Menopause: hormone therapy or rather not?
Dr. Eva Schindele, 54, science journalist and author of two books, lives in Bremen. Her main topics include medicine, life sciences, ethics and women's health.
ChroniquesDuVasteMonde woman: Dr. med. Shudder, Mrs. Schindele, the debate over hormone therapy has made waves - how do you stand as a specialist?
Dr. Eva Schindele: In the nineties, many doctors said: It would be a mistake to give women in the menopause no hormones. Finally, they suffered from a hormone deficiency disease. I have always been particularly annoyed by this argument, which was presented in particular by the German Menopausegesellschaft. The older gentlemen who were there on the board have worked closely with the pharmaceutical industry. I regard this view of older women as "hormone deficiency" as enormously offensive. And I think - that's what I say to you now, too. Schaudig, as a board member of the Menopausegesellschaft - that today it needs a correction, even an apology.
Dr. Kathrin Schaudig, 45, three children, specialist in gynecology, has specialized since 1993 in the treatment of women with hormonal disorders. She runs her own practice and holds regular hormone consultations at the University of Lübeck.
Dr. Kathrin Schaudig: I also do not see women over the age of 50 as being hormone deficient - that would mean that we can only define ourselves via our hormones. I think: At this stage, an organ system stops working. This can cause symptoms but does not have to. If these significantly affect the quality of life of the woman - and this happens in many cases - it is best to use hormones. God, or evolution, did not make us look 80 years old.
Dr. Eva Schindele: That's a stupid argument that has annoyed me for years. And it is wrong: The average life expectancy was earlier lower, because many people died at a young age. But when women have survived childbearing, they have always been able to turn 80 and feel comfortable with it ...
Dr. Kathrin Schaudig: ... but sometimes also with enormous afflictions, which were unfortunately partly hormone dependent.
Dr. Eva Schindele: Hormones have been prescribed as Smarties in the past 15 years - because we women are supposedly young and crisp. Do you actually think that works?
Menopause: How Does Hormone Therapy Help?
Dr. Kathrin Schaudig: With all reservations I would say: Yes. I just watch this in my practice. Of course, my perception is also influenced by the fact that hormone users often do a lot for their appearance: they often go to the hairdresser, are well-groomed and dressed smartly. Still, and I do not like to say that: women who take long hormones seem somehow more vital and also a bit fitter ...
Dr. Eva Schindele: ... unless you get breast cancer or a stroke. I think all this bad talk of menopause influences our feelings. When a woman enters the menopause with great anxiety because she thinks, "Now comes the time of discomfort and devaluation," she also perceives her hot flashes much more.
Dr. Kathrin Schaudig: Among my patients, women who are fully employed are, for example, managing directors. They say, "Without hormones, I'm not functional, I can not attend a meeting, and suddenly I'm sweating." Or they sleep badly, are never properly rested, suffer from constant mild depressive moods. Others say, "I feel so thin-skinned, I constantly burst into tears, yelling at my children." One patient just told me that without hormones, she can only do half of her jogging track. Of course you can ask: does a woman have to run a jog with 50 ten kilometers? Or work with 55 in the job still as with 30? But our society has an enormous claim on us.
Dr. Eva Schindele: Do we ourselves have too high expectations - to work constantly? A representative study by Freie Universität Berlin shows that it is not the women who have the most menopausal symptoms who take hormones, but those who are most afraid of becoming unattractive and old.
Dr. Kathrin Schaudig: To put it bluntly, we gynecologists are enforcers of social pressure. But there is a lot we need to do to take on the role of pastors, therapists or society and change paradigms. We can only inform women about the benefits and risks of estrogens.
ChroniquesDuVasteMonde woman: So let's talk about the medical facts. What do you really know about it today?
Dr. Kathrin Schaudig: At first I would like to differentiate.Women who no longer have a womb can be treated with estrogen monotherapy. And their risks are much lower than those of a combined estrogen-progestin therapy.
Dr. Eva Schindele: Does that mean all women over 50 should have their uterus removed?
Dr. Kathrin Schaudig: For God's sake, no, we've been through these times for a long time. But in about 20 to 25 percent of women, the uterus has been removed, and that creates different conditions. In women with uterus, estrogen and progestin must be combined. And I would always be more worried about the long-term risks.
ChroniquesDuVasteMonde woman: Which are these?
Dr. Kathrin Schaudig: The first three studies published in 1996 show that the risk of thrombosis is increased. That was the first low blow. Where transdermal therapies, ie patch or gel, this risk is unlikely to have or significantly less. Then in 1997 came the first large study, which showed that the risk of breast cancer is slightly increased. And our hope for a protective effect against myocardial infarction was dashed by the 2002 WHI study.
Dr. Eva Schindele: There are more problems: A further evaluation of the WHI study shows that hormone users suffer more from urinary incontinence. In addition, the study has shown that memory and perception through hormone therapy not better, but worse. In the advertising of the pharmaceutical industry that sounds different: Thereafter, hormones protect against dementia.
Dr. Kathrin Schaudig: The topic of dementia is important. However, this result of the WHI study - which, incidentally, I think is very good - must be put into perspective: it is likely that the cases recorded there are predominantly a vascular dementia - the so-called calcification. And you have to know: There were relatively old women, with an average age of 60, who started taking hormones for the WHI study. So you had no hormone protection effect from an earlier age. And if you give a 70-year-old high-dose hormones, then she has a high risk of thrombosis, heart attack, stroke and also for vascular changes in the brain. However, there is also the risk of contracting Alzheimer's - in women it is at least twice as high as in men. And there are a number of observational studies to a protective effect of hormones.
