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What happened to my sleep?

Difficulty sleeping is one of the most common problems brought up by women who come to see me. It can be one of the earliest symptoms women notice in the perimenopause, affecting roughly half of us. Women are more likely to experience insomnia than men. Why this should be is not well understood. The times in a woman’s life when she is most likely to experience insomnia are premenstrually, in the third trimester of pregnancy and in menopause. Mood disorders can contribute to insomnia, and persistent insomnia increases the occurrence of depression. Chronic insomnia is also common in women with breast cancer.

What to do about sleep problems? The first recommendation in any discussion of the topic is to apply the principles of sleep hygiene. These include going to bed and getting up at the same time every day (including weekends), avoiding caffeine and alcohol in the evening, avoid exercising close to bedtime, keeping the bedroom quiet and cool, and using the bedroom only for sleeping and sex. Vasomotor symptoms (VMS), hot flashes and night sweats, are notorious for disrupting sleep. Hormone therapy in low doses has been shown to be effective for many women with VMS, and any related sleep problem. Cognitive behavioral therapy has been shown to be helpful in cases of chronic insomnia and is preferable to medications as a first-line treatment. If the access to a therapist is limited, there are books and DVDs available that teach relaxation techniques and meditation that may be helpful to sleep. For insomnia related to depression and/or anxiety, an anti-depressant medication may help sleep and the mood symptoms. Sleeping pills may be helpful in the short term, but their use should be limited due to the risks of developing a tolerance to them or a dependence on them.

Our approach to sleep problems should be built around sleep hygiene and relaxation techniques first, hormones and medications if needed later.

What do we mean when we talk about risk?

Many discussions about health, wellness, illnesses and treatments include mention of risks. A risk is defined as a threat of loss to that which we value, real or perceived. The Oxford English Dictionary defines it as a situation that could be dangerous or have a bad outcome, or the possibility that something unpleasant will happen. A simpler definition is that the risk of something happening is the chance of it taking place. It has been a topic of several presentations at medical conferences on women’s health in the past year, no doubt due to the constant debate of benefits versus risks of menopausal hormone therapy. One of the best presentations pointed out perception versus reality and how risks of medical treatments compare to every day risks that people take without thinking about it. The same academic stated that the population in general developed a cancer phobia once we could measure concentrations of substances in the parts-per-billion range.

Many of us lack an in-depth knowledge of statistics. It is fascinating and frightening how various ways of stating information statistically can be used to support or refute ideas or theories. An example is the use of relative risk and absolute risk. An absolute risk is the actual number of people affected by an outcome, for example 6 out of 10,000 people. If a trial is done that shows now 8 out of 10,000 people are affected by whatever, that is an increased relative risk of 33% even though only 0.08% of participants had the outcome. Relative risk compares the risks with and without what is being tested.

In general, risks are calculated on the best available data. Any assessment of an individual’s risk of any given ailment or condition is usually based upon a model that was developed from cases that have gone before. It must be kept in mind when discussing risks, that they are not cast in stone. Day-to day life is full of risks that we either ignore or are unaware of. Avoidance of known or suspected risks is no guarantee that you will live your life disease- or cancer-free. Life is not like that.

Heart Disease and Women

Heart disease is the number one killer of women. Only 54% of women know this; only 13% believe it is their own greatest health risk. Most telling is that many women polled state they would call an ambulance for a family member with chest pain, but would not do so for themselves. The death rate from heart disease in women between ages 35 and 54 is increasing. There are more women dying from heart disease than men since 1984. Why is this?

The majority of medical research done in the past has excluded women, largely because it was not known how to factor in the effects of women’s complicated and fluctuating hormones. There are no requirements in Canada to include women in medical studies. The well-known Framingham study, which started in 1948 and is still adding data, led to the identification of risk factors for heart disease. The model based on data from Framingham is still widely used to calculate an individual’s risk of heart disease, although it has been found to be less helpful for women, especially those who are younger. The initial Framingham data suggested that only men developed heart disease. Women were only included in the 1964 American Heart Association conference in the talk “Hearts and Husbands: How to Care for Your Man”. Nothing was included about self care for the women themselves.

