March 31, 2025 • 33 mins
Hormone replacement therapy (HRT) remains a cornerstone of managing menopausal symptoms, but understanding the latest evidence is crucial for safe and effective use. This episode dives into evidence-based therapies, weighing benefits and risks and highlighting the pharmacist’s role in guiding personalized care. Tune in to stay updated on the science behind HRT and its evolving role in patient care.
HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact
GUEST
Ashley Meredith, PharmD, MPH, BCACP, BCPS, CDCES, FCCP
Clinical Professor
Purdue University
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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe the latest evidence-based approaches to hormone replacement therapy (HRT) for managing menopausal symptoms.
2. Identify key considerations for pharmacists when counseling patients on the benefits, risks, and appropriate use of HRT.
0.05 CEU/0.5 Hr
UAN: 0107-0000-25-087-H01-P
Initial release date: 3/31/2025
Expiration date: 3/31/2026
Additional CPE details can be found here.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:11):
Hey CE Impact subscribers, Welcome to the Game
Changers Clinical Conversationspodcast.
I'm your host, Josh Kinsey, andas always, I'm super excited
about our conversation today.
Hormone replacement therapy haslong been a cornerstone of
managing menopausal symptoms,but navigating the latest
evidence is essential for safeand effective patient care.
(00:31):
In this episode, we'll explorethe science behind HRT, discuss
its benefits and risks, andhighlight how pharmacists can
guide patients in makinginformed decisions about their
treatment options.
It's so great to have AshleyMeredith as our guest for today.
Ashley welcome.
Thanks for joining us.
Speaker 2 (00:49):
Thanks, Josh.
It's exciting to be here today.
Speaker 1 (00:51):
Yeah, we appreciate you taking time out of your
schedule to be with us today.
So before we jump in, I alwayslike to give our learners a
little background information onthe speaker for today, our
guest for today.
So if you want to take a fewminutes to tell us a little bit
about yourself maybe yourpractice site and just anything
that you're passionate about inthe pharmacy world- Absolutely
(01:13):
so.
Speaker 2 (01:14):
I'm currently a clinical professor at Purdue
University in Indiana.
I've been on faculty there forbasically my whole career.
Post-training I did residencytraining but then started on
faculty right after that.
So I've been a proudBoilermaker faculty for going on
15 years now and I practice inthe ambulatory care world, so
(01:36):
doing you know, sort ofone-on-one patient interactions,
more of that patient engagement.
But really the area ofreproductive health is something
that for me, over the last Iwould say probably seven to 10
years, has really become aprimary focus, both for my
research and my teaching butalso in the way that I engage
patients.
(01:56):
And so I think it's somethingthat you know.
For me, as I've gone throughdifferent phases of my own life,
it has hit home in a differentway and I have two daughters
myself, and so just the idea ofthe whole reproductive health
across the entire lifespan issomething that I feel really
strongly about.
Speaker 1 (02:16):
Yeah, yeah, that's great and it's interesting.
We have done a few podcastsalready kind of on similar
topics and and it's allowed mean opportunity to kind of
reconnect with that learningbecause I feel like, you know, I
haven't really had a connectionto that, those topics since
pharmacy school.
So it's really allowed me tokind of remember some things,
(02:38):
learn some new things and kindof really be up to date on stuff
.
So, and you know the, as youmentioned, it's, it's such, it
is a lifetime span, you know,like it is something that we're
looking at over life and in thefemale reproductive system, and
I think it's really important tobe sure that we understand all
the working parts and how theygo together.
So, yeah, so, thanks again, Ireally appreciate you joining us
(03:01):
and I'm excited to dig in andtalk a little bit more about
hormone replacement therapy.
So I always like to just kindof set the stage for our
learners, make sure that we havethe foundation and the
background and we're all on thesame page as we start talking
about a topic.
So if you can just remind usexactly what hormone replacement
therapy is, kind of it's youknow, it's history, it's
(03:23):
inception, what's its overallpurpose and goal, and just kind
of give us the foundation thereand then we can kind of jump
into the bigger topics.
Speaker 2 (03:32):
Absolutely so, josh.
Before we even jump into that,I do always like to give a
little disclaimer aroundlanguage use when talking about
reproductive health topics, andso many of the studies and
things that have looked at HRTor other reproductive health
(03:53):
categorize participants as womenor men, and so please know that
if I'm discussing and using theword women, it's because that's
what was used in the studies,but really I'm intending to
include all people that eithercurrently have a uterus or
previously had a uterus.
So I always just like to startwith that disclaimer around
language use here.
Speaker 1 (04:08):
Yeah, that's perfect.
And again, it's great to setthat foundation and just make
sure we're all understandingwhat you're discussing.
That's perfect, thank you.
Speaker 2 (04:16):
Absolutely so.
Then, jumping into sort of HRTor hormone replacement therapy,
what it's used for some of theyou know history of it.
Really, when we're talkingabout HRT, we're thinking about
during the menopause orperimenopausal time, you know,
in the years before menopause,and so current recommendations
(04:39):
are that HRT be considered forpeople who are experiencing
moderate to severe symptoms.
So that would be hot flashes,vaginal or urinary symptoms.
That spectrum of symptoms iswhat we're really talking about.
When we're thinking about whatHRT can be used for, it's
available in a lot of differentformulations.
(04:59):
So it can be oral, it can belocal in creams and gels, or it
can be transdermal, just reallyto meet folks, sort of where
they're at and what they'relooking for and how severe their
symptoms are.
So you know that's kind of whatit's used for, how it's
available.
But when we think about thedifferent types that are out
(05:21):
there, we break it down reallyinto more three big buckets of
the types of HRT that's outthere.
So we have estrogen onlytherapy, which really should
only be used in people who havehad a hysterectomy or no longer
have a uterus.
Then we've got combined therapy, which combines both an
(05:42):
estrogen and a progestogen, andthe reason for that is because
in someone who still has auterus, if we give estrogen
alone it does increase the riskof endometrial cancer.
So adding that combination withthe progestogen as part of it
helps to really reduce that riskof endometrial cancer.
And then the third bucket,which I think you know, at least
(06:04):
in the last probably decade orso, has become a little bit
trendy you hear about it a bitmore is this idea of
bioidentical hormone therapy.
And that's really where moresynthetic hormones are designed
to be chemically identical tonaturally occurring hormones,
and so they may come from plantsources, they may come from
other places.
(06:25):
They do claim to be more naturaland safer, but really there's
limited evidence that supportsthose claims of safety and being
more natural and really they'recompounded, so you open up a
whole other potential risks interms of not being regulated.
Do they actually contain whatthey claim to contain?
(06:46):
Everything that I'm sure all ofour listeners think about when
they think about compoundingmedications.
Speaker 1 (06:53):
Yeah, yeah, no, that's great, and how you know,
I guess, one thing to kind ofbring about or reiterate as well
as how long has HRT been around?
Obviously, I think I know theanswer, but I might be shocked.
So how long have we really hadthis sort of therapy?
Speaker 2 (07:12):
Yeah, so HRT has been used for decades and decades.
It really first started beingused back in the 1960s, is where
we first started really seeingcome into play and I would say
it had a sharp increase in use,with maybe a peak sometime in
the 1990s really meant to managethose menopausal symptoms.
