October 15, 2025 • 60 mins
Hormone therapy remains the gold standard for treating menopausal symptoms—hot flashes, night sweats, sleep disturbances, mood changes, and vaginal dryness. When started within 10 years of menopause onset, it offers a remarkable 30% reduction in all-cause mortality. Yet this fact rarely makes headlines.
Join Speaking of Women's Health Podcast Host Dr. Holly Thacker as she reads and discusses Chapter 10: The Risks and Benefits of Hormone Therapy from her book, "The Cleveland Clinic Guide to Menopause."
The most important takeaway? Don't let fear dictate your menopause journey. Work with a knowledgeable physician to assess your individual risks and benefits. Whether you're experiencing severe symptoms, concerned about bone health, or dealing with early menopause, safe and effective options exist.
Have you been avoiding hormone therapy based on outdated information? It might be time to reconsider.
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Episode Transcript
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Speaker 1 (00:04):
Welcome to the Speaking of Women's Health
podcast.
I'm Dr Holly Thacker, your hostand author, and thanks for
joining me back in the SunflowerHouse for Chapter 10, the Risk
and Benefits of Hormone Therapy.
Hormone therapy is still thebest available treatment to
(00:27):
treat menopausal symptoms andthe case is far from closed
regarding its long-term effectsin terms of helping blood
pressure, reducing heart disease, colon cancer, potentially
reducing Alzheimer's disease,depression, parkinson's,
arthritis and even maculardegeneration.
We do need more study.
(00:48):
Furthermore, lower doses ofhormones than previously studied
may provide some of the samebenefits while reducing side
effects, particularly on theuterus and breast.
The use of progestogens, whichare synthetic progestins or
natural progesterone, may bepart of the equation that
(01:08):
affects the risk of breastcancer while protecting the
uterus.
Using estrogen transdermally,as in a weekly patch, like
Climera or Climera Pro orVivelle Dot or Minivel twice a
week, or a daily estrogen gel orlotion or spray, may reduce the
risk of blood clots, but it maynot raise the HDL cholesterol
(01:34):
as well as oral estrogen.
In short, we always need moreresearch, but in the meantime we
have more options for treatingmenopausal symptoms than ever
before.
This should be the best time formidlife women and beyond, but
instead many suffer needlessly.
Take Anne-Marie, for instance.
Anne-marie, I didn't know whatto believe.
(01:55):
One said he said don't take anyhormones.
Another one said estrogen useby older women could increase
their risk of stroke.
Every day there's a newheadline with a different
warning.
Ah, you'd think I was treatingmy menopausal symptoms with
illegal drugs.
I took PremPro for several yearswithout a problem before I
discovered that I thought I wasrisking my life, at least
(02:17):
according to the media reports.
My doctor suggested I taperdown the dosage, but I insisted
on just stopping it completely.
So I quit cold turkey.
Well, the result of my rashdecision was disastrous.
I felt as if someone had pulledthe rug from right out
underneath me.
I was anxious and extremelyuncomfortable all the time.
(02:39):
My hot flashes were so severe Isometimes wondered whether I
could leave the house to runerrands.
I had never realized how muchthe hormone therapy had been
helping me until I stopped.
I tried some alternatives blackcohosh in the form of remifemin
for hot flashes, vitamin E oilfor vaginal discomfort, but
(03:01):
nothing worked quite as well asmy original therapy.
And to add insult to injury, Ilost an inch of height and I
found out on bone density, I hadosteopenia, bone thinning.
With so many misleading reportsabout what's good for women.
Today it just seems as ifbreathing is a risk.
But I decided I had to feelcomfortable.
So I went back on hormonetherapy.
(03:23):
I went on low dose PremPro andfinally I felt normal again
Taking hormone therapy.
Millions of women have done verywell on hormone therapy,
finding relief from the worst oftheir symptoms without
increasing any other health risk.
Hormone therapy was and stillis the only FDA-approved
(03:46):
treatment for the symptoms ofmenopause, including vaginal
atrophy and the management ofpostmenopausal osteoporosis.
Now we do have indications fornon-hormonal treatments of
vaginal atrophy, such as Asfina,aspemafen, asermirm, a
selective estrogen receptoragonist antagonist.
(04:06):
We have several options thatare FDA approved to treat
osteoporosis, to prevent andtreat and we are going to go
over that in a future chapter onboosting bone health.
And we do have FDA-approvednon-hormonal treatments to treat
hot flashes in the form ofBrisdell paroxetine and
(04:30):
hopefully soon to be some candyneuron antagonist.