It is a common misconception that women have symptoms of acute heart attack that are different than those of men. While a few studies show that women may have a slightly lower incidence of chest pain specifically than men, most of the presenting symptoms of a heart attack are the same between the two genders. Roughly one-third of all heart attack patients, women and men, present without chest pain. Many other symptoms experienced before or during heart attacks have been described in studies, including profound unusual fatigue, anxiety, palpitations, difficulty breathing, indigestion, nausea, vomiting, sweating, dizziness and headache.

It is important that women know that the diagnostic procedures used for cardiac disease are not as helpful in women as they are in men. This is believed to be for a number of reasons. It has been shown in studies that women with heart disease often have involvement of smaller vessels than most men. Women have been shown to do more poorly during hospitalization for heart attacks; more women die compared to men. Women tend to bleed more, and are harder to graft. Women are less often admitted to specialized cardiac care units and are less frequently under the care of specialist cardiologists. Even with the increased knowledge gained in more women-centered research over the last decade or so, more women are discharged without being prescribed what has become regarded as “standard care” because their angiograms did not show significant occlusion of the coronary arteries.

Knowledge is power. In heart disease, as with many diseases and health problems, prevention is best. Learning what the risks for heart disease are and how to reduce them with lifestyle changes is something we all can do. Menopause is a time in a women’s life that leads many of us to change; make yours for the better.

Breast Cancer – Risk Factors

Please keep in mind when reading about or discussing risks of anything, that none of it is cast in stone. Depending on which studies you read, you can often find two that will contradict each other and say completely different things. Avoidance of known or suspected risks is no guarantee that you will live your life disease- or cancer-free. Life is not like that.

A woman’s lifetime risk of developing breast cancer is 1 in 8, or 12.3%. This should be further clarified by breaking it down as to risk at different ages, because the risk of developing breast cancer increases with advancing age. Breast Cancer risk in US women has been calculated by age group as follows:

Age 30 0.44% (1 in 227)

Age 40 1.47% (1 in 68)

Age 50 2.38% (1 in 42)

Age 60 3.56% (1 in 28)

Age 70 3.82% (1 in 26)

Data from www.cancer.gov/cancertopics/factsheet/detection/probability-breat-cancer

There have been many factors identified as associated with a higher risk of developing breast cancer. Inheritance of the genes BRCA1 and BRCA2 significantly increase ones’ risk; only 5 to 6 % of all breast cancers are caused by the inheritance of these susceptibility genes, however. The risk of breast cancer is doubled by having a first-degree relative with breast cancer, and tripled if one has two affected first-degree relatives. The risk is higher if the affected relative was diagnosed before menopause. Having had breast cancer yourself increases your risk of developing cancer in the other breast.

Having dense breasts increases the risk of breast cancer. This is a factor that is difficult to measure, however, because mammography reports rarely report an estimate of density outside of a qualitative comment. Hormone therapy may be related to an increase in density of breasts, although medical research is not conclusive about breast cancer risk in women with naturally higher estrogen levels.

Established risk factors for breast cancer include those above, as well as being female (women have breast cancer 100 times more frequently than men), being white in the US (although research hasn’t teased out how much of this is genetic as opposed to due to lifestyle factors and access to health care), and obesity in postmenopausal women. Premenopausal women who are obese (BMI>30 kg/m2) have been found to have a lower risk of breast cancer, the explanation of which remains unclear to researchers. Being taller has been found to be associated with a higher risk of breast cancer.

Having an early menarche (start of periods) or a late menopause has been related to higher risk of breast cancer, as has never having children. These are all related to having more menstrual cycles over a lifetime. Having your first baby when older than 30 increases risk; this is said to be due to the proliferative stimulation place on the breast cells that are fully developed and possibly more prone to damage than a younger women’s breast cells. The news has recently been trumpeting that taller women have a higher risk of breast and other cancers. There are theories involving various growth factors of why this is so, but time will tell if this association noted in data from the Women’s Health Initiative in the 1990s is confirmed.