(07:32):
And so you know what has beenfound and why it had such a
large initial uptake and whythere's still a role, for it
really comes down to the factthat during menopause, estrogen
levels decline and that canreally cause some bothersome
symptoms for folks, and so byproviding some extra estrogen it
(07:55):
can really help to alleviatethose symptoms and then may also
play a role in preventing someof the complications we may see
with osteoporosis andosteoporotic fractures as well.
So it even goes beyond symptomrelief and may help to prevent
additional problems down theroad.
Speaker 1 (08:13):
Yeah, yeah, that's great I would have.
If pressed to guess, I wouldhave said around the 70s, so I
wasn't too far off.
Speaker 2 (08:19):
You're close, you're close.
Speaker 1 (08:20):
Yeah, Great.
So let's talk about keyevidence.
Obviously, you know thisepisode.
We want to focus onevidence-based treatment, and so
what is some of the latestresearch that we're seeing?
You've put into perspective thekind of the three buckets,
which I think is important, butwhat are some of the latest
(08:43):
research surrounding kind ofwhich option to choose?
I guess?
Speaker 2 (08:48):
Yeah.
So you know, I think tounderstand what the focus of the
current research, we do have totake a step back a little bit
and understand why maybe thereis this gut reaction of HRT is
bad, we shouldn't be using itright.
So that really comes from.
There were two trials that werepublished in the late nineties
(09:11):
early two thousands.
That really changed the publicand maybe provider perception
about using HRT.
And so the first of those thatcame out in the nineties was the
Heart and Estrogen ProgestinReplacement Study, or HERS, and
it was a randomized trial.
It enrolled lots of folks,average age of 66 years.
(09:34):
They had established coronaryheart disease.
So that's an important pointabout the folks that were
enrolled in this.
They were followed for anaverage of about four years and
really the goal of the study wasto look at HRT's effect on
reducing overall cardiovascularevents.
(09:55):
So that's what the trial setout to prove, and so they did
not find that as a positiveoutcome and in fact found that
particularly during the firstyear of use, risks and rates of
those events actually increased.
Then it leveled off after thatfirst year, but in that first
year there was a significantincrease in cardiovascular
(10:18):
events that were happening.
So we had that.
That came out in the late 1990sand then in the early 2000s we
had the Women's HealthInitiative study.
Results start to come out and Ithink that's probably a study
that most people have heardabout as being a major
groundbreaker in terms ofhormone use in women's health
(10:38):
over a long period of time.
And so the Women's HealthInitiative study really began to
(11:13):
find major health issues.
So they started to see a higherincidence of things like breast
cancer, heart disease, stroke,blood clots, and that arm of the
study was stopped early, wasstopped early.
And so then also looking atthose who were receiving
estrogen but didn't receive thecombination therapy, they had
(11:35):
had a hysterectomy that also wasstopped early because of a
significant risk of stroke thatwas seen without additional
benefits in preventing heartdisease.
So I think these two trials arereally pivotal in defining why
there was a shift away fromusing HRT and why folks are
maybe scared to even think aboutit.
As a reasonable option.
Speaker 1 (11:53):
Right, yeah, no, and you?
I mean, you bring a great point.
But also I feel like we need toreiterate the fact that in the
first study, the patientsalready had known heart disease,
right, like they already had.
Speaker 2 (12:06):
Exactly.
Speaker 1 (12:07):
Exactly.
So I feel like that isimportant, because not all of
our patients who are on HRT havea cardiovascular diagnosis in
some way, you know right.
So I think that that's reallykey.
And I think what I heard in thesecond one is that they had a
uterus right.
Was that all that was looked at?
Speaker 2 (12:27):
There was a small group that didn't have a uterus.
And those risks were differentthan the folks who still had
their uterus.
Speaker 1 (12:35):
So I feel like that's kind of informed how we look at
treating and I hope I'm sureyou're going to bring that kind
of back around and make thatpoint later.
So yeah, but that's great toset the stage because it's
important, like you said, and wewere talking in the green space
before where we were kind ofdiscussing our plan and you know
(12:56):
I was going to call out thatthere's a lot of scare out there
around cardiovascular events,stroke, blood clots, cancer, all
that kind of stuff.
So I think it's reallyimportant that we really break
down what those studies said,and so I appreciate you doing
that because it's key to makesure that we fully understand
exactly what their implicationswere.
(13:17):
So that's great.
So, on that note, that was thefoundation research.
So what has that led us to now?
What has that informed how wemove forward with research?
Speaker 2 (13:32):
Yeah.
So I really think, thinkingabout where the research has
gone in the last five years,even just sort of limiting it to
the most recent timeframe,really, the focus has been on
who are the appropriate patientsto use HRT in, because we know
it improves the menopausalsymptoms that people are
(13:53):
experiencing and we also knowthere are certain risks that
come along with using hormonesright.
So I think the evidence mostrecently is focusing on how do
we use it safely, who can it beused in and what does that look
like?
And so.
I really think you know where wehave seen the shift is in
(14:16):
identifying.
Okay, how do we moreappropriately look at those who
have maybe low to moderatecardiovascular risk factors?
Those are likely the folks thatwe can more confidently, more
safely use HRT in, whereas insomeone who has established
cardiovascular disease, no, wewant to make sure we're avoiding
(14:37):
HRT because the risks justoutweigh the benefits at that
point but you know, if we'relooking at someone, it's really
focusing on what are thosetraditional cardiovascular risk
factors, and so the data is justhelping to support that.
So we're taking intoconsideration things like
someone's smoking status, what'stheir blood pressure, what's
(14:58):
their cholesterol, do they havediabetes, do they have metabolic
syndrome?
I mean all the things that takeit outside of menopause and
you're going to say they have ahigher cardiovascular risk
already right.
So it's just taking that andthen applying it in the context
of what is the additional riskthat's going to come along with
(15:18):
adding hormones on top of that.
Speaker 1 (15:21):
Yeah, and you know it's not, this doesn't sound
like a foreign concept thatwe're actually, like you know,
making sure that the therapy isappropriate before starting it
on a patient.
Like I feel like it's, you knowit.
Just it just seems like HRT hasgotten a bad rap in years past
because of I feel like thosestudies and they may have just
not been fully understood or,you know, it just hasn't really
(15:44):
fully come back to circle.
That, okay, that happens with alot of medications.
Like it may they're not allright for everyone, you know, we
have to still make sure thatit's an appropriate use and it's
safe and effective.
So, again, it doesn't soundlike a foreign concept.
It makes total sense to me.
Speaker 2 (15:59):
So yeah, right, it shouldn't be, but I think part
of it, josh, is that naturalreaction of something comes out
and it seems so great right, andthen all of a sudden, it's like
pump the brakes, there's somethings we need to consider, and
so then it's that reversal oflike okay, now we shouldn't be
doing this, but, exactly likeyou said, it's like we should be
doing with a lot of ourmedications.
(16:20):
It's not one size fits all.
It's what's most appropriatefor this patient.
Speaker 1 (16:25):
Exactly, exactly, yeah, so we've touched on a
little bit well, kind of barely,but I really want to focus on
what's the pharmacist role inHRT, like where, you know, where
do we come into play with that?
Is it appropriate therapy?
