For Anita MacDonald, turning 50 marked the beginning of menopause and a range of related symptoms. “The worst part was the night sweats – waking up totally drenched and having that fire burning from your chest up to your face – as well as the moodiness,” she said.
Even more pressing for her, though, was her mother’s diagnosis that same year with ovarian cancer – and the concern that her mother’s many years of menopause hormone therapy (MHT) to treat menopausal symptoms might have been to blame.
“I suffered with my symptoms because I didn’t want to take that chance,” MacDonald, now 58, said. “She had been on hormone replacement for more than 30 years, so that was a scary thing.”
Chilling effect of a widely reported study
MacDonald, like countless other women, was wary of hormone supplementation because of the widely reported results of the Women’s Health Initiative, a long-term study that concluded in 2002 that the risks of MHT, including a higher likelihood of cancer in some scenarios, largely outweighed the benefits.
Up until then, hormonal therapy had been widely used due its effectiveness in helping alleviate the numerous and often debilitating symptoms associated with perimenopause (the years leading up to menopause) and menopause (defined as taking place 12 months after a woman has her last period). After the study’s publication, however, MHT prescriptions dropped dramatically.
In the more than two decades since, there’s been widespread acknowledgment that the original study was flawed for numerous reasons, and that newer formulations of MHT, including lower-dose versions, are still indicated in many cases. However, countless women have remained wary of hormone supplementation and instead opted for alternative treatments or simply resigned themselves to living with their symptoms, which include hot flashes, mood changes, disrupted sleep and vaginal dryness. These symptoms may start during perimenopause and continue several years after menopause, with hot flashes often persisting the longest.
Years-long search for effective treatment
Because of MacDonald’s reticence about hormone therapy, she sought out homeopathic options. “They’d work for a short time,” she said, “and then I’d try something else.” These supplements helped with her mood but had little to no effect on her ongoing hot flashes and night sweats.
Eventually, after reading some of the newer studies that largely refuted the earlier information about the cancer risks of MHT, particularly for someone in their fifties, MacDonald started taking a low dose of hormone supplementation, overseen by her then-gynecologist.
By now it was 2024, seven years into her search for relief.
“I’ve gone to various gynecologists, but they kind of all would say ‘try this,’ and if you don’t want (hormones), there was no other recourse,” she said.
By chance, just a couple of months after starting MHT, MacDonald received the UCLA Health “Healthy Living” email with a link to an article about the Comprehensive Menopause Care program. She immediately called to make an appointment.
“I was really excited about having a group that was actually talking about menopause and treating all of the symptoms – and your whole body – at this stage in your life,” she said.
MacDonald’s first visit was in July, when she met with Rajita Patil, MD, director of the Comprehensive Menopause Care program and assistant clinical professor of obstetrics and gynecology at the David Geffen School of Medicine at UCLA.
Dr. Patil asked questions “about everything,” MacDonald said, “not just hormonal things and MHT. She asked about my sleep, my bones, my cholesterol. She looked at everything, and that was so eye-opening. I’d never had a doctor do that before – not even my general doctor.”
MacDonald’s case was “very typical” of the patients seen by the Comprehensive Menopause Care Program, Dr. Patil said.
“Patients come in and they’re pretty miserable because they have a lot of different symptoms,” she said. “In her case, hormones were just one part of it – she needed a multidisciplinary approach to managing her symptoms, because just slapping on hormones doesn’t fix everything.”
After meeting with Dr. Patil, MacDonald was referred to a number of specialists, including a cardiologist, given that she had an elevated level of lipoprotein A (which can be a risk factor for cardiac disease), a sleep specialist to see if she had an underlying sleep disorder, given that she didn’t feel rested, and a bone endocrinologist, given her low-bone-density test.
A core team, backed by a network of specialists
The Comprehensive Menopause Care program, created by Dr. Patil, also includes co-directors Brittany Davis, MD, and Erica Oberman, MD, along with three other core physicians. All six have completed additional specialized menopause education and are certified by The Menopause Society.
Prior to being seen by one of the six core providers, patients complete an extensive online questionnaire that feeds into organ-specific menopause care algorithms developed for the program with the input of more than 30 collaborating UCLA specialists, Dr. Patil said.
“It covers most organ systems affected by menopause, taking a whole-person and whole-body approach,” she said. At the same time, the approach is tailored specifically for each individual, taking into account their health factors, symptoms, preferences and values for care and treatment.
“There are estrogen receptors throughout the body, so when hormone levels change, first fluctuating in perimenopause and then leaving the body in menopause, it very much affects all of the organ systems,” Dr. Patil explained. “For each person, the effect is very different from both a short-term and a long-term perspective.”