Lifestyle factors are associated with an increased risk of breast cancer and other disease. Alcohol consumption, starting with amounts as low as three to six drinks per week, has been shown to increase breast cancer risk. Night shift work has been shown to be a probable risk factor for cancer. Some studies have shown smoking is a risk factor, especially in younger women and long-term smokers.

What’s the good news in all of this? Well, physical activity has been shown to lower risk. A healthy lifestyle of nutritious food, minimal alcohol, regular exercise can lower risk. There are no guarantees in life, but living as well as we can, physically and mentally, means our quality of life today is the best we can make it.

What is Menopause?

What is menopause? Many women are unaware there is an agreed-upon definition, set by the STRAW and STRAW+10, the Stages of Reproductive Aging Workshop in 2001 and STRAW+10: Addressing the Unfinished Agenda of Staging Reproductive Aging in 2011, respectively. This was done to standardize research and discussions about women’s health, so that everyone was on the same page as to what stage they were discussing. Menopause, by definition, occurs once a woman has gone 12 months without a period, after which she is considered postmenopausal. Being a retrospective definition, though, presents problems as women don’t know which menstrual period is their last at the time. Perimenopause and/or the Menopausal Transition are defined as beginning with changing cycles of variable length; there is no concrete marker, as FSH may be raised but is often variable up until 3 or more years after the final menstrual period. Contrary to popular belief, estrogen levels in perimenopause may be higher instead of lower, and are often chaotically up and down. Progesterone levels go down. The FSH level being variable makes it an unreliable marker of menopause. Vasomotor symptoms, hot flashes and night sweats, are most likely to be problematic in the one to three years prior to the final menstrual period (FMP) until two years after. The work of defining the stages of reproduction in women is ongoing, as the 2011 meeting identified seven areas of research priorities.

In a nutshell, the answer to the question is that there is no actual point in time that is menopause. A woman is premenopausal throughout her reproductive years until her periods start to change in frequency or amount of bleeding, at which time she becomes perimenopausal. Perimenopause lasts until a year after the final menstrual period (FMP), when a woman is regarded as postmenopausal. Many changes occur to us over this time, and they affect all the systems of the body. This is menopause.

Mayo Clinic Controversies in Women’s Health, June 2013

A third of this conference involved menopause issues; appropriate, as women spend one-third of their lives in menopause. Except for Dr. Sanjay Asthana of the University of Wisconsin, all of the presenting doctors noted below were from the Mayo Clinic.

Dr. Lynne Schuster is a specialist in internal medicine; she is in charge of the Women’s Health Clinic at the Mayo Clinic. Her talk was on the effects of hormones on moods. Women have a 21% lifetime risk of developing depression, with the highest risk in perimenopause. Women are at higher risk of depression if they previously experienced post-partum depression or PMDD (premenstrual dysphoric disorder, a severe variant of PMS). This risk is affected by genetic factors, psychological factors, social factors, physical health and one’s environment; absolute levels of estrogen and progesterone have not been linked to depression. There are many difficulties in assessing associations between hormones and mental health. These include the wide fluctuations of hormone levels that affect women daily, appreciating the time lag between hormonal changes and mood symptoms, and inaccuracies in the scales used to assess moods, and in using the menstrual cycle the indicator of hormone levels. Checking hormone levels is not helpful in determining if hormones are the cause of mood problems. It is known that estrogen acts as a neuromodulator and it shares common pathways with neurotransmitters in the brain. Research has shown that estrogen increases norepinephrine and serotonin levels, serotonin receptor activity, and endorphin levels, among other actions. All of these chemicals affect our moods. Women are at greater risk of depression than men from decreased serotonin levels. Thus while hormones affect mood, mood disorders are not due to a deficiency of hormones. Lifestyle changes with healthy diet, increased exercise and social engagement are the most important ways of treating perimenopausal depression.

