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Breaking Down Hormone Therapy: A Menopausal Roadmap

Breaking Down Hormone Therapy: A Menopausal Roadmap

I delve into the crucial topic of menopause and hormone therapy. With an estimated 2 billion women entering post-menopause by 2030, the impact of menopause cannot be overlooked. 

I explore the criteria for determining good and bad candidates for hormone therapy, the reasons behind prescribing hormone therapy, and the various formulations I favor. 

Drawing from the 2022 Hormone Therapy position statement by the now Menopause Society, I present compelling insights backed by extensive research, including the Women’s Health Initiative and post hoc analysis. 

I emphasize that hormone therapy remains the most effective treatment for vasomotor symptoms, such as hot flashes and night sweats, along with managing the genital urinary syndrome of menopause and preventing bone loss and fracture.

Prepare to gain valuable knowledge on this fundamental aspect of women’s health in today’s episode.


-Good and Bad Candidates for Hormone Therapy: insights into the factors that determine whether an individual is a suitable candidate for hormone therapy, as well as those who may not be.

– It’s not just a one-size-fits-all. Different hormone therapy formulations that I tend to use. Understanding these options empowers women to make informed choices about their health. Knowledge is power, especially when it comes to our bodies. 

-The Purpose of Prescribing Hormone Therapy: the rationale behind prescribing hormone therapy, emphasizing its effectiveness in addressing vasomotor symptoms such as hot flashes and night sweats, as well as its positive impact on preventing bone loss and fractures.

-Different Formulations: The discussion also included an overview of the various formulations of hormone therapy used, shedding light on the diverse options available.


Menopause Society

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00:01 - Speaker 1

Hey y'all, it's me, dr Smeena Rahman, guineal Girl, so excited to bring you another episode of Guineal Girl Presents Sex, drugs and Hormones. We're going to talk about hormones today just me over viewing how I treat my patients in my office for hormone therapy and it's going to be just some basic overview, because we're going to delve deep into hormone therapy and menopause and all the good stuff when I have other of my colleagues and experts in the field come and talk to you guys. But today, essentially, I'm going to go over some basics and I'm going to have a separate podcast altogether when I talk about the actual women's health initiative, because it's important to understand what that study was and how it impacted our use of hormone therapy.


If you were with us on a previous episode where I had Heather Zimmerman, who is an actual patient of mine who has gone through the menopause journey, she's a fierce advocate for menopause treatment for women in the midlife and she discussed a couple of things that I wanted to get into and I'll be discussing in my overview today. One of the things she mentioned was the difficulty in finding somebody that can help her with hormone therapy, and we talked about how a recent study demonstrated that OBGYNs in their residency which is obviously a women's health specialty only about 30% of the residents had some training in menopause. Over 90% was in lecture form and the majority of the residents graduated from residency without even seeing a menopausal patient. So we know that we have work to do from an educational standpoint with clinicians, because it's even worse in other specialties, but there's also you know that's one of the biggest hindrances for patients to get the care they need. The other hindrance has to do with the women's health initiative. Again, I'm going to talk about this study, but it is one of the largest studies that has ever played out for women's health and basically looking at how hormone therapy if it was, how it impacted prevention of. Again, it was one of the biggest studies that has ever been done on women's health in general. It started in the 90s, in 1991. It was a long-term national health study focused on looking at strategies for preventing heart disease, breast cancer, colorectal cancer and colorectal cancer in osteoporosis in postmenopausal women. It was a study that looked at menopause, hormone therapy and its effectiveness. It enrolled more than 160,000 patients between the ages of 50 and 79, and it stopped abruptly on July 2, 2002, when there was some concern about breast cancer rates increasing in the patients that had been given estrogen and progesterone.