Dr. Eva Schindele: I do not find it responsible for giving women the feeling that they have to use hormones to protect themselves from Alzheimer's! Especially since it has been proven that physical and mental movement protects against dementia.
Dr. Kathrin Schaudig: Totally right. But there are patients who tell me, "I've been forgetting so much lately." And there are studies that improve word memory with estrogen ...
Dr. Eva Schindele: ... and again studies that prove exactly the opposite.
ChroniquesDuVasteMonde woman: Dr. med. Shudder, do you actually plead for hormones for menopausal symptoms or as a long-term medication into old age?
Dr. Kathrin Schaudig: First and foremost, I would recommend hormones for a limited time if you have severe complaints - unless there are high individual risk factors. Also, about 10 to 15 percent of women still have 20, 30 years after the transition complaints. And there is the problem of osteoporosis, which is currently slipping away from public perception. One in four women suffers - with severe pain and the danger of becoming immobile over the long term. Here's what's really proven: Hormones are the most researched, effective and cheapest means of preventing osteoporosis.
Dr. Eva Schindele: But what about other health risks? You would have to take the hormones for decades to prevent getting 75 with osteoporosis! I also doubt that every fourth woman suffers from it. Such numbers come from a definition that any woman who measures a lower bone density will be declared an osteoporotic patient. I recently talked to an osteoporosis specialist who told me he also sees the situation as an opportunity. He used to recommend hormones for too little bone density. Today, he encourages women to do sports and develops prophylactic services with sports physicians.
ChroniquesDuVasteMonde woman: All this is something every woman can think about in peace. Nevertheless, this discussion is highly emotional. Do you understand that? Women take the pill or decide to have a fertility treatment, so there is no religious war.
Dr. Eva Schindele: Our generation has also dealt with the pill. I stopped them at some point - and felt the difference: whether my cycle is controlled hormonally or if I let nature run its course. If you've already taken the pill or had a fertility treatment, hormones during menopause are another massive intervention in our biology.
Dr. Kathrin Schaudig: The contraceptive pill represents a much more gigantic intervention in the hormone balance. And there are risks as well as with the fertility treatment. Even deaths occur. Nevertheless, these risks are more likely to be accepted.I'm afraid that's because the pills and the nursery women have a different lobby. The pill is available for the fun of sex. And also a fertility treatment is socially accepted. But in the menopause it is said: now she should take the hot flashes without hormones. That's totally misogynistic.
ChroniquesDuVasteMonde woman: Speaking of sex - how do you see the effects of hormones?
Dr. Eva Schindele: It is always said, through the menopause, the women are unattractive and have no desire for sex. I doubt it. Studies show that it depends more on the partnership, whether older women are sexually active and enjoy it. And of course, sexuality changes with age. But in this context, I find it completely inappropriate that now is constantly being warned that the vagina is dry. It does not have to be that way. If the woman stays "in exercise", also through masturbation, secretion continues to be formed.
Dr. Kathrin Schaudig: That sounds good. But I warn against generalizations. I have a number of patients who have had a down-to-earth sexuality in a functioning relationship for years. And suddenly, during the menopause, the libido subsides, and the vagina no longer moisturizes. This is also visible as a consequence of the estrogen deficiency in the cell structure. With a local estrogen treatment in the vagina, this is very easy to treat - and according to the current state of knowledge that is completely harmless. But that's still such a taboo subject that many women do not even hear about it from their gynecologist.
Dr. Eva Schindele: But I know more women, who hear from the doctor or the doctor: "There's a new hormone pill, which is low doses, because you even lose weight. Take the, that is completely harmless ..."
Dr. Kathrin Schaudig: Is it that time again? Of course, the newer drugs are not risk-free. But in the future there will be even lower-dose preparations. And we have to try to reduce the risk of progestogens. There is a very low dose of estrogen patch in the US for osteoporosis prophylaxis - maybe a perspective.
Dr. Eva Schindele: In addition, many gynecologists do not know how to stop hormones. As a result, women get into the hormone trap - as soon as they stop, they get complaints again.
Dr. Kathrin Schaudig: We recommend taking the hormones for six to twelve months and then sneaking them out. There are certain pills that can be cut in half. Or you can take a gel, because you can easily reduce the dose more and more, but must swallow a luteal hormone. Some patients stay permanently on a mini-remainder gel, and that works quite well. Some have hormone levels that I can not measure - but it works.
ChroniquesDuVasteMonde woman: And what about vegetable estrogens?
Dr. Kathrin Schaudig: It took 30 years to research what risks estrogens and combination therapies have. However, such long-term studies are not yet available with regard to herbal preparations. When patients want something "natural," I tell them, "The estrogen I give you is natural, because it's bioidentical with your own hormones. But the black cohosh, for example, from which many herbal remedies are made, grows nowhere in you. Maybe it works well against hot flashes - but I do not know exactly what is in it and how the long-term effects are.
ChroniquesDuVasteMondewoman: As we can see, the debate over hormone therapy is also about aspects such as lifestyle and performance, looks and aging: are such questions actually part of a doctor's office?
Dr. Kathrin Schaudig: The task of the doctor is to inform the patient about the pros and cons and to check her individual risk situation with her. I always encourage them to do something for themselves with nutrition, sport, but also mental exercise. Everything else must take the woman in the hand and decide.
Dr. Eva Schindele: This is an important aspect: where is the room for the questions and worries that women have with aging? First of all, my girlfriends or self-help groups come to mind. And only with severe symptoms, the doctor. Not every woman is in need of treatment when it comes to menopause. This tunnel view of the hormones does not do us any good at all. I just see it with my friends: This is an age when a lot of things happen again.