Drs. Walter Rocca and Sanjay Asthana spoke on the effects of estrogen on cognition. Summarizing all of the research in the past decade on this topic has led to “The timing hypothesis for dementia”. In summary, this hypothesis states that estrogen may be strongly protective before the age of natural menopause around 50 yr; moderately protective in early postmenopause (age 50 to 59 yr); and deleterious if started in later post-menopause (over the age of 60 yr).

Dr Virginia Miller spoke about the KEEPS study. KEEPS stands for Kronos Early Estrogen Prevention Study. This study randomized 727 women to low dose estrogen, either 0.45 mg oral conjugated equine estrogen or 0.5 mcg transdermal estradiol patch, plus cyclic micronized progesterone for 12 days per month or placebo instead of any hormone. The average age of women in the KEEPS study was 52.7 yrs, and all the women were within 6 to 36 months of their final menstrual period. The initial results came out in 2012, and showed an overall favorable benefit-to-risk ratio of the hormone therapy. Positive effects were seen on bone, VMS and sexual function, while there were neutral effects on cardiovascular disease, stroke and blood clots.

Dr. Sharon Mulvagh spoke about prevention of cardiovascular disease in women. Six to ten times more women die of heart disease than breast cancer; one in three women’s deaths in the US are caused by heart disease. She reviewed the estrogen effects on the blood vessels, most of which are protective pre-menopausally. Women with chronic persistent angina who do not have obstructive coronary artery disease have a worse prognosis than women with no angina. More women die following CABG (coronary bypass) than men. A large number of women have microvascular coronary disease (MCD), which is also called female-pattern ischemic heart disease. The good news is that more than 80% of heart attacks can be prevented with lifestyle changes. Every woman should know her body mass index, waist circumference, blood pressure, fasting glucose and cholesterol. The recommendations were mindful eating with heart-healthy food choices and regular activity of 30 to 60 minutes increased heart rate daily with weight training twice a week.

Dr. Richard Sood reviewed the controversies in menopausal hormone therapy. He reviewed recommendations for HT before the WHI, when it was offered to women between ages 40 and 60, and was sometimes prescribed for prevention of CVD and osteoporosis as well as to treat menopausal symptoms. He spoke to the controversies of the WHI including overgeneralization of results and the use of relative risks instead of absolute risks to provide risk estimates. Now, 11 years after the WHI, HT is not controversial for use in a healthy, young menopausal woman (

Physiatrist Dr. Edward Laskowski presented on exercise in older adults. Muscle mass declines 30% between ages 30 and 70. Basal metabolic rate declines 2 to 5 % per decade after 30. Lean muscle decreases and body fat increases to result in a gain of 10 lbs fat per decade. There is a decrease in elasticity and compliance of connective tissue with age. Regular exercise can mitigate these changes. Weak muscles contribute to falls and trouble with stairs and walking. Exercise decreases blood pressure and insulin resistance, helps prevent osteoporosis, decreases pain in osteoarthritis, has beneficial effects on mood, depression and anxiety, and helps to maintain cognitive status. Recommended to get at least 150 minutes of moderate cardiovascular exercise per week along with 2 strength training sessions and regular stretching to maintain flexibility.

Dr. Donald Hensrud spoke on the optimal diet for weight management. He stated there is no one best diet for weight loss and that diet recommendations should be individualized. Writing down everything we eat is helpful, as we tend to underestimate our caloric intake. To lose one pound in a week requires a calorie deficit of 500 Cal per day. Very low calorie diets work, but people regain the weight once they eat normally again. The Nurses Health Study found that women with the largest increase in intake of fruits and vegetables had a 24% decreased risk of becoming obese. We should emphasize eating healthy foods. Several of the many available diet programs available by book, club or online apps were reviewed. The importance of eating breakfast was noted, as were the facts eating one meal per day lowers metabolic rate and that it is best to eat small frequent meals throughout the day. The Mayo Clinic Diet was highly recommended (Dr. Hensrud is the medical editor-in-chief of the book). Further information on this may be found at www.mayoclinic.com .

