As a gynecologist, I often hear from my menopausal patients that they are not getting enough reliable information about menopause. As a society, there is an unspoken taboo that we don't talk about menopause, so women aren't told what to expect and they don't ask. A recent surge in discussions about menopause, spurred primarily by celebrity interest and new drug development (as well as aging by the feisty Gen Xers), has spurred another problem. Unfortunately, some people, most of whom are trying to sell their products to you, try to convince menopausal women that they have the magical answer. First, there is no such thing as a magic answer, and if there was, your doctor would tell you about it. Second, there are a lot of buzzwords that appear in the media and get shared amongst women, but those words don't have any medical relevance...they are simply marketing techniques to push specific products over other ones.
Let's back up for a minute. Menopause is a natural process in which women no longer release eggs just as puberty is a process in which girls start to release eggs. As part of menopause, women experience changes in sex hormones and elsewhere (e.g., muscle loss and bone loss, among other things.) The menopausal decrease in the sex hormones estradiol and progesterone can produce unwanted symptoms like hot flashes, night sweats, and vaginal dryness that some women would prefer not to experience.
"Natural" is usually a marketing term. Think, for instance, about how it's used in the food industry. Marketers use the term because people associate it with something that is better and safer for them. But that simply is not true. Cherry pits and apple seeds contain cyanide. Nutmeg is delicious in holiday dishes but when eaten by the spoonful is poisonous due to high concentration of myristicin. Even water can be unsafe if consumed in enormous quantities. No one argues that cherries, apples, nutmeg, and water are not natural. The same idea of using "natural" as a marketing term applies in medicine. And it's equally inappropriate. Women naturally produce estradiol during their reproductive years, but that same estradiol causes some of those women to develop breast cancer (usually because of their genetic makeup). Insulin is naturally produced by the pancreas to regulate glucose levels, but too much insulin causes cells in your body to absorb too much glucose (sugar) from your blood and causes the liver to release less glucose, which creates dangerously low glucose levels in your blood (hypoglycemia). In short, when you see "natural" used anywhere something is being sold, you should ignore it since it's meaningless.
Like puberty, pregnancy, and postpartum, menopause is a normal variation in sex hormone production experienced during a woman's life. Unfortunately, some people, most of whom are trying to sell their products to you, try to convince menopausal women that they are broken or "unbalanced" unless their sex hormone levels during menopause are the same during menopause as during their reproductive years. There is no evidence that "customizing" hormone dosages for a particular individual using blood, saliva, or urine testing improves symptoms or risks. And chasing the dose of MHT based on testing levels can exercise in irresponsible medicine. MHT should be used only to treat symptoms (more on this later.) There is no scientific data that recommends that menopausal women take menopause hormone therapy (MHT) solely to restore their levels of estrogen and progesterone to some arbitrary value. In fact, every relevant international medical association recommends against it. Do not get confused by marketing schemes playing on the myth of menopause as a disease that needs to be cured in an attempt to sell you blood tests, saliva tests, urine tests, hormone replacement, products, or supplements for the sole purpose of "returning you to your younger self." It's predatory, unethical, a waste of your time and money, and possibly dangerous.
"Bioidentical" is another marketing term that is inaccurate. You'll see "bioidentical" used in women's health settings to refer to hormones, specifically those used for menopause hormone therapy (MHT.) Bioidentical hormones are ones that have the same chemical structure as the hormones produced by women. Almost all FDA-approved MHT products have bioidentical active ingredients, so the term is unhelpful in describing the product as either more natural, more effective, or safer. Interestingly, the primary FDA-approved MHT drug that is not bioidentical is Premarin, which contains a mix of estrogens derived from horse urine. It's arguably the most "natural" option. Bioidentical estrogen is derived from a compound found in wild yams or soybeans, but that compound must undergo several chemical processes not seen in nature before it becomes the "bioidentical" estrogen used in the MHT drug.
In today's marketing environment, many are using "bioidentical" to mean "compounded" so let's discuss FDA-approved versus compounded drugs. To become FDA-approved, there are several hurdles a potential therapy/product must clear, including proving its safety and effectiveness. The Endocrine Society notes that "there is no evidence-based medical need for the use of compounded hormone therapy when an FDA-approved preparation is available." There are dozens of FDA-approved hormones for use in MHT in all types of preparations - patch, pill, cream, gels, sprays, and injections. The Menopause Society and the Society of the National Academies of Sciences, Engineering, and Medicine (NASEM) agree that compounded hormones should be considered in only two situations - the patient is allergic to one or more of the ingredients used in an FDA-approved product or available FDA-approved products don’t offer a certain dosage level of a medication. In summary, nearly all FDA-approved MHT products contain active ingredients that are bioidentical in that they contain active ingredients with molecular structures like those made by women. And compounded MHT is not safer or more effective than FDA-approved drugs.
What do we know about the safety of FDA-approved MHT? The 2022 Consensus Statement for Hormone Therapy published by The Menopause Society found that "the benefits of hormone therapy outweigh the risks for most healthy symptomatic women who are aged younger than 60 years and within 10 years of menopause onset.” Although there are increasingly more non-hormone treatments for menopause symptoms, hormone therapy remains the most effective treatment for hot flashes and night sweats, and as a preventive for bone loss and fracture. Low-dose vaginal estrogen therapy for treatment of the genitourinary syndrome of menopause (vaginal atrophy, pain, itching, dryness), appears safe and effective, even for some survivors of breast and endometrial cancer. MHT is not recommended as a first-line treatment for any other menopause symptom, but your doctor may decide MHT is helpful for you in some other instances.
Unfortunately, some people are more interested in making money than in supplying accurate, helpful information to menopausal women. Too often, many of the words used in the media and by social media influencers are marketing terms that confuse women and prey on their insecurities about aging and their significant life disruption as a result of the myriad of unwanted symptoms of menopause. Give extra scrutiny to anyone using words like special, natural, bioidentical, or customized to describe menopause therapies. Talk with a doctor who specializes in menopause to get the most up-to-date, evidence-based information and treatments for menopause symptoms. You can find one near you at https://portal.menopause.org/NAMS/NAMS/Directory/Menopause-Practitioner.aspx
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