Or, you know, are they on theright thing?
If, if it is been deemed thatthey should be on hrt, are they
on the right combo or not comboor whatever?
(16:47):
Like what?
What's our role as a pharmacist?
Where should we be coming intoplay?
Speaker 2 (16:52):
yeah.
So I think, just like in anycondition, pharmacists can
certainly help patientsunderstand their options right.
So whether you're a pharmacistwho's dispensing HRT right
Taking that extra minute to sortof evaluate and say, okay, is
this patient on lots of othermedications for cardiovascular
disease and should that sort ofraise a red flag that maybe
(17:15):
there should be some questionsabout, is the HRT the safest?
I think that's certainly onerole.
I think another option you know,if you we are seeing more and
more pharmacists in clinics, inoffices that are providing
women's health focused services-and so there are opportunities
for pharmacists to be the oneswho are actually selecting the
(17:37):
medications, adjusting the HRT,choosing the route of
administration with that patientto figure out what best meets
their needs.
So I think it kind of spansthat whole spectrum, just
depending on what environmentyou're working on.
But certainly lots ofopportunities for pharmacists to
be engaged.
Speaker 1 (17:56):
Yeah, and I think that's the take home is that we
do have a role, and it mighttake you a little bit of effort
to find out what your specificrole is, but pharmacists
certainly have a role in HRT.
So with that, let's seguestraight into opportunities.
So what are some of theopportunities?
I guess we can position this asa couple of things
(18:17):
opportunities of likeimplementing HRT, you know, like
actually having HRT in apatient, and then also
opportunities for pharmacistslike where else can we be
involved?
So one of the things thatobviously comes to mind is
improving quality of life of thepatient, and clearly we've
touched on how that kind ofworks with treating the symptoms
(18:38):
and that they are effective atthat.
So I think we've really kind ofcovered that opportunity.
What are some opportunities forcollaboration?
So let's say that we're in moreof a dispensing role as a
pharmacist and so we're gettingit after the decision has been
made.
You mentioned like making surethat it's appropriate, you know
that kind of thing.
What if we find a red flag?
(18:59):
What are some collaborationopportunities for us to kind of
reach back out to the othermembers of that team?
Speaker 2 (19:06):
Yeah, I mean, I think it's you know.
For me I would take it as firsttalk to the patient have they
already had some of theseconversations with their
prescriber?
Because if they have andthey're comfortable with the
risks and benefits that comealong with it then fantastic,
maybe that's where theintervention ends right.
But if they haven't, then maybeit's that opportunity to say
(19:26):
okay, are you comfortable withme reaching out to your provider
to voice these concerns, like Iwould for any other drug-drug
interaction that comes up, orinappropriate dosing, or is that
a conversation that you, as thepatient, would rather have with
the provider the next time youfollow up with them?
So that would be how I wouldthink about approaching that
type of situation where younotice, ok, maybe maybe there's
(19:49):
something more here, maybe thisisn't the best choice, and you
know, and then it's really justtaking the time to reach out to
that provider, that provider'soffice, provider, that
provider's office.
We know it's often difficult toget the provider themselves on
the phone, but relaying theinformation and just, you know,
continuing to provide theevidence, I think is really
where.
I always end up back at is whatdoes the evidence actually say?
(20:13):
And then what does that meanfor this patient?
Speaker 1 (20:16):
And you know that's that reiterates what we've
talked about many times beforein the podcast with other
episodes, where we talk aboutthe collaborative opportunities,
the opportunities to reach outand advocate for a patient or
change something or whatever.
It's important to make surethat you have the facts and to
make sure that you have theevidence to back it up, because
oftentimes what that providersays is okay, well then, what do
(20:37):
I need to do?
Or what are my options, youknow?
And to just sit there and say,oh well then, what do I need to
do, or what are my options, youknow?
And to just sit there and say,oh well, I don't know, I didn't
have anything planned for that.
So I think, again, that'simportant to be sure that we do
have the facts, that we can backit up and that we know what the
evidence is.
You know, again, if we see asingle therapy, when we think it
should be a combo therapy,backing up the fact that we're
(20:58):
going to advocate and recommendfor combo therapy, and this is
why.
So I think that's really key aswell.
You touched on the bioidenticaland I want to make sure that I
fully understand.
That Is that kind of where weget the whole idea of like
personalized therapy.
Like is that where testingoccurs and you determine kind of
what options they need and thenit's compounded to suit the
(21:21):
patient.
Speaker 2 (21:22):
Yeah, so that's where , when you hear personalized
therapy for HRT, that's reallywhat we're talking about.
Now, you know there's probablygoes beyond the scope of our
conversation here today, Josh,but just the like pros and cons
of monitoring hormone levels andwhat they mean and who should
be doing that, I mean that's awhole other.
Speaker 1 (21:39):
That could be a whole other episode.
Yeah, for sure.
Speaker 2 (21:42):
But yes, when we think about personalized
medicine in terms of HRT, it isaligned with that bioidentical
therapy.
Speaker 1 (21:51):
Okay, perfect, that's what I wanted to make sure that
I was making the rightconnection there, and so I think
that that's what we can leaveit at.
You know again for time's sakeis that there is an opportunity
there.
If that's something thatpharmacists want to explore,
there is an opportunity to diptheir toe into that.
Personalized care, the testingand then the compounding and
whatever, if you're equipped forthat, if you have the
(22:13):
compounding lab and you meet thestandards and all that kind of
good stuff, which, again, wholenother conversation, a whole
nother topic.
But yeah, I just wanted to besure we touched on that.
So let's talk again some aboutsome of the challenges
surrounding HRT.
We've really hit on thosemisconceptions and I think it's
important that we did, and wespent a lot of time on that,
because I do feel like you know,even I remember as a kid my mom
(22:35):
went on HRT super early.
She had a hysterectomy early inher life and she would have
gone on one of those firstconjugated estrogens I won't say
the brand name, but we all knowwhat it is probably and then
all of this negative stuffstarted coming out.
So I think that it reallyshaped me.
(22:57):
That was about the time I wasthinking about pharmacy school
and going into pharmacy schooland she kept asking me should I
stay on them, should I go off ofthem?
You know the side effects areterrible if I go off because of
my hot flashes and whatever.
So I think it's reallyimportant that we address those
misconceptions, because theywere real and they really, you
know, they really made patientsask questions and pharmacists
(23:18):
really had to kind of step up.
So it's key to still understandthat those misconceptions may
still exist in patients becausethat information didn't go away.
I mean those, those studiesstayed firm as far as, like,
even prescribers decidingwhether or not to choose to
initiate HRT.
So I think we touched on that, Iguess is my point.
Sorry to go down a rabbit holethere, but I feel very connected
(23:42):
to that because I remember whenall of those negative things
coming out and then how thatweighed into, like patients
decisions and what they did.
So anyway, very personal for meon that one um.
So then, managing patientspecific risks.
So again, you taught youtouched on determining whether
or not they have other cardiorisk, cardiovascular risk
factors.
Um, I think that's key.
(24:03):
Is there anything else you wantto add there?
Any other things that we'relooking for, that would yeah,
absolutely, josh.
