Hormones & Mood: Hot Flashes, Anger, Insomnia Relief

Myths, uncertainties, long-outdated assumptions: In hardly any other area of ​​health is this more prevalent than when it comes to menopause. This is particularly true for menopausal hormone therapy, often called hormone replacement therapy, which is intended to help women with significant menopausal symptoms.

Menopause – what is it exactly? The menopausal transition describes the transition from the reproductive phase of life to permanent infertility in women and is associated with significant hormonal changes. Menopause or climacteric are terms for the entire transition phase, which usually lasts 10 to 15 years. There are currently around nine million women in Germany going through menopause, according to the German Menopause Society (DMG).

The term is often used differently, but in fact “menopause” only refers to the time of the last menstrual period and is determined retrospectively when no period has occurred for twelve months. On average, menopause occurs at the age of 51. The egg supply that was created before birth is then exhausted. This point in time has remained unchanged, even though women today live significantly longer on average and are, for the most part, much fitter at 50 than their counterparts 50 or 100 years ago.

How does menopause happen?

“Most women think that they don’t have any menopausal symptoms yet as long as their period comes on time,” says Katrin Schaudig. President of the DMG. But as early as your late 30s or early 40s, the first cycle changes and symptoms such as mood swings can occur – the first signs of the onset of menopause.

During the so-called perimenopause, mainly between the ages of 45 and 50, the cycle becomes increasingly irregular, with intermenstrual bleeding and longer periods between periods. Fluctuations in both cycle-determining hormones (progesterone and estrogen) characterize this phase. “These are spring tides and tsunamis in terms of hormone levels instead of ebb and flow as before in the cycle,” says Schaudig. It could lead to psychological problems. Towards the end of perimenopause, estrogen levels drop significantly. Complaints such as hot flashes and sleep disorders are increasing.

Postmenopause is characterized by increasingly low but more stable levels of both sex hormones. The risk of cardiovascular and bone diseases increases, and other long-term consequences such as changes in the skin, mucous membranes and body composition are also typical.

In each phase, symptoms and levels of symptoms vary greatly from person to person, as experts emphasize. In addition, the problems usually do not last continuously, but flare up periodically. About a quarter of women have severe, only mild, at times clear or no symptoms, as Olaf Ortmann from the University Clinic for Gynecology and Obstetrics in Regensburg says.

In addition, menopause has a very unpleasant peculiarity: “The earlier the symptoms start, the longer they usually last,” explains Ortmann. “It could take three years – but it could also take 15 years.” Sometimes certain symptoms exist in a milder form, even for life. “Hot flashes are extremely rare, even at 80.”

Menopause or aging process?

A classic symptom associated with changes in hormone levels is hot flashes, associated with heavy sweating, especially at night. On average, menopausal women have frequent hot flashes for more than seven years – on more than six days in the last two weeks, as stated in the guideline “Peri- and postmenopause – diagnostics and interventions” drawn up by specialist societies.

Sleep disorders, depression, mood swings, anxiety, sexual problems and joint problems are symptoms that can have various causes, but according to Schaudig, these symptoms become more frequent and worse during menopause.

In her book “Woman on Fire,” gynecologist Sheila de Liz also names depression, tantrums, hair loss, itchy skin or mysterious eczema, headaches, frequent bladder infections, nighttime urination, hearing loss, weight gain and dizziness as possible menopausal symptoms.

In many cases it is not possible to say clearly what is specifically caused by the menopause – which is ultimately also part of the natural aging process, says the guidelines coordinator Ortmann. Stress and strain in everyday life also play a major role in the development of symptoms – and can be significant, especially in women around 50.

According to experts, socially disadvantaged women who are under great pressure and have little chance of creating well-being and freedom for themselves are often severely affected. It is fitting that, according to studies, menopausal symptoms play little or no role in societies in which older people are held in high esteem – i.e. among women who tend to be very well-being.

Should women have their hormone status checked?

Not generally. During the perimenopause, the hormone status fluctuates greatly – according to experts, sometimes by 20 times – and therefore does not reflect well the level during the menopause. “The different phases of the menopausal transition can be diagnosed primarily based on clinical criteria,” says the current guideline. “Hormone tests are usually not necessary.”

In the case of certain problems such as a racing heart, increased blood pressure or depressive moods, it can definitely make sense to take the hormone status into account, says Ortmann. Time and again, women with sleep problems are prescribed a sleeping pill and an antidepressant if their mood is low, or they end up at the orthopedist or rheumatologist with joint pain without even thinking about menopause.

What can women do?

Experts emphasize that symptoms can be reduced through diet, exercise, mindful behavior and targeted relaxation exercises. “There are many things you can do yourself,” says Ortmann. During heat waves, for example, it can help to lower the room temperature in the bedroom. Many users also rate herbal remedies as helpful.

