The BRIA team spoke with Dr Jennifer Blake, one of BRIA’s gynaecologists, about various hot topics in menopause.
BRIA: How do you talk to people about measuring hormone levels in perimenopause or menopause and is there any value in doing this?
Jenny: The business of taking hormone levels or measuring levels comes up a lot. Unfortunately, although it seems that it would be a useful thing to do, it is not. It is fair to say that it is a “pseudo science”. There is no correlation between your hormone levels and the symptoms you are experiencing, so we do not gain anything useful from the blood tests. Hormones change quickly from hour to hour, day to day, especially in perimenopause, so there is no value. We do not make treatment decisions based on levels. “Choosing Wisely” (https://www.hqontario.ca/quality-improvement/Quality-Improvement-in-Action/choosing-wisely-ontario) actually has a specific recommendation not to measure levels in menopause. Hormone treatment is based on symptoms and not on blood levels, so you may actually not get the proper treatment you need based on blood levels from the day the test was taken!
However, it is important to test hormones in certain situations, namely for people using testosterone.
BRIA: Please tell us about bioidentical hormones and how you discuss this with patients.
Jenny:
With bioidentical hormones, people believe they are “natural” and therefore “safer” than the hormones that are prescribed by MDs and are regulated by the government. But the truth is that they all come from the same manufacturer.
Estrogen is a steroid hormone that comes from cholesterol that is made in animals, not in plants. The only natural hormones are the ones we make or animals make. They all are synthetic hormones. Plant based compounds are not estrogens (although some of the “phyto estrogens”, such as in soy, can interact weakly at the estrogen receptor).
A counselling tip and analogy that is helpful when discussing bioidenticals is that I ask people if their front door key is made by Chubb or Schlag or Home Depot? (insert smiley emoji) In reality, it doesn’t matter. In a similar way all hormone therapy interacts with the receptor, which is like the lock on the door and unlocks the door. All hormones, regardless of the source, work in the same way via the same receptors.
Bioidentical compounded hormones are not regulated and may contain contaminants as well as dangerously high amounts of estrogen and progesterone. These products do not benefit from research and quality control measures. As a result, this can put people at risk if they are exposed to very high hormone levels.
BRIA: How do you help people address weight gain in perimenopause?
Jenny: Our bodies’ fat metabolism changes when we lose reproductive levels of estrogen. Body fat accumulates in the belly, as a result. This can be distressing to people who are particularly body-conscious, by which I mean, most people. Nobody wants this. But I tell people “it is biological” and I preach self-acceptance, and tell people that this comes with the territory of getting older! I don’t always practise what I preach, but I try. The most important thing is to be active and as fit as we can be. Body fat increases but muscle mass declines. To protect our muscle mass and remain healthy we need to work on strengthening our muscles, specially our core, cardio and flexibility. That doesn’t mean you have to go to a gym; any activity that you can build into your routine helps.
BRIA: Please tell us about the use of testosterone in mid-life.
Jenny: In Canada, we used to have Premarin with methyltestosterone, which was an injection. Women loved this! They used to feel great, and have increased well-being and energy, and increased vigour, and they would come back more and more for this and in shorter intervals. Unfortunately, testosterone accumulated in womens’ bodies, and many people then started coming back with signs of hyperandrogenism, which are not reversible, such as acne, increased coarse hair growth, irritability and aggression as well as clitoromegaly (an enlarged clitoris).
Anything injectable with testosterone is something to be very, very nervous about because it accumulates in the body and has a narrow therapeutic index, meaning that it can easily become dangerously high.
In Canada, there are no testosterone products that are properly formulated for women, so we use transdermal AndroGel or Testim, both of which are only formulated for men. Androgel comes in a grey pump bottle that looks like they belong at the bottom of a hockey bag! And it is hardly feminizing to give to a woman!
Plus, pharmacists are likely to say, “this is testosterone and it is for men!” and “does your doctor understand what this is?” So, you need to prepare for hearing these types of comments.
Testosterone can be helpful for women who have had gynaecological cancers, such as pelvic cancers when ovaries have been removed and they have lost their libido. In this group, testosterone is particularly helpful. But I do tell women: “when you get that bottle at home, make it your own, put it inside some fishnet stockings or maybe something pink – whatever it is that speaks to your sexuality. Patients need a lot of support and monitoring when they are put on testosterone .
For women in menopause and struggling with hypoactive sexual desire, which is very common, testosterone doesn’t really help a lot, and has risks, including physical side effects and adverse effects, such as hair loss and acne. I also ask people: when are you going to stop this medication? How long are you going to be on this? Because once they stop it, they are back to where they were. I feel it is much more productive to deal with the underlying issues and help people understand how their desire works, and how their sexuality changes as they age. It may be helpful to have a bit of testosterone but most of the time, unless you are a young woman, this is not a preferred treatment. Unfortunately, we don’t have great options in Canada to help women with low libido yet.
In terms of mental health issues, people may feel more aggressive and more “coarse” when they are on testosterone. For those taking testosterone, it is important to be aware of the potential for behaviour change and to reduce the dose.
BRIA: Can you tell us about MHT shortages in Canada right now?
Jenny: Estrogen patches and gel have been in short supply these days but seem to be coming back now. Ozempic and ADHD medications have also been in shorter supply too. Progesterone has not been in short supply. But things can change quite quickly. Health Canada keeps a list of drug shortages: https://www.drugshortagescanada.ca/. Please check this link to stay up to date.
