Cynthia A. Stuenkel, MD

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Women  are more likely to explore their options for hormone therapy earlier in  life compared with their mothers and grandmothers, said Cynthia  Stuenkel, M.D., clinical professor of medicine and endocrine metabolism,  University of California, San Diego.

“I think many women start thinking, ‘What am I going to do?’ even in  their earlier 40s,” Dr. Stuenkel said. “By the time a woman gets to be  45 to 50, it’s very likely that she may already be experiencing some  changes,” Dr. Stuenkel said. These changes include menopausal symptoms  such as hot flashes around the time of their period, mood swings, sleep  troubles, vaginal dryness, and abnormal periods.

Women are more likely to inquire about their menopausal symptoms  because they want to plan for the life changes it will bring, Dr.  Stuenkel said. “They want to feel they have the advantage of  anticipating this transition, and they want to be like they are in other  phases of their life, one step ahead of the game,” she said.

The stresses of daily life lead women to question whether typical  symptoms they experience are menopause related or stress related, she  said. “It can be a very tough time because you don’t know if you are  just tired and doing too many things, or is something changing with you  physiologically,” Dr. Stuenkel said.

Greater awareness of and information about menopausal symptoms-and  less tolerance of them-lead these patients to seek help, Dr. Stuenkel  said. Plus, the large number of women physicians  who have undergone menopausal and perimenopausal changes has prompted a  larger focus on the issue and better understanding from physicians of  both sexes, she said.

Patients usually ask about their symptoms and hormone therapy during a  visit for a pap smear or annual exam, Dr. Stuenkel said.  However, if  hot flashes or abnormal bleeding concern patients, they usually make a  special appointment, she said.

When patients suspect they have menopausal symptoms, Dr. Stuenkel  believes they should pro-actively initiate a discussion with their physician.  “I would encourage them to do so, often by saying, ‘Could this be  happening to me? Could I be there? Am I at this threshold?’” she said.

Some women are better suited for hormone therapy than others,  depending on their symptoms, lifestyle, and health background, Dr.  Stuenkel said. She discussed some hypothetical-and typical-patient  scenarios.

The first is a woman who is bothered by hot flashes, loss of interest  in sex, or dry skin. The decision about HRT is fairly easy with this  patient, Dr. Stuenkel said. “This is the symptomatic woman who comes in  and says, ‘I am miserable. I am tired of not sleeping, I am tired of  crying at my office. I am tired of shouting at my family all the time.  I’m tired of not getting a good night’s rest,’” she said. “I think  that’s the one that we know responds the most clearly and the most  beautifully to hormone therapy.”

Study results show that hormone therapy can especially aid women with hot flashes.

“If there is a number one indication, and it is not just the  clinicians who say this, this is what the FDA Food and Drug  Administration has told us as well, the number one indication for the  use of hormone therapy is treatment of basal motor or hot flash  symptoms,” she said. It is also helpful for vaginal dryness, she said.

The physician and patient can then talk about the best hormone  therapy approach, she said. Some patients may benefit from a lower dose  of hormones.

“Many women will have symptom relief from a lower dose. I think that  it is reassuring to always start with a little bit less. Nevertheless,  you can move it up if you need to,” she said. The therapy can start  before a woman stops menstruating, she said.

The second is a patient who is somewhat bothered by some menopausal  symptoms but does not think the symptoms warrant the use of any  medication. This patient history that makes them likely to develop  osteoporosis, a condition that hormone therapy could potentially help.

It is difficult to decide on the best treatment course for this  middle-of-the-road patient, as Dr. Stuenkel characterizes her. To help  make the hormone therapy decision, Dr. Stuenkel would ask questions  about how much calcium the patient takes, whether the patient has  adequate vitamin D intake, and exercise, smoking, and alcohol habits.

“It makes it a little tricky because we really don’t have good  guidelines for measuring bone density in pre-menopausal women,” Dr.  Stuenkel said.

Dr. Stuenkel would most likely opt for a conservative approach and  steer clear of hormone therapy initially. “If you wait a year and have  the bone density re-measured, maybe this patient who is concerned about  osteoporosis will develop bad symptoms of hot flashes that will make her  choice to go on estrogen easier,” she said.

Within the next year, the World Health Organization is expected to  release guidelines on bone mineral density that will help physicians  estimate a patient’s risk for related problems, she said. “I think this  is going to help us feel comfortable and might give us more information  to say to that woman, ‘With this family history, maybe you’ve had a  fracture in the last couple of years, maybe you should be treated.’ It  will make us feel more strongly justified in our choices,” she said.

The third patient is a woman who does not have any bothersome  menopausal symptoms and has good bone density test results. This patient  may have the right mix of good genes and a healthy lifestyle, Dr.  Stuenkel said.

“She probably has a good diet, may or may not exercise, and I would  just reinforce with her that those lifestyle things become increasingly  important as women pass through menopause transitions,” Dr. Stuenkel  said.

This patient is not well suited for hormone therapy, she said.

“I am not convinced that we have strong enough data to recommend  hormone therapy for prevention, and prevention alone, of osteoporosis, heart disease, or cognitive decline,” she said.

Although patients who are symptomatic are more likely to ask their  physician for advice, even women with no problems are seeking  information on lifestyle changes for a healthier transition into  menopause, Dr. Stuenkel said.

“I think more and more women say, ‘What do we need to stay healthy?’”  she said. “I try to convince women to look at menopause as a tiny  haystack. We all know what we are doing right and what we’re not doing  right. You don’t need to go to your doctor to find out that you should  exercise more, because everybody knows this. But your doctor might help  you measure things like your fasting blood sugar, your cholesterol, or ask if you’ve had a mammogram. Those are good things to do to take stock,” she said.

Women should not feel boxed in by the hormone therapy decision, Dr.  Stuenkel said. “I think women toss and turn and feel ‘I have to make the  estrogen decision.’ It’s not like you can’t go back,” she said. Women  may bear the hot flashes for a few months and then decide to get hormone  therapy, or they may try hormone therapy and decide that it is not  helping, so they stop it, she said.

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