SIGMA Canadian Menopause Society 1st Annual Conference, May 2013

This conference was the first one held by SIGMA (Special Interest Group in Menopause and Aging) Canadian Menopause Society. Many renowned experts from NAMS (North American Menopause Society), IMS (International Menopause Society) and Canada spoke on a variety of topics. Summaries of several of these talks follow.

Osteoporosis as a topic is always included in menopause conferences as women experience a period of rapid decrease in their bone mineral density at the time of the menopause transition. Osteoporosis is one of the major risk factors of sustaining a bone fracture. Fractures are often regarded in the categories of vertebral and non-vertebral fractures; studies of treatments look at the incidence of both categories of fractures.

Talks about osteoporosis were by Dr.John Stevenson of London, UK, Dr. Robert Josse of the University of Toronto, and David Kendler of the University of British Columbia. Drs. Stevenson and Josse reviewed current treatments and prevention of osteoporosis. After discussing the use of bisphosphonates (alendronate, risedronate, zoledronic acid), calcitonin, raloxifene, tibolone, teriperitide, denosumab, Dr. Stevenson concluded that for most women, excluding the elderly with severe osteoporosis, hormone therapy appears to be the best management. He also felt that hormone therapy should be the first choice for prevention of osteoporosis in women without contraindications. Hormone therapy has been shown to increase bone mass, decrease bone turnover and decrease the incidence of osteoporotic fractures. Dr. Stevenson also noted that the bisphosphonates appear no safer than hormones in terms of unwanted effects, and other unexpected adverse effects could still arise in future. Dr. Josse reviewed existing treatments and new agents being developed. Dr. Kendler spoke on the importance of prevention of the first fracture; a woman is at increased risk of more fractures once she has had one.

Dr. Cynthia Stuenkel of the University of California at San Diego reviewed women’s risk factors for cardiovascular disease (see Heart Disease unders Topics of Interest). She discussed a few new trends emerging from current research. Women who experience a preterm birth, deliver a SGA (small for gestational age) baby or preeclampsia have been shown to have endothelial (lining of blood vessels) dysfunction, which is likely related to cardiovascular disease. Dr. Stuenkel also quoted studies that have suggested increased cardiovascular risk in women with early menopause, excessive stress and PCOS. Her discussion of risk management emphasized the need for women to make lifestyle changes at all risk levels. These lifestyle changes include, but are not limited to, stopping smoking, eating a heart-healthy diet, managing weight, and regular physical activity.

Many women will not have heard of the “Window of Opportunity” as it pertains to hormone therapy. Research on perimenopausal and early postmenopausal women have shown that those on hormones often are at lower risk of heart disease. Dr. Stevenson discussed this in detail, quoting many studies that appear to support the idea, including one from Denmark that followed 1008 women for 16 years. The women in this study were randomized to start either hormones or a placebo within a year of their last menstrual period, and continue the treatment for 10 years. The women on hormones had decreased numbers with coronary heart disease with no increase in stroke, blood clots or breast cancer. He noted that although hormone therapy may be beneficial for prevention of heart disease, this is not yet an indication for women to take it.

Dr. Robert Reid of Queens University discussed Breast Cancer and hormone therapy, how to interpret the risk. He described in some detail the breast cancer awareness pink ribbon campaigns, and noted “the #3 killer of women raised 15 times more money for research that the #1 killer.” He attempted to put into perspective the media preoccupation with purported risks of breast cancer of menopausal hormone therapy compared to the risks of other significant diseases that affect mid-life and older women, and further noted the risks of overdiagnosis and treatment of DCIS (ductal carcinoma in situ).