So the FDA and most physiciansregard hormones as having
potential benefits.
As, like with anything,potential risk.
Nothing is 100% safe andeffective with no risk, nothing,
not even water.
(04:50):
So unfortunately, the risk manytimes get completely
overshadowed by fearful mediahype.
So where do all thesemisconceptions and fears come
from?
Well, the Women's HealthInitiative, which was a large
randomized trial that changedthe way women, as well as much
of the media and medicalcommunity, view hormone therapy,
(05:12):
and this change was not for thebetter.
My fifth podcast in thespeakingofwomenshealthcom
website podcast series was onthe 20th anniversary of the WHI.
Fear, anxiety, fewer choicesfor women resulted from
misinterpretations of sectionsof the study that focused on
(05:35):
hormone therapy in much olderwomen who were several years
past the age of the onset ofmenopause.
Ironically, these studies hadbeen initially designed to help
women better understand the riskand benefits.
So, unfortunately, the mediafriends, even some of our
doctors and nurses, areinappropriately waving
accusatory fingers at hormonetherapy as a treatment for
(05:57):
menopausal symptoms, and thisshould infuriate women and spark
a new debate that asks somevery pointed questions about the
treatment of modern, maturewomen in modern America.
For example, some might wonderhow accurate are randomized
studies when applied todifferent groups of women for
different reasons?
Why does the media scare womeninto thinking that they don't
(06:21):
have options, and why otherwisegood doctors into thinking that
they don't have options, and whyotherwise good doctors
misinterpreted these studies andjust followed what the media
said?
Hmm, where else have.
We have seen that.
What about the quality of lifeand sexual function for midlife
women?
How can women fairly assesswhat hormone therapy truly
represents for their ownindividual case?
In this chapter about the riskand benefits of hormone therapy,
(06:45):
I'll discuss the facts thatwomen absolutely must know.
These are details that you'renot going to read in the
newspaper, because so manyarticles for the lay public just
skim the surface, and there'sfar too much at stake with your
health for research to beinterpreted in such a glib and
superficial way.
Millions of women have donewell on hormone therapy, finding
(07:07):
relief from the worst of theirsymptoms without increasing
other health risk.
The FDA and most physiciansregard hormones as having
significant potential benefitsas well as potential risk, just
like with any prescriptionmedicine and even
non-prescription therapies.
I mean, my goodness, there aredeaths from acetaminophen
Tylenol, which is over thecounter.
(07:29):
So just because something isoff the shelf or available
without a prescription doesn'tmean that it's safer than
prescription medicines.
Women's Health Initiative thehard facts.
In 2002, researchers haltedpart of the WHI, and this was a
large preventive study funded bythe National Institute of
(07:51):
Health, nih, to focus onstrategies for preventing heart
disease, breast cancer,colorectal cancer and
osteoporosis in postmenopausalwomen.
It was a 15-year multi-milliondollar project.
The WHI involved over 161,000women that ranged from ages 50
(08:11):
to 79.
The segment of the study thatwas halted had been assessing
the long-term use of hormonetherapy as a prevention tool for
chronic illness, and that'sbecause a preventive agent can
essentially have no side effects.
It's important that this was nota menopausal treatment trial,
(08:34):
so when you're using somethingto prevent something in a
healthy person, the bar is setextremely high.
It really can have no sideeffects or risk.
When you're using something totreat an existing condition, you
have to accept some amount ofside effects and risk because
you're treating a problem.
And this is important toseparate, because some women use
(08:55):
hormone therapy just fortreatment.
Some women use it for bothtreatment and prevention and
there's some women who just useit for prevention.
And it's very important toclarify your goals and it's so
important to understand that theWHI was not a menopausal
treatment trial and inretrospect it actually really
(09:15):
wasn't a very good preventivetrial because most of the women
were an entire decade past theage of menopause and within that
decade you lose some of theeffects on the estrogen receptor
with methylation and many womenget subclinical disease.
Even if they're not diagnosedwith heart disease, they may
have some existing plaques.
(09:35):
So it truly wasn't thepreventive trial that we had
thought it was, and earlyinformation indicated that women
who are postmenopausal andusing the combination
prescription drug which wascommonly prescribed at that time
, called Prempro, which was acombination of 0.625 of
conjugated estrogens and 2.5milligrams of
(09:56):
medroxyprogesterone acetate, or5 milligrams of
medroxyprogesterone acetate orfive milligrams of
medroxyprogesterone acetate thatthey faced a slightly increased
risk of just being diagnosedwith breast cancer, heart
disease, stroke and blood clots,compared