Based on the questionnaire responses and any additional electronic medical data, such as prior cholesterol readings, blood pressure results or bone scans, the menopause care algorithms have been designed to flag areas that need attention. With sleep, for example, a patient who reports sleep disturbances will be prompted to answer further questions about their level of disturbance, sleep habits and general sleep hygiene and may be referred to a sleep specialist to be evaluated for a potential sleep disorder.
Dr. Patil thinks of the core menopause provider team as the hub and the various specialists as the “spokes:” These include specific providers in women’s cardiology, bone health, cancer survivorship, neurology, neuropsychology, mental health, integrative medicine, gastroenterology, urogynecology, sexual health and sleep medicine.
“We very specifically chose people who wanted to improve the care provided to patients in menopause,” Dr. Patil said. “And as we’ve done that, we’ve expanded our network, because more and more providers are seeing the value added and want to be part of it.”
Having providers understand the many ways that various symptoms and conditions can be related to menopause is critical to be able to treat them effectively, she noted. If providers don’t understand that symptoms are menopause-related, they can end up going down different “rabbit holes” and treating each symptom separately without recognizing that they’re all connected to menopause.
Referrals, refinement and ongoing monitoring
In MacDonald’s case, “the cardiologist felt comfortable with her being on hormones,” Dr. Patil said. “They did a calcium artery score just to make sure that she doesn’t have existing cardiac disease.”
Her bone scan revealed that she had osteopenia (a precursor to osteoporosis), Dr. Patil said. Although MHT is a protective factor against bone loss, her bone density will continue to be monitored.
“People can lose up to 15% of their bone density in the first five years of menopause,” Dr. Patil explained. “We spend a lot of time talking about weight-bearing resistance training, and we also talk to them about vitamin D and calcium supplements. And we try to get bone scans on every single person because we know this is a timeframe when they’re at risk for a lot of bone loss. If we wait until they’re 65, there’s no prevention that can be done.”
Hot flashes and bone density loss made MacDonald a good candidate for MHT, Dr. Patil said. After conferring with MacDonald, Dr. Patil gradually increased her dosage to boost its effectiveness. “After she bumped it up, I noticed a difference,” MacDonald said. “I felt like I was able to sleep better, my night sweats were subsiding, and my mood was very much improved.”
Despite the sleep improvement, Dr. Patil still wanted to ensure there weren’t other contributing factors. MacDonald recently underwent an overnight sleep study and is awaiting the results.
MacDonald will continue to be seen yearly, Dr. Patil said. “We don’t just start hormones and then say, ‘All right – see you later.’ You really have to follow up at regular intervals, even when patients are on a steady state and everything’s going great. Their health might change; their symptoms might change.”
The average person is on hormones for three to five years, Dr. Patil noted, but ongoing monitoring is essential in determining when to taper off and when to consider alternate approaches.
Understanding the risks and options
In addition to being beneficial for maintaining bone density, MHT’s role in reducing hot flashes has important health implications, Dr. Patil said. “A hot flash is not just a hot flash – it’s an inflammatory process that’s happening in the body. We take those seriously. We know they’ don’t feel good in the short term, but they’re not good in the long term either.”
She noted that there’s a direct correlation between both the number and severity of hot flashes someone has and their later risk for cardiac disease, bone disease and brain disease, as well as mood and sleep disorders.
Because of these risks, there’s now much more awareness that the benefits of MHT generally outweigh the potential harms for symptomatic patients who don’t have any contraindications to using hormones. Even so, she noted, the discussion with patients is more nuanced than simply whether or not to take hormones. Other options include cognitive behavioral therapy or non-hormonal medications such as fezolinetant, which was approved by the U.S. Food and Drug Administration in 2023. Moreover, given that about 10% of women will have hot flashes for the rest of their lives, shifting to non-hormonal options as they age can be an important way to manage health risks, Dr. Patil said.
The potential risks of MHT vary based on a woman’s age when she starts, as well as pre-existing health conditions and risks for certain conditions like breast cancer or heart disease. Even so, the risks are low, which is much easier to convey when discussing risk in terms of absolute numbers rather than percentages, she noted. For example, the increased risk of a getting a blood clot is less than one in a thousand, which is considered rare.
A growing demand
The bottom line, and the cornerstone of the program’s approach, is to address the whole person. This involves identifying menopause symptoms and understanding how declining estrogen affects the person’s body systems. It also includes evaluating various treatment options within the context of other health factors and implementing prevention measures for the various organ systems. This comprehensive and individualized approach is crucial for effectively caring for menopausal patients, Dr. Patil said.
It’s an approach that fills a previously unmet need, she added. The Comprehensive Menopause Care program treated 730 patients during its first year and is currently on track to double that number this year.
“The demand is definitely rising as we’ve gotten our name out there,” she said. “Demand is also rising because public awareness (of menopause) is rising, which it should be.”