“If there are significant symptoms, herbal remedies can’t do much,” emphasizes Ortmann. Hot flashes every few hours or a lack of sleep that lasts for weeks could be so distressing that the quality of life and ability to work suffer significantly. As a result, some women even retired earlier than planned, says Schaudig. With the right hormone therapy, this could often be avoided. “The quality of life of many women is unnecessarily poor.”

The effectiveness of menopausal hormone therapy (MHT) is particularly high for hot flashes and sleep problems. The term is still quite new; for decades the treatment was known as hormone replacement therapy (HRT). The new name is intended to put more focus on the normal hormonal decline during menopause and to avoid the misunderstanding that hormones that should actually be there have to be replaced, as Ortmann explains. This is the case, for example, with hypothyroidism, but not with menopause.

In Germany, estradiol is mainly used through the skin to alleviate symptoms. In addition, progesterone is often prescribed as a capsule to protect the lining of the uterus from excessive growth caused by estrogens. It can also alleviate sleep disorders.

Does the risk of breast cancer increase?

The widespread concern that hormone therapy significantly increases the risk of breast cancer goes back, among other things, to the WHI study (Women’s Health Initiative) published in 2002. The study was stopped prematurely because a subgroup was found to have a slightly increased risk of breast cancer.

The participants were primarily older, postmenopausal women who received oral estrogens in combination with a specific progestogen. Subsequent evaluations showed that when therapy begins early – a maximum of ten years after menopause or at a maximum age of 60 – the beneficial effects often exceed the potential negative consequences.

“With adequate therapy, the risks are comparatively low,” emphasizes Ortmann. However, a misinterpretation of the WHI results meant that hormone therapy, which had previously been used very widely, was prescribed significantly less for decades. There are still doctors who are very hesitant to prescribe – also because of the high consultation effort – says Schaudig. “Although there are also those who do so very carelessly.”

According to experts, there has been less research in the area since the WHI study – which is one reason why many connections are only suspected but are not considered certain. Apart from breast cancer, there is hardly any reliable information about the interactions of hormone therapy with existing diseases. The revision of the guidelines, which is expected to be completed by the end of the year and coordinated by Vanadin Seifert-Klauss from the Technical University of Munich, will include MHT in pre-existing diseases as a new chapter.

Are there positive long-term effects of MHT?

Yes. Menopausal hormone therapy has been proven to reduce the risk of osteoporosis as well as coronary heart disease and heart attacks, explains Ortmann. There is evidence of a connection with a reduced risk of diabetes, but so far no clear proof.

Do women live longer with hormone therapy?

No, says Ortmann. Studies have shown no associated increase in life expectancy – which could be because the benefits and risks balance out on average in the long term. Evidence of a reduced risk of dementia cannot be derived from the data available so far. However, the therapy may enable seniors to live a life with fewer complaints and signs of aging, according to experts.

Should all women take hormone therapy?

In fact, there are books and articles on the subject that propagate this. The hair stays beautiful for longer and the skin wrinkles less – for some women this may even be more important than the reduced risk of illness. But experts like Schaudig and Ortmann warn that hormone therapy is not suitable as a lifestyle product. General, purely prophylactic hormone therapy is absolutely not recommended. The risks should be taken seriously.

According to Ortmann, more serious risks are known primarily from high blood pressure and certain existing cardiovascular and tumor diseases; In most cases, those affected are advised against hormone therapy.

Aren’t bioidentical hormones supposed to be completely harmless?

You can read that in some forums and posts, but it is wrong. The term “bioidentical” is often assumed to mean a natural substance, explains Ortmann. What is meant is that the active ingredient is structurally similar or identical to the estrogen produced in the human body.

However, the so-called equine estrogens, which are produced from mare urine, are structurally somewhat different. “They are no worse than the bioidentical ones and do not have any higher or different risks when taken using the same route,” emphasizes Ortmann.

According to experts, the main difference is whether the active ingredients are administered as tablets or through the skin – via gel, patch or spray. With transdermal absorption, initial processing in the liver is avoided, the so-called first-pass effect: oral estrogen administration promotes the formation of coagulation factors there, which in turn increases the risk of venous thrombosis and strokes, as Ortmann explains.

However, it also applies to other processes that the effects mediated via the liver are stronger – possibly also for the desired effects, as experts point out. Overall, the long-term side effects are lower than with tablets – but it is also feared that the effect on the risk of osteoporosis, for example.

How long do you take the hormones for?

Menopausal hormone therapy is usually given for a few years, says Ortmann. Therapy should be carried out for as long as it is necessary in view of moderate or severe menopausal symptoms. The limit is a matter of consideration, says Schaudig. Some people continue the therapy for a long time, sometimes until they retire – also because symptoms can get worse again after stopping.