fills a gap for medical health-
care providers through teaching them about hormone treatment and its correct and
ix
x Preface
adequate application for the right patient. Various case histories help the reader
understand the process of professional consultation, examination, treatment and
follow-up.
As a specialist in gynaecology and obstetrics, I have worked with thousands of
menopausal patients during my professional career in Sweden. I want to thank all
my patients who have trusted me. They are the primary source of my experience
with hormonal changes in menopause and their treatment. I am also grateful for all
the valuable education received at professional meetings, seminars and workshops,
provided by the International Menopause Society, the German Menopause Society
and many other international and national scientific meetings.
I want to thank professor emeritus Tord Naessén, Uppsala, Sweden, for his pro-
fessional assistance over many years, for rewarding discussions and for his positive
opinion on this manuscript. He is outstanding in his research on positive oestrogenic
effects. His convincing arguments for hormone treatment are based on rigorous sci-
entific studies.
My friend, Lena Hallergård, has contributed with precious arguments on how to
teach the climacteric woman about hormones. Thank you Lena, for your passion to
spread knowledge about hormones to the “woman-in- the-street”!
My husband Johan Löfqvist has been much involved in the writing process. He
has, not only shown enthusiasm for my work, but also given unstinting professional
support, being himself a specialist in surgery, urology and family medicine. Thank
you, Johan, for your never-ending love and assistance.
Last, but not least, I wish to thank my friend and colleague Meryl Dhir for her
excellent proofreading of my English manuscript. She is an English ophthalmolo-
gist living in Sweden. We have shared our background as foreign doctors here in
Sweden, and a friendship based on similar opinions on life. Thank you Meryl, for
your loyalty offering time to read and correct my manuscript during the sum-
mer 2021.
It is my hope that this book can help women and healthcare professionals alike
to be more aware of the problems arising for the woman during menopause, and
how women, in such a situation, can be helped.
I disclose all relationships or interests that could have direct or potential influ-
ence or impact bias on my work.
Stockholm, Sweden Hilde Löfqvist