They use premarin and premperol. Estrogen is a synthetic estrogen that is, a conjugated equine estrogen which is essentially from a pregnant mare's urine. It's different forms of estrogen conjugated together in the form of a pill. It's just not estradiol, which is your bioidentical hormone that is similar to what we make in our ovaries. Additionally, it was used as a synthetic progesterone for those patients who had a uterus medroxy progesterone acetate. The pill that they took was premperol, so it stopped abruptly because of some concerns around breast cancer, which didn't really play out. In the end it wasn't as big of an issue as was previously thought. We're going to get into that specifically when I do a podcast about the women's health initiative.


Let's just step back for a second. Let's redefine menopause. Menopause is a clinical diagnosis where you have 12 months without a men's disease, so it's retrospective. You have your final menstrual period In the years leading up to menopause your 30s and 40s your estrogen levels will fluctuate and sometimes in perimenopause, which is a period of time leading up to menopause, you get grand fluctuations of your hormones with real high rises and real high lows, and those are the symptoms that seem to be the worst for patients. I tell my patients often that estrogen receptors are located everywhere in your body, pretty much from head to toe. So menopause symptoms can range. We can hit headaches and hot flashes and night sweats. Those are the vasomotor symptoms from the estrogen receptors in our brain.


Our hair can become thinner, it can lose luster, we can get looser teeth and gums recede. Our skin becomes drier, it becomes rough inner and texture and when we lose that collagen that estrogen helps us with, we become more wrinkled. The breasts can droop and flatten. Your risk of cardiovascular disease goes up. Then, because of the protective effect of estrogen on cholesterol and your muscles, your nipples can become smaller and flatter. You can get more backaches. You get five to seven pounds of weight gain potentially, and that's that visceral fat in the midsection. You lose muscle tone. You can have thicker body hair or pubic hair. You can get joint pain. You can get weakened bones.


You have the genital urinary syndrome, menopause, which encompasses symptoms such as vaginal dryness, itching, thinning of the vagina, painful sex, urinary frequency, urinary urgency, recurrent UTIs. So pretty much, if you think about it, it may be related to menopause and perimenopause. People develop anxiety out of the blue when they hit midlife. Many times that's related to the hormonal fluctuations, and so what we have here is multitude of symptoms that can really detrimentally impact your quality of life.


It's said that by 2030, 1.2 billion women will be in postmenopausal, so it's really important to recognize the burden that menopause can have on patients, and so what I'm going to review today in my discussion is really who are good candidates for hormone therapy, who are bad candidates for hormone therapy, why we prescribe hormone therapy and the different formulations that I tend to use, and so this is really a basics overview and it kind of reviews sort of the position statement I talked about, the 2022 hormone therapy position statement by the North American Menopause Society, which is now the Menopause Society. The synopsis of the statement and what holds true is that hormone therapy and this is based on not only the women's health initiative, the post-hack analysis and all the subsequent data from the last 20 years because, again, the study started in 91. We still have some post-hack analysis going on and it's a very large study, so and then other prospective clinical trials and studies that have been done on, you know, transdermal estrogen and other types of estrogen and progesterone. So the one thing I'm going to say is one of the biggest statements that they make is that hormone therapy still remains the most effective treatment for those vasomotor symptoms and that is what we're talking about Hot flashes, the ones that you hear about, where you get a flush of heat in your face, in your chest.


You might have those night sweats at night that preclude you from sleeping. So that's you know, tossing and turning because you're drenched in sweat. It also is the most effective treatment for the genitourinary syndrome and menopause, which I would briefly discussed, and it has been shown to help the most in preventing bone loss and fracture. And that is important because people don't get symptoms from bone loss typically, but it does put them at risk for more fractures. And what happens to an 80-year-old female who falls down and breaks her hip? It is many times the start of her demise because subsequent things and medical conditions happen and they can really suffer. So that is important to recognize. So there are really these top reasons that we use hormone therapy in this population and, again, that is for the treatment of hot flashes and night sweats, which are the vasomotor symptoms that we're discussing. Right, it is for the prevention of bone loss. So, really, those patients who get a DEXA score and that is, your bone density score of minus one to minus 2.4, which is osteopenia, which is a weakened bone structure, and so those patients will benefit from hormone therapy because it will help prevent further bone loss and, hopefully, fractures and early death.