Speaker 2 (24:09):
So I think, beyond just the risk of cardiovascular
disease, we do know there aresome other patient
characteristics that are goingto lend themselves to HRT being
a bit safer of a choice, and soreally, the way it plays out
right now is it should be.
Hrt should be recommended ifsomeone is younger than 60 years
(24:29):
of age, if they're within 10years of the onset of menopause,
if they have a low risk ofbreast cancer.
So that's one thing that wedidn't really talk about earlier
.
But in addition to thatcardiovascular disease, you know
what, does that family historyof breast cancer look like and
are they at increased riskbecause of that?
But assuming family history ofbreast cancer look like, and are
(24:49):
they at increased risk becauseof that, but assuming their risk
for breast cancer is low,they're sort of in that low,
moderate risk of cardiovasculardisease and they're less than 60
years of age.
That would be the type ofpatient that we'd really be
looking at as saying, okay, thisis probably a relatively safe
use of HRT, but if someone isabove the age of 60, or they've
(25:12):
had the onset of menopause for along time because that's the
other piece is, these symptomscan last for a long time after
menopause itself has actuallystarted or occurred, and so you
know, making sure again thatthey're younger relatively close
to that onset of menopause andthen low risks for breast cancer
and cardiovascular disease.
Speaker 1 (25:31):
How defined does that low risk of breast cancer have
to be?
Like are we talking about?
Is it enough to just say, oh,no one in my family that I know
of has had breast cancer, or arewe talking about the need to
actually have the test to see ifthey're?
You know what I mean.
Speaker 2 (25:47):
Absolutely.
Yes, I see exactly where you'regoing with this, josh.
So from my perspective and Ithink for most providers it's
going to be just that there'snot a significant family history
, and you know, take it at that.
Of course, if someone wants togo down the whole testing and
you know, make sure that theirrisk isn't any higher than they
(26:10):
think it is then fantastic ifthat's going to make them more
comfortable with using HRT.
But that's not where we seemost clinical practice playing
out.
Speaker 1 (26:19):
Decision factors.
Yeah, okay, okay.
One other thing I wanted totouch on too.
While we're in that, with thatwhole the cancer scare and
whatever, because you touched ona couple of different types, is
there anything else around thatthat we need to be aware of?
Or even with conversations withpatients when it comes up and
says, oh, I thought HRT causedcancer, like, what other things
(26:40):
do we need to be aware of fromthe pharmacist's perspective
when the cancer word gets throwninto the mix?
Speaker 2 (26:47):
I mean, I think there's obviously a lot right
and I think every day we learnsomething new about potential
causes for all the differenttypes of cancer.
I think for me, what I wouldinclude as part of this
conversation for the person inmenopause who's seeking guidance
is also kind of looking at havethey used hormones at other
(27:07):
points in their life and whatdid?
That look like right.
So were they on hormonalcontraceptive for extended
periods of time, which, again,not that that's a definitive tie
to cancer, but it's additionalhormone right.
And so does that factor into itversus not?
So I think those would be someof the questions that I might
(27:27):
think about exploring a bit more.
But really, in terms of thetypes of cancers we're talking
about, it's breast cancer andit's endometrial cancer are
really the two that arepotentially a higher risk when
we're looking at HRT.
Speaker 1 (27:44):
Okay, one thing I wanted to talk about too and
maybe this is a challenge, Idon't know determining dose like
is it just, is it arbitrary?
Is there a way to start?
Is there a guideline forstarting dosing?
You know, because I know thatthere's multiple different
strengths of the different, youknow, hormones on the market.
(28:05):
So what are the?
How do you start with dosing?
I guess?
Speaker 2 (28:10):
Yeah, so really I mean we think about it as use
the lowest dose, see how thesymptoms respond If they don't
fully respond, then intensifythe treatment dose.
I mean and you'll also seerecommendations of try, you know
, treat the symptoms for a yearand then take a break and see if
(28:31):
the symptoms recur, right,because I think what we also see
, that's maybe a challenge is,once someone gets started on HRT
, when does it get stopped?
At what point is it appropriateto stop?
And if the symptoms are beingtreated.
You don't know if you're stillhaving the symptoms.
So you're sort of taking acouple months off after a year
or two of treatment andreevaluating, I think is also a
(28:53):
really important considerationwhen we're talking about
managing these medications.
Speaker 1 (28:57):
That's great advice, because I feel like that was
also something with my mother.
It was like when is itappropriate to stop?
And she was so worried aboutstopping and those terrible side
effects coming back or symptomscoming back that she was
fearful of stopping, you know.
And so I think that's a reallyimportant conversation to have
with the patient.
So that's great.
(29:17):
Are there any sort ofcontraindications otherwise that
we want to be aware of whentalking about initiating HRT?
Speaker 2 (29:25):
Dr Amy Moore.
Yeah, so I mean really what wethink about in terms of true,
absolute contraindications,would be someone that has
current or a history of breastor end not happen, depending on
the situation?
And the reason for anyundiagnosed vaginal bleeding has
been evaluated and assessed.
Got it?
Speaker 1 (30:08):
Where does the whole stro and clot come into play?
Like, is the stroke part of thecardiovascular contraindication
or is there?
You know what I'm saying.
And then also with the clot, isthat that bleeding part, or is
there another thing that weshould be aware of, because
those were kind of two thingsthat were come from that study?
Speaker 2 (30:26):
So I mean the stroke is part of that cardiovascular
disease spectrum for sure,exactly.
Exactly.
And then the blood clots.
You know that's always a hardthing when we're talking about
what puts someone at risk right.
So again we're looking atthings like do they have a
history of it?
Do they have a family history?
(30:47):
Are they overweight andsedentary?
Speaker 1 (30:51):
I was going to say does it come into mobility and
exercise?
And weight, because I feel likethose would also put you at
risk for a clot.
Speaker 2 (31:00):
Absolutely so.
It's just taking again thatwhole patient picture and
looking at what are theyotherwise at risk for, and then
is adding this medication goingto make that risk unacceptably
high yeah, yeah, no, that'sgreat.
Speaker 1 (31:14):
Um, well, I told you we would be shocked to find that
we get through our time quickly.
I say that every episode.
I can't believe we're alreadyover time.
Um, actually, is there anythingelse that you definitely wanted
to be sure that we covered that, that you didn't get a chance
to Anything in the whole worldof HRT?
I think we've discoveredthere's plenty of things we
(31:37):
could talk about right.
Speaker 2 (31:38):
I think we certainly hit on the most important points
that I would want to make suresomeone has heard about.
Speaker 1 (31:45):
Yeah, perfect To set them up to have success with
either discussing with patientsor collaborating with other
healthcare teams and whatnot.
So, yeah, that's great.
Well, as I do with everyepisode, I always like to ask
the guest what's the gamechanger here?
So, ashley, what's our takehome point?
What do you want to leave withlisteners?
Speaker 2 (32:04):
I think that the game changer for this is that HRT is
not universally bad and that itcan be really safely used as
long as you're making sure toevaluate that person,
particularly for cardiovasculardisease risk.
Speaker 1 (32:22):
Yeah, so being aware of those risks, those
contraindications and beingaware of everything the patient
has going on, whether they areat cardiovascular risk or they
do have a history of breastcancer and whatever so yeah,
that's great.