Dr. Claudio Soares is a psychiatrist and professor at McMaster University. He presented a talk on Depression and the Mature Woman. While noting that depression in mid-life is complex and influenced by many factors, research in neurochemistry has shown, simply put, that decreased estrogen levels lead to decreased serotonin levels in the brain. Most women will transition into their postmenopausal years with no psychiatric or psychological difficulties, but there are some who have an increased risk of recurrent depression. Women who have experienced previous post-partum depression, severe PMS, and prior trauma and/or abuse are all at higher risk of depression in menopause. The presence of hot flashes and night sweats have been associated with increased occurrence of depression, but this may be due to or worsened by the related sleep disturbances and life stressors, as well as concurrent medical conditions. Many women experience increased anxiety in the menopause transition. In research on this, anxiety was found to peak in perimenopause, with symptoms declining afterwards.

Dr. Jan Shifren of Harvard University spoke about sexuality in mid-life and the continued controversy about testosterone therapy. It is estimated that 40% of women in the US suffer from low libido (called hypoactive sexual desire disorder, or HSDD, in medical circles). The possible causes of this in mid-life women are innumerable, and may include depression or anxiety, relationship problems, illness or medications, stress, fatigue, among others. Treatment is complex, but obviously must deal with identifiable problems. Many women and couples may benefit from consultations with a sex therapist. There are no approved testosterone products available for women in Canada or the US. There was a testosterone patch available in Europe, but it is no longer available. If a woman chooses to try a compounded product or one formulated for men, blood levels should be monitored, as should lipid levels and liver function. Results from studies of the effects of testosterone therapy on women’s sexual desire, activity and pleasure have not consistently shown benefit.

Hormone Therapy – The Women’s Health Initiative

The Women’s Health Initiative

It has now been 11 years since the first publications came out using data from the Women’s Health Initiative (WHI). For anyone who may not have heard of the WHI, it was the largest trial to date on the use of hormone therapy in menopausal woman. It was designed and overseen by the National Institutes of Health in the US. The WHI was, in particular, designed to assess the risks and benefits of hormone therapy on prevention of chronic diseases such as heart disease, breast and colorectal cancer, and fractures in postmenopausal women. In the original publication of the initial results in the Journal of the American Medical Association, the authors state: “This trial did not address the short-term risks and benefits of hormones given for the treatment of menopausal symptoms.” In the study of combined estrogen plus progestin, 16 608 women between the ages of 50 and 79 years were recruited, mean age 63, and started on hormones or placebo. They stopped this trial after an average of 5.2 years. In real terms, the findings at that point showed increases over the placebo group of 7 more heart attacks per 10 000 women, 8 cases of breast cancer per 10 000 women, 8 more strokes per 10 000 women and 18 cases of blood clots; there were 6 fewer cases per 10 000 of colorectal cancer, 44 fewer fractures of all kinds per 10 000 women, and 5 fewer hip fractures per 10 000.

The WHI study of estrogen therapy only in postmenopausal women who have had hysterectomies was stopped in 2004 after 6.8 years. This study included 10739 women between the ages of 50 and 79 who were randomized to treatment with estrogen alone or placebo. The findings differed from the previous study, and showed 5 per 10 000 fewer cases of CHD, 12 per 10 000 more strokes, 7 per 10 000 more episodes of blood clots, 7 per 10 000 fewer cases of breast cancer, 6 per 10 000 fewer each of hip and vertebral fractures; no difference was seen for colorectal cancer.

The media had a field day publishing articles on the first study BEFORE it was peer-reviewed and analyzed in any further detail. Of course, all of the articles published reported the above results as relative risks, which are percentages. For example, this changes the attributable risk of breast cancer of 0.08% per year in these results to an increase in relative risk of 26% (38/30). The World Health Organization considers 0.08% as a low, if not very low, risk. 26% is downright scary.

Not understanding statistics makes interpretation of scientific study results all the more scary. I have attended talks where I have heard said there is a lack of statistical literacy in society. Very few people have a chance to take a course in statistics, much less need to use it daily. However, it is good to have a general understanding. For some simple explanations, please see “Statistics for the rest of us” in the general blogs.

The huge database generated by the WHI, which included the study discussed above, and studies on estrogen use alone, in postmenopause, low-fat dietary patterns and calcium and vitamin D supplementation, has been subjected to extensive analysis over the past decade, providing much useful information to research on menopause and disease.