Premature hypostrogenism is essentially when you get either surgically induced menopause before, maybe 10 to 15 years before you're supposed to have natural menopause so those patients really do need hormone therapy or patients that have primary ovarian insufficiency, which is where you might go into premature, or basically you're going into early menopause before the age of 40. And so you need that medication to help prevent further bone loss, to prevent heart disease and hopefully prevent cognitive decline and dementia. Again, we have estrogen receptors in our brain which can affect us pretty. It helps to regulate a lot of neurotransmitters, and so we do end up with patients that have that brain fog, anxiety, depression and cognitive decline after they lose estrogen from menopause. Menopause, I like to say, is when your ovaries decide to retire. Your ovaries are responsible for making those hormones, the estrogen, the progesterone, as well as 50% of your testosterone. So you lose all of that when you enter menopause.


The next important reason to take hormone therapy is really genital urinary syndrome, menopause that we talked about, previously known as Volvo vaginal atrophy, and it is really the FDA has approved it to treat these problems for women the vaginal dryness, the sexual pain, the urinary symptoms such as urgency frequency or current uterus. And remember, recurrent uti is. If you get them later in life and you're 70 or 80 years old getting recurrent uti's, you can end up with your osepsis and actually that can also lead to your demise. So that is not something that we like to mess with. So that is in the form. Sometimes systemically it helps, but most people still need that topical vaginal estrogen or vaginal DHEA, which I will discuss in a separate segment.


Okay, so those are the reasons we give it to patients who are the patients that cannot take hormone therapy. That is a hard stop that we should not allow these patients or we should not promote hormone therapy in this population. And these are the patients that specifically have active breast cancer, particularly the ones that are estrogen and progesterone receptor positive. So this active breast cancer can lead to worsening symptoms and recurrences if you take hormone therapy. The other type of patient that has active heart disease has had a myocardial infarction or a heart attack or a stroke. Those are patients that we should steer clear from as well.


Patients that have had an unprovoked deep venous thrombosis or pulmonary embolus. That is thromboembolic disease. That is, blood clots that cause swelling in your calves, and that blood clot can go to your lungs and cause a pulmonary embolus, which can also lead to early death. So these are things. If someone has an unprovoked blood clot, that means that maybe they have a familial disposition to hypercoagulability, so this means that they are at risk for getting blood clots. For that reason, they should not receive hormone therapy. Then there are patients that have active liver disease and it's really end stage liver disease, or cirrhosis is what we're referring to. And finally, if you had abnormal bleeding that has not been evaluated heavy flow or postmenopausal bleeding we should really evaluate that prior to getting on any kind of hormone therapy systemically.


That is really important, and so I want to reiterate something I had told my previous patient, heather Zimmerman, that was on the show that when we do menopausal medicine, we're really practicing more of what I say precision medicine we're taking. It's an individualized approach, it's shared decision making between the patient and the clinician who's helping them and, at the end of the day, we're talking about Looking at all your factors, your medical conditions, your comorbid conditions, your looking at all the other genetics, social conditions, everything that might be contributing to your healthcare issues and concerns, and we look at that and we do practice individualized medicine. We review these things every year. We make sure that you get your mammograms and your colonoscopies and your screening tests and your coronary artery I mean your calcium score, your coronary artery calcium scores and so those are all pretty important things that we do on a yearly basis for these patients to make sure that there's still candidates for hormone therapy, as well as looking at any new medical conditions that may have evolved. So that is really really important to remember. And so those are the people that really cannot take it. And now I want to kind of get into what. So those are patients that are contraindicated. They should not be on hormone therapy. There are specific cases where there might be, instead of a hard stop, some negotiation that can occur. I do speak to my patients about their risk. I calculate what their cardiac risks are, I calculate all their risk of breast cancer, genetic risks, all that stuff, and so we have these discussions and it's really important that we just educate our patients and have them finally make the decision with them.