So hopefully we gave youlisteners some nuggets to take
back to your practice site withHRT and Ashley.
(32:43):
Thank you so much for joiningus.
We really appreciate it.
Speaker 2 (32:46):
It's a pleasure, Josh .
Speaker 1 (32:47):
Thank you.
If you're a CE plan subscriber,be sure to claim your CE credit
for this episode of GameChangers by logging in at
CEimpactcom.
And, as always, have a greatweek and keep learning.
I can't wait to dig intoanother game-changing topic with
you all next week.
Hey CE Impact subscribers, Welcome to the Game
Changers Clinical Conversationspodcast.
I'm your host, Josh Kinsey, andas always, I'm super excited
about our conversation today.
Hormone replacement therapy haslong been a cornerstone of
managing menopausal symptoms,but navigating the latest
evidence is essential for safeand effective patient care.
(00:31):
In this episode, we'll explorethe science behind HRT, discuss
its benefits and risks, andhighlight how pharmacists can
guide patients in makinginformed decisions about their
treatment options.
It's so great to have AshleyMeredith as our guest for today.
Ashley welcome.
Thanks for joining us.
Speaker 2 (00:49):
Thanks, Josh.
It's exciting to be here today.
Speaker 1 (00:51):
Yeah, we appreciate you taking time out of your
schedule to be with us today.
So before we jump in, I alwayslike to give our learners a
little background information onthe speaker for today, our
guest for today.
So if you want to take a fewminutes to tell us a little bit
about yourself maybe yourpractice site and just anything
that you're passionate about inthe pharmacy world- Absolutely
(01:13):
so.
Speaker 2 (01:14):
I'm currently a clinical professor at Purdue
University in Indiana.
I've been on faculty there forbasically my whole career.
Post-training I did residencytraining but then started on
faculty right after that.
So I've been a proudBoilermaker faculty for going on
15 years now and I practice inthe ambulatory care world, so
(01:36):
doing you know, sort ofone-on-one patient interactions,
more of that patient engagement.
But really the area ofreproductive health is something
that for me, over the last Iwould say probably seven to 10
years, has really become aprimary focus, both for my
research and my teaching butalso in the way that I engage
patients.
(01:56):
And so I think it's somethingthat you know.
For me, as I've gone throughdifferent phases of my own life,
it has hit home in a differentway and I have two daughters
myself, and so just the idea ofthe whole reproductive health
across the entire lifespan issomething that I feel really
strongly about.
Speaker 1 (02:16):
Yeah, yeah, that's great and it's interesting.
We have done a few podcastsalready kind of on similar
topics and and it's allowed mean opportunity to kind of
reconnect with that learningbecause I feel like, you know, I
haven't really had a connectionto that, those topics since
pharmacy school.
So it's really allowed me tokind of remember some things,
(02:38):
learn some new things and kindof really be up to date on stuff
.
So, and you know the, as youmentioned, it's, it's such, it
is a lifetime span, you know,like it is something that we're
looking at over life and in thefemale reproductive system, and
I think it's really important tobe sure that we understand all
the working parts and how theygo together.
So, yeah, so, thanks again, Ireally appreciate you joining us
(03:01):
and I'm excited to dig in andtalk a little bit more about
hormone replacement therapy.
So I always like to just kindof set the stage for our
learners, make sure that we havethe foundation and the
background and we're all on thesame page as we start talking
about a topic.
So if you can just remind usexactly what hormone replacement
therapy is, kind of it's youknow, it's history, it's
(03:23):
inception, what's its overallpurpose and goal, and just kind
of give us the foundation thereand then we can kind of jump
into the bigger topics.
Speaker 2 (03:32):
Absolutely so, josh.
Before we even jump into that,I do always like to give a
little disclaimer aroundlanguage use when talking about
reproductive health topics, andso many of the studies and
things that have looked at HRTor other reproductive health
(03:53):
categorize participants as womenor men, and so please know that
if I'm discussing and using theword women, it's because that's
what was used in the studies,but really I'm intending to
include all people that eithercurrently have a uterus or
previously had a uterus.
So I always just like to startwith that disclaimer around
language use here.
Speaker 1 (04:08):
Yeah, that's perfect.
And again, it's great to setthat foundation and just make
sure we're all understandingwhat you're discussing.
That's perfect, thank you.
Speaker 2 (04:16):
Absolutely so.
Then, jumping into sort of HRTor hormone replacement therapy,
what it's used for some of theyou know history of it.
Really, when we're talkingabout HRT, we're thinking about
during the menopause orperimenopausal time, you know,
in the years before menopause,and so current recommendations
(04:39):
are that HRT be considered forpeople who are experiencing
moderate to severe symptoms.
So that would be hot flashes,vaginal or urinary symptoms.
That spectrum of symptoms iswhat we're really talking about.
When we're thinking about whatHRT can be used for, it's
available in a lot of differentformulations.
(04:59):
So it can be oral, it can belocal in creams and gels, or it
can be transdermal, just reallyto meet folks, sort of where
they're at and what they'relooking for and how severe their
symptoms are.
So you know that's kind of whatit's used for, how it's
available.
But when we think about thedifferent types that are out
(05:21):
there, we break it down reallyinto more three big buckets of
the types of HRT that's outthere.
So we have estrogen onlytherapy, which really should
only be used in people who havehad a hysterectomy or no longer
have a uterus.
Then we've got combined therapy, which combines both an
(05:42):
estrogen and a progestogen, andthe reason for that is because
in someone who still has auterus, if we give estrogen
alone it does increase the riskof endometrial cancer.
So adding that combination withthe progestogen as part of it
helps to really reduce that riskof endometrial cancer.
And then the third bucket,which I think you know, at least
(06:04):
in the last probably decade orso, has become a little bit
trendy you hear about it a bitmore is this idea of
bioidentical hormone therapy.
And that's really where moresynthetic hormones are designed
to be chemically identical tonaturally occurring hormones,
and so they may come from plantsources, they may come from
other places.
(06:25):
They do claim to be more naturaland safer, but really there's
limited evidence that supportsthose claims of safety and being
more natural and really they'recompounded, so you open up a
whole other potential risks interms of not being regulated.
Do they actually contain whatthey claim to contain?
(06:46):
Everything that I'm sure all ofour listeners think about when
they think about compoundingmedications.
Speaker 1 (06:53):
Yeah, yeah, no, that's great, and how you know,
I guess, one thing to kind ofbring about or reiterate as well
as how long has HRT been around?
Obviously, I think I know theanswer, but I might be shocked.
So how long have we really hadthis sort of therapy?
Speaker 2 (07:12):
Yeah, so HRT has been used for decades and decades.
It really first started beingused back in the 1960s, is where
we first started really seeingcome into play and I would say
it had a sharp increase in use,with maybe a peak sometime in
the 1990s really meant to managethose menopausal symptoms.
(07:32):
And so you know what has beenfound and why it had such a
large initial uptake and whythere's still a role, for it
really comes down to the factthat during menopause, estrogen
levels decline and that canreally cause some bothersome
symptoms for folks, and so byproviding some extra estrogen it
(07:55):
can really help to alleviatethose symptoms and then may also
play a role in preventing someof the complications we may see
with osteoporosis andosteoporotic fractures as well.