Reassessment of the risk data after stratifying it by age helped to show less risk of heart disease in the 50 to 59 age group, with increased risk in the 60 to 69 and 70 to 79 age groups. It is now not recommended to start hormone therapy in a woman over 60, as it may increase her heart attack risk. Several more recent studies have shown that use of hormone therapy around the time of the menopause transition in a woman’s 50s is likely to be protective against heart disease. This phenomenon is discussed in other sections as the “timing hypothesis” or “critical window”, as well as other monikers. Although this is not yet considered a reason to prescribe HT, some experts feel that recommendation may yet happen.

Analyses of data from numerous studies have found that a woman’s risk of breast cancer does not increase with the use of less than five years of hormone therapy. In estrogen and progesterone-receptor positive tumors, hormones are considered to be promoters and not initiators of tumor growth. This means they may stimulate an existing tumor to grow, but they are not responsible for it starting in the first place. The recommendations for HT use today are similar to what we knew in the 1990s, with a small increase in risk of breast cancer for longer use of HT. I have heard it said that a tumor often starts up to six years prior to its detection, although this would obviously be affected by numerous factors.

Thus, the WHI led to a media storm that led to many women discontinuing hormone therapy on the basis of incomplete information. In medicine and science, information is never “complete”, as we are learning and discovering new things all the time. It’s time for the media to reassure women that we know differently now.

Hormone Therapy – Where are we now?

Statement of Agreement of Hormone Therapy Use, 2012

A joint statement on hormone therapy use prepared by the North American Menopause Society (NAMS), the American Society for Reproductive Medicine (ASRM) and The Endocrine Society was published in July 2012. The statement has been endorsed by 12 other leading organizations in women’s health. The major points of agreement were:

Hormone therapy is an acceptable option for the relatively young (up to age 59 or within ten years of menopause) and healthy women who are troubled by moderate to severe menopausal symptoms. Decisions to be made on individual basis.
If women are experiencing vaginal dryness or discomfort with intercourse, the preferred treatments are low dose vaginal estrogen.
Women who still have a uterus need to take a progestogen (progesterone or synthetic) along with estrogen to prevent cancer of the uterus. Women who have had their uterus removed can take estrogen alone.
Both estrogen therapy and estrogen plus progestogen therapy increase the risk of blood clots in the legs and lungs, similar to birth control pills, patches and rings. Although the risks of blood clots and stroke increase with either type of hormone therapy, the risk is rare in women ages 50 to 59.
There is an increased risk in breast cancer seen with 5 or more years of continuous estrogen with progestogen therapy, possibly earlier. The risk decreases after hormone therapy is discontinued.

It has been recommended that women work with their health care providers to assess their personal risks and benefits. It is recommended that the lowest dose of estrogen that provides symptoms relief be used, and for the shortest duration needed.

The 2012 Hormone Therapy Position Statement of the North American Menopause Society

In addition to the above, NAMS published their most recent position Statement on Hormone Therapy in March, 2012. Their conclusions and recommendations:

The decision to use HT should be made individually for each woman based on her health, her quality of life priorities and her personal risk factors for diseases.
The duration of therapy is different for HT and ET. HT use should be limited to 3 to 5 years due to increasing risk of breast cancer with longer use. ET has been shown to have a favorable risk-benefit profile up to 7 years of use and 4 years follow-up.
ET is the most effective treatment of symptoms of vulvar and vaginal atrophy. Low-dose, local vaginal ET is recommended when only vaginal symptoms are present.
Women with premature or early menopause, who are otherwise appropriate candidates for HT can use HT at least until the median age of natural menopause (51 years). They may use HT longer if needed for symptom management.
Although ET did not increase breast cancer risk in the WHI, there is a lack of safety data supporting the use of ET in breast cancer survivors; one RCT reported a higher increase in breast cancer recurrence rates.
Both transdermal and low-dose oral estrogen have been associated with lower risks of VTE and stroke than standard doses of oral estrogen (RCT evidence not yet available at publication time).