One of the other statements that was made and understood after the Women's Health Initiative that stopped 70% of all prescriptions of hormone therapy in 2002, was really it's important to understand the timing of when we should start it. So for women younger than age 60 or who are within 10 years of menopause and they don't have the contraindications that I discussed, the benefit-risk ratio is more favorable to treat them for those symptoms, for the vasomotor symptoms, for preventing bone loss. So that is important to know. It's called the timing hypothesis and it really means that it really is a reflection of some of the data from the Women's Health Initiative, which we'll discuss, but has to do with how the average age of that study was 62.5. And we know that most women enter menopause around at age 51. So when we looked at the women that were in menopause within five years of menopause, we saw a lot of benefit to hormone therapy and the thought is maybe that if you take hormone therapy past a certain age, you already have developed the preexisting conditions that might lead you to worsening coronary artery disease, stroke, venous thromboembolism. So basically, the menopause society further stated that for women who take hormone therapy more than 10 years from menopause or are older than 60 years old, the benefit-to-risk ratio appears really less favorable and there are greater risks for coronary artery disease, coronary heart disease, stroke, those blood clots, and for dementia. So that is why it's not 100% recommended against shared decision making for longer durations and looking at the individualized approach For bothersome symptoms of genital urinary syndrome and menopause.


We use low-dose vaginal estrogen, vaginal DHEA or oral ospemapheme, and I'll discuss that. Let's talk about systemic hormone therapy that I utilize for hormone menopausal hormone therapy, and I'm really referring to estrogen and progesterone. I'm going to do a separate discussion on testosterone. Systemic testosterone in an FDA-approved version that we sort of titrate for women is really important for hypoactive sexual desire disorder, which is low libido with bother. That's when you want to want to have sex and you can't, and I'm going to do a separate discussion on that.


But the way I look at it is I look at patients' total history, their family history, their medical history, the medications that they're on, and I usually just start with a transdermal patch, and that is because the risks are really overall lowest for transdermal patches. You know, when it comes to venous thromboembolism, the risk I want to say is 2 in 10,000 for a blood clot. But for transdermal, which is a patch, a gel or even a vaginal estrogen that is absorbed systemically. The risk does not appear to be there for at least thromboembolic disease, and that has to do with how oral medication, oral estrogen, is metabolized through the liver and you get, you can avoid the first-past metabolism with transdermal estrogens, but with oral estrogens you do get, you know, that liver metabolism and you may have a bump in your sex hormone binding globulin, which is the SHGB, that binds to your testosterone, that many of your tissues need, and so it can eventually, you know, potentially contribute to sexual dysfunction for some patients. So I start on a estrogen patch, that do the estradiol patch alone If you have no uterus, and then I'll do an estradiol patch alone, that with progesterone, and my go-to is usually oral micronized progesterone, and that again is similar to the biologic molecule that we make, the progesterone we make, and the estradiol is similar as well. So it's biologically identical.


And that whole term bio-identical really stems from and that is another statement that was reviewed in this position, statement that bio-identical hormones is really a marketing term. It evolved after the women's health initiative and 70% of those prescriptions stopped and so women were left with wanting hormones but couldn't because no one would give them to them, and so these compounding pharmacies started coming up with their own formulations of hormone therapy that are not tested and not regulated, and so it comes across in terms of a difficult thing for us to utilize. Specifically, when it comes to the bio-identical phrase that is utilized by these compounding pharmacies, hold on one second. Okay once more. Okay, sorry, sorry about that, kira. So specifically, when it comes to compounded bioidentical hormones, which is supposed to be similar to what we carry endogenously, it's a misleading term because these are not government approved, regulated and studied hormone therapies that come from these compounding pharmacies and so they can really combine multiple hormones. They are untested, they have unapproved combinations, they're formulations, they're administrations.