So it even goes beyond symptomrelief and may help to prevent
additional problems down theroad.
Speaker 1 (08:13):
Yeah, yeah, that's great I would have.
If pressed to guess, I wouldhave said around the 70s, so I
wasn't too far off.
Speaker 2 (08:19):
You're close, you're close.
Speaker 1 (08:20):
Yeah, Great.
So let's talk about keyevidence.
Obviously, you know thisepisode.
We want to focus onevidence-based treatment, and so
what is some of the latestresearch that we're seeing?
You've put into perspective thekind of the three buckets,
which I think is important, butwhat are some of the latest
(08:43):
research surrounding kind ofwhich option to choose?
I guess?
Speaker 2 (08:48):
Yeah.
So you know, I think tounderstand what the focus of the
current research, we do have totake a step back a little bit
and understand why maybe thereis this gut reaction of HRT is
bad, we shouldn't be using itright.
So that really comes from.
There were two trials that werepublished in the late nineties
(09:11):
early two thousands.
That really changed the publicand maybe provider perception
about using HRT.
And so the first of those thatcame out in the nineties was the
Heart and Estrogen ProgestinReplacement Study, or HERS, and
it was a randomized trial.
It enrolled lots of folks,average age of 66 years.
(09:34):
They had established coronaryheart disease.
So that's an important pointabout the folks that were
enrolled in this.
They were followed for anaverage of about four years and
really the goal of the study wasto look at HRT's effect on
reducing overall cardiovascularevents.
(09:55):
So that's what the trial setout to prove, and so they did
not find that as a positiveoutcome and in fact found that
particularly during the firstyear of use, risks and rates of
those events actually increased.
Then it leveled off after thatfirst year, but in that first
year there was a significantincrease in cardiovascular
(10:18):
events that were happening.
So we had that.
That came out in the late 1990sand then in the early 2000s we
had the Women's HealthInitiative study.
Results start to come out and Ithink that's probably a study
that most people have heardabout as being a major
groundbreaker in terms ofhormone use in women's health
(10:38):
over a long period of time.
And so the Women's HealthInitiative study really began to
(11:13):
find major health issues.
So they started to see a higherincidence of things like breast
cancer, heart disease, stroke,blood clots, and that arm of the
study was stopped early, wasstopped early.
And so then also looking atthose who were receiving
estrogen but didn't receive thecombination therapy, they had
(11:35):
had a hysterectomy that also wasstopped early because of a
significant risk of stroke thatwas seen without additional
benefits in preventing heartdisease.
So I think these two trials arereally pivotal in defining why
there was a shift away fromusing HRT and why folks are
maybe scared to even think aboutit.
As a reasonable option.
Speaker 1 (11:53):
Right, yeah, no, and you?
I mean, you bring a great point.
But also I feel like we need toreiterate the fact that in the
first study, the patientsalready had known heart disease,
right, like they already had.
Speaker 2 (12:06):
Exactly.
Speaker 1 (12:07):
Exactly.
So I feel like that isimportant, because not all of
our patients who are on HRT havea cardiovascular diagnosis in
some way, you know right.
So I think that that's reallykey.
And I think what I heard in thesecond one is that they had a
uterus right.
Was that all that was looked at?
Speaker 2 (12:27):
There was a small group that didn't have a uterus.
And those risks were differentthan the folks who still had
their uterus.
Speaker 1 (12:35):
So I feel like that's kind of informed how we look at
treating and I hope I'm sureyou're going to bring that kind
of back around and make thatpoint later.
So yeah, but that's great toset the stage because it's
important, like you said, and wewere talking in the green space
before where we were kind ofdiscussing our plan and you know
(12:56):
I was going to call out thatthere's a lot of scare out there
around cardiovascular events,stroke, blood clots, cancer, all
that kind of stuff.
So I think it's reallyimportant that we really break
down what those studies said,and so I appreciate you doing
that because it's key to makesure that we fully understand
exactly what their implicationswere.
(13:17):
So that's great.
So, on that note, that was thefoundation research.
So what has that led us to now?
What has that informed how wemove forward with research?
Speaker 2 (13:32):
Yeah.
So I really think, thinkingabout where the research has
gone in the last five years,even just sort of limiting it to
the most recent timeframe,really, the focus has been on
who are the appropriate patientsto use HRT in, because we know
it improves the menopausalsymptoms that people are
(13:53):
experiencing and we also knowthere are certain risks that
come along with using hormonesright.
So I think the evidence mostrecently is focusing on how do
we use it safely, who can it beused in and what does that look
like?
And so.
I really think you know where wehave seen the shift is in
(14:16):
identifying.
Okay, how do we moreappropriately look at those who
have maybe low to moderatecardiovascular risk factors?
Those are likely the folks thatwe can more confidently, more
safely use HRT in, whereas insomeone who has established
cardiovascular disease, no, wewant to make sure we're avoiding
(14:37):
HRT because the risks justoutweigh the benefits at that
point but you know, if we'relooking at someone, it's really
focusing on what are thosetraditional cardiovascular risk
factors, and so the data is justhelping to support that.
So we're taking intoconsideration things like
someone's smoking status, what'stheir blood pressure, what's
(14:58):
their cholesterol, do they havediabetes, do they have metabolic
syndrome?
I mean all the things that takeit outside of menopause and
you're going to say they have ahigher cardiovascular risk
already right.
So it's just taking that andthen applying it in the context
of what is the additional riskthat's going to come along with
(15:18):
adding hormones on top of that.
Speaker 1 (15:21):
Yeah, and you know it's not, this doesn't sound
like a foreign concept thatwe're actually, like you know,
making sure that the therapy isappropriate before starting it
on a patient.
Like I feel like it's, you knowit.
Just it just seems like HRT hasgotten a bad rap in years past
because of I feel like thosestudies and they may have just
not been fully understood or,you know, it just hasn't really
(15:44):
fully come back to circle.
That, okay, that happens with alot of medications.
Like it may they're not allright for everyone, you know, we
have to still make sure thatit's an appropriate use and it's
safe and effective.
So, again, it doesn't soundlike a foreign concept.
It makes total sense to me.
Speaker 2 (15:59):
So yeah, right, it shouldn't be, but I think part
of it, josh, is that naturalreaction of something comes out
and it seems so great right, andthen all of a sudden, it's like
pump the brakes, there's somethings we need to consider, and
so then it's that reversal oflike okay, now we shouldn't be
doing this, but, exactly likeyou said, it's like we should be
doing with a lot of ourmedications.
(16:20):
It's not one size fits all.
It's what's most appropriatefor this patient.
Speaker 1 (16:25):
Exactly, exactly, yeah, so we've touched on a
little bit well, kind of barely,but I really want to focus on
what's the pharmacist role inHRT, like where, you know, where
do we come into play with that?
Is it appropriate therapy?
Or, you know, are they on theright thing?
If, if it is been deemed thatthey should be on hrt, are they
on the right combo or not comboor whatever?
(16:47):
Like what?
What's our role as a pharmacist?
Where should we be coming intoplay?
Speaker 2 (16:52):
yeah.
So I think, just like in anycondition, pharmacists can
certainly help patientsunderstand their options right.
So whether you're a pharmacistwho's dispensing HRT right
Taking that extra minute to sortof evaluate and say, okay, is
this patient on lots of othermedications for cardiovascular
disease and should that sort ofraise a red flag that maybe
(17:15):
there should be some questionsabout, is the HRT the safest?
I think that's certainly onerole.
I think another option you know,if you we are seeing more and
more pharmacists in clinics, inoffices that are providing
women's health focused services-and so there are opportunities
for pharmacists to be the oneswho are actually selecting the
(17:37):
medications, adjusting the HRT,choosing the route of
administration with that patientto figure out what best meets
their needs.
So I think it kind of spansthat whole spectrum, just
depending on what environmentyou're working on.
But certainly lots ofopportunities for pharmacists to
be engaged.
Speaker 1 (17:56):
Yeah, and I think that's the take home is that we
do have a role, and it mighttake you a little bit of effort
to find out what your specificrole is, but pharmacists
certainly have a role in HRT.
So with that, let's seguestraight into opportunities.
So what are some of theopportunities?
I guess we can position this asa couple of things
(18:17):
opportunities of likeimplementing HRT, you know, like
actually having HRT in apatient, and then also
opportunities for pharmacistslike where else can we be
involved?
So one of the things thatobviously comes to mind is
improving quality of life of thepatient, and clearly we've
touched on how that kind ofworks with treating the symptoms
(18:38):
and that they are effective atthat.
So I think we've really kind ofcovered that opportunity.
What are some opportunities forcollaboration?
So let's say that we're in moreof a dispensing role as a
pharmacist and so we're gettingit after the decision has been
made.
You mentioned like making surethat it's appropriate, you know
that kind of thing.
What if we find a red flag?
(18:59):
What are some collaborationopportunities for us to kind of
reach back out to the othermembers of that team?
Speaker 2 (19:06):
Yeah, I mean, I think it's you know.
For me I would take it as firsttalk to the patient have they
already had some of theseconversations with their
prescriber?
Because if they have andthey're comfortable with the
risks and benefits that comealong with it then fantastic,
maybe that's where theintervention ends right.
But if they haven't, then maybeit's that opportunity to say
(19:26):
okay, are you comfortable withme reaching out to your provider
to voice these concerns, like Iwould for any other drug-drug
interaction that comes up, orinappropriate dosing, or is that
a conversation that you, as thepatient, would rather have with
the provider the next time youfollow up with them?
So that would be how I wouldthink about approaching that
type of situation where younotice, ok, maybe maybe there's
(19:49):
something more here, maybe thisisn't the best choice, and you
know, and then it's really justtaking the time to reach out to
that provider, that provider'soffice, provider, that
provider's office.
We know it's often difficult toget the provider themselves on
the phone, but relaying theinformation and just, you know,
continuing to provide theevidence, I think is really
where.
I always end up back at is whatdoes the evidence actually say?
(20:13):
And then what does that meanfor this patient?
Speaker 1 (20:16):
And you know that's that reiterates what we've
talked about many times beforein the podcast with other
episodes, where we talk aboutthe collaborative opportunities,
the opportunities to reach outand advocate for a patient or
change something or whatever.
It's important to make surethat you have the facts and to
make sure that you have theevidence to back it up, because
oftentimes what that providersays is okay, well then, what do
(20:37):
I need to do?
Or what are my options, youknow?
And to just sit there and say,oh well then, what do I need to
do, or what are my options, youknow?
And to just sit there and say,oh well, I don't know, I didn't
have anything planned for that.
So I think, again, that'simportant to be sure that we do
have the facts, that we can backit up and that we know what the
evidence is.
You know, again, if we see asingle therapy, when we think it
should be a combo therapy,backing up the fact that we're
(20:58):
going to advocate and recommendfor combo therapy, and this is
why.
So I think that's really key aswell.
You touched on the bioidenticaland I want to make sure that I
fully understand.
That Is that kind of where weget the whole idea of like
personalized therapy.
Like is that where testingoccurs and you determine kind of
what options they need and thenit's compounded to suit the
(21:21):
patient.
Speaker 2 (21:22):
Yeah, so that's where , when you hear personalized
therapy for HRT, that's reallywhat we're talking about.
Now, you know there's probablygoes beyond the scope of our
conversation here today, Josh,but just the like pros and cons
of monitoring hormone levels andwhat they mean and who should
be doing that, I mean that's awhole other.
Speaker 1 (21:39):
That could be a whole other episode.
Yeah, for sure.
Speaker 2 (21:42):
But yes, when we think about personalized
medicine in terms of HRT, it isaligned with that bioidentical
therapy.
Speaker 1 (21:51):
Okay, perfect, that's what I wanted to make sure that
I was making the rightconnection there, and so I think
that that's what we can leaveit at.
You know again for time's sakeis that there is an opportunity
there.
If that's something thatpharmacists want to explore,
there is an opportunity to diptheir toe into that.
Personalized care, the testingand then the compounding and
whatever, if you're equipped forthat, if you have the
(22:13):
compounding lab and you meet thestandards and all that kind of
good stuff, which, again, wholenother conversation, a whole
nother topic.
But yeah, I just wanted to besure we touched on that.
So let's talk again some aboutsome of the challenges
surrounding HRT.
We've really hit on thosemisconceptions and I think it's
important that we did, and wespent a lot of time on that,
because I do feel like you know,even I remember as a kid my mom
(22:35):
went on HRT super early.
She had a hysterectomy early inher life and she would have
gone on one of those firstconjugated estrogens I won't say
the brand name, but we all knowwhat it is probably and then
all of this negative stuffstarted coming out.
So I think that it reallyshaped me.
(22:57):
That was about the time I wasthinking about pharmacy school
and going into pharmacy schooland she kept asking me should I
stay on them, should I go off ofthem?
You know the side effects areterrible if I go off because of
my hot flashes and whatever.
So I think it's reallyimportant that we address those
misconceptions, because theywere real and they really, you
know, they really made patientsask questions and pharmacists
(23:18):
really had to kind of step up.
So it's key to still understandthat those misconceptions may
still exist in patients becausethat information didn't go away.
I mean those, those studiesstayed firm as far as, like,
even prescribers decidingwhether or not to choose to
initiate HRT.
So I think we touched on that, Iguess is my point.
Sorry to go down a rabbit holethere, but I feel very connected
(23:42):
to that because I remember whenall of those negative things
coming out and then how thatweighed into, like patients
decisions and what they did.
So anyway, very personal for meon that one um.
So then, managing patientspecific risks.
So again, you taught youtouched on determining whether
or not they have other cardiorisk, cardiovascular risk
factors.
Um, I think that's key.
(24:03):
Is there anything else you wantto add there?
Any other things that we'relooking for, that would yeah,
absolutely, josh.
Speaker 2 (24:09):
So I think, beyond just the risk of cardiovascular
disease, we do know there aresome other patient
characteristics that are goingto lend themselves to HRT being
a bit safer of a choice, and soreally, the way it plays out
right now is it should be.
Hrt should be recommended ifsomeone is younger than 60 years
(24:29):
of age, if they're within 10years of the onset of menopause,
if they have a low risk ofbreast cancer.
So that's one thing that wedidn't really talk about earlier
.
But in addition to thatcardiovascular disease, you know
what, does that family historyof breast cancer look like and
are they at increased riskbecause of that?