These pellets, these sub-dermal implants, these trochies they are really can be dangerous for patients. I've had many patients come to me with certain pellets or transdermal implants and basically like they'll end up having endometrial cancer because they're not getting enough protection or other issues. They have super physiologic doses of testosterone, have maybe micro penises when I see them, a lot of potential complications. So we do not recommend compounded bioidentical hormone therapy. We recommend FDA approved bioidentical therapy, which is what I'm discussing when I talk about the patches and the gels. There's really not enough safety or efficacy profile to know even the pharmaconetics of how these compounded therapies are, so we do not recommend them for systemic use.


So again, I'll start with the patch and the prometrium. The estradiol gel is also something I can use, or the other gel, the divi gel, or the transdermal spray, which is the eva mist. I also will use the fem ring, which is a vaginal ring. That is for systemic absorption. And these forms of estrogen are really good because they're transdermal. Again, less side effects in terms. I'm sorry they're transdermal, so less possibility of increasing your risk of blood clotting disorders and blood clotting like a pulmonary embolus, thromboembolic disease and pulmonary embolus. Remember some of the side effects of estrogen breast tenderness, nausea and spotting.


We use progesterone. The micronized progesterone is like one of these sleepily, help you relax. Take it at night, excuse me, take it at night. It gives you better coverage on opposed estrogen. Meaning if you have a uterus and you take estrogen without the progesterone, it can lead to thickening of the lining of the uterus, endometrial hyperplasia or cancer. We do not recommend topical compounded progesterones like the type that you use on your skin. That is not recommended. Sometimes I'm happy to use a merena or leave an agestral IUD, which is a synthetic progesterone and it is locally absorbed. It will prevent endometrial thickening or cancer and is great to use with some of these transdermal estrogens.


There are some systemic estrogen patches that are combination patches with either nor-ethan-drone or leave-in-adgesterol, and some patients do really well with them. We tend to stay away more from synthetic for first line because of the study from the Women's Health Initiative using synthetic progesterones, which is believed to be the one that had the slight increased risk of breast cancer. But we'll go into the nuances of that because even that can be debunked. So that's the first line. Some patients don't absorb it well, some patients don't tolerate the patch well, so we will often then switch to an oral pill with estradiol plus prometrium. The trade name for that is byjuva and my patients do well on that. That tells that Stemic progesterone can cause bloating, nausea, abdominal cramping, and we have to avoid that prometrium or that micronized progesterone in patients with a peanut allergy. So those are the patients that really will need to get synthetic progesterones, which is like your IUD or the combination patch.


So that's how I approach it. It's a trial and error for each patient. Every patient is different in how they absorb it and how they tolerate their side effects. So initially, you heard Heather talk about how we met very frequently initially as we try to figure out, and the other factor, excuse me, and the other factor, of course, is what your insurance covers. So, as you know, heather and I were discussing all of those things around insurance coverage. What we were talking about which one patient can afford, which one is the most effective for them with the least number of side effects, and so, again, it's trial and error, it's individualized care and it's shared decision making and that is what you should be looking for. So this is a general overview of the NAMS position statement, the North American Menopause or the Menopause Society position statement on hormone therapy, the people that should take it, the people that shouldn't take it and the routes that I use.


You know I will go into more detail with all of this when I have other clinicians on with me, and I just wanted to give you guys a brief overview today. Thank you for joining me, thank you for listening. Please continue to listen. Tell me what you need to hear more of, what you'd like to hear more of. Do you like the stories that you hear from patients? Do you want to see more experts. I'm going to have all of that, you know, hopefully within this podcast. So, thanks again and please, you know, subscribe to my podcast and hope to see you next time. I'm here to educate so you can advocate. Thanks so much.