But assuming family history ofbreast cancer look like, and are
(24:49):
they at increased risk becauseof that, but assuming their risk
for breast cancer is low,they're sort of in that low,
moderate risk of cardiovasculardisease and they're less than 60
years of age.
That would be the type ofpatient that we'd really be
looking at as saying, okay, thisis probably a relatively safe
use of HRT, but if someone isabove the age of 60, or they've
(25:12):
had the onset of menopause for along time because that's the
other piece is, these symptomscan last for a long time after
menopause itself has actuallystarted or occurred, and so you
know, making sure again thatthey're younger relatively close
to that onset of menopause andthen low risks for breast cancer
and cardiovascular disease.
Speaker 1 (25:31):
How defined does that low risk of breast cancer have
to be?
Like are we talking about?
Is it enough to just say, oh,no one in my family that I know
of has had breast cancer, or arewe talking about the need to
actually have the test to see ifthey're?
You know what I mean.
Speaker 2 (25:47):
Absolutely.
Yes, I see exactly where you'regoing with this, josh.
So from my perspective and Ithink for most providers it's
going to be just that there'snot a significant family history
, and you know, take it at that.
Of course, if someone wants togo down the whole testing and
you know, make sure that theirrisk isn't any higher than they
(26:10):
think it is then fantastic ifthat's going to make them more
comfortable with using HRT.
But that's not where we seemost clinical practice playing
out.
Speaker 1 (26:19):
Decision factors.
Yeah, okay, okay.
One other thing I wanted totouch on too.
While we're in that, with thatwhole the cancer scare and
whatever, because you touched ona couple of different types, is
there anything else around thatthat we need to be aware of?
Or even with conversations withpatients when it comes up and
says, oh, I thought HRT causedcancer, like, what other things
(26:40):
do we need to be aware of fromthe pharmacist's perspective
when the cancer word gets throwninto the mix?
Speaker 2 (26:47):
I mean, I think there's obviously a lot right
and I think every day we learnsomething new about potential
causes for all the differenttypes of cancer.
I think for me, what I wouldinclude as part of this
conversation for the person inmenopause who's seeking guidance
is also kind of looking at havethey used hormones at other
(27:07):
points in their life and whatdid?
That look like right.
So were they on hormonalcontraceptive for extended
periods of time, which, again,not that that's a definitive tie
to cancer, but it's additionalhormone right.
And so does that factor into itversus not?
So I think those would be someof the questions that I might
(27:27):
think about exploring a bit more.
But really, in terms of thetypes of cancers we're talking
about, it's breast cancer andit's endometrial cancer are
really the two that arepotentially a higher risk when
we're looking at HRT.
Speaker 1 (27:44):
Okay, one thing I wanted to talk about too and
maybe this is a challenge, Idon't know determining dose like
is it just, is it arbitrary?
Is there a way to start?
Is there a guideline forstarting dosing?
You know, because I know thatthere's multiple different
strengths of the different, youknow, hormones on the market.
(28:05):
So what are the?
How do you start with dosing?
I guess?
Speaker 2 (28:10):
Yeah, so really I mean we think about it as use
the lowest dose, see how thesymptoms respond If they don't
fully respond, then intensifythe treatment dose.
I mean and you'll also seerecommendations of try, you know
, treat the symptoms for a yearand then take a break and see if
(28:31):
the symptoms recur, right,because I think what we also see
, that's maybe a challenge is,once someone gets started on HRT
, when does it get stopped?
At what point is it appropriateto stop?
And if the symptoms are beingtreated.
You don't know if you're stillhaving the symptoms.
So you're sort of taking acouple months off after a year
or two of treatment andreevaluating, I think is also a
(28:53):
really important considerationwhen we're talking about
managing these medications.
Speaker 1 (28:57):
That's great advice, because I feel like that was
also something with my mother.
It was like when is itappropriate to stop?
And she was so worried aboutstopping and those terrible side
effects coming back or symptomscoming back that she was
fearful of stopping, you know.
And so I think that's a reallyimportant conversation to have
with the patient.
So that's great.
(29:17):
Are there any sort ofcontraindications otherwise that
we want to be aware of whentalking about initiating HRT?
Speaker 2 (29:25):
Dr Amy Moore.
Yeah, so I mean really what wethink about in terms of true,
absolute contraindications,would be someone that has
current or a history of breastor end not happen, depending on
the situation?
And the reason for anyundiagnosed vaginal bleeding has
been evaluated and assessed.
Got it?
Speaker 1 (30:08):
Where does the whole stro and clot come into play?
Like, is the stroke part of thecardiovascular contraindication
or is there?
You know what I'm saying.
And then also with the clot, isthat that bleeding part, or is
there another thing that weshould be aware of, because
those were kind of two thingsthat were come from that study?
Speaker 2 (30:26):
So I mean the stroke is part of that cardiovascular
disease spectrum for sure,exactly.
Exactly.
And then the blood clots.
You know that's always a hardthing when we're talking about
what puts someone at risk right.
So again we're looking atthings like do they have a
history of it?
Do they have a family history?
(30:47):
Are they overweight andsedentary?
Speaker 1 (30:51):
I was going to say does it come into mobility and
exercise?
And weight, because I feel likethose would also put you at
risk for a clot.
Speaker 2 (31:00):
Absolutely so.
It's just taking again thatwhole patient picture and
looking at what are theyotherwise at risk for, and then
is adding this medication goingto make that risk unacceptably
high yeah, yeah, no, that'sgreat.
Speaker 1 (31:14):
Um, well, I told you we would be shocked to find that
we get through our time quickly.
I say that every episode.
I can't believe we're alreadyover time.
Um, actually, is there anythingelse that you definitely wanted
to be sure that we covered that, that you didn't get a chance
to Anything in the whole worldof HRT?
I think we've discoveredthere's plenty of things we
(31:37):
could talk about right.
Speaker 2 (31:38):
I think we certainly hit on the most important points
that I would want to make suresomeone has heard about.
Speaker 1 (31:45):
Yeah, perfect To set them up to have success with
either discussing with patientsor collaborating with other
healthcare teams and whatnot.
So, yeah, that's great.
Well, as I do with everyepisode, I always like to ask
the guest what's the gamechanger here?
So, ashley, what's our takehome point?
What do you want to leave withlisteners?
Speaker 2 (32:04):
I think that the game changer for this is that HRT is
not universally bad and that itcan be really safely used as
long as you're making sure toevaluate that person,
particularly for cardiovasculardisease risk.
Speaker 1 (32:22):
Yeah, so being aware of those risks, those
contraindications and beingaware of everything the patient
has going on, whether they areat cardiovascular risk or they
do have a history of breastcancer and whatever so yeah,
that's great.
So hopefully we gave youlisteners some nuggets to take
back to your practice site withHRT and Ashley.
(32:43):
Thank you so much for joiningus.
We really appreciate it.
Speaker 2 (32:46):
It's a pleasure, Josh .
Speaker 1 (32:47):
Thank you.
If you're a CE plan subscriber,be sure to claim your CE credit
for this episode of GameChangers by logging in at
CEimpactcom.
And, as always, have a greatweek and keep learning.
I can't wait to dig intoanother game-changing topic with
you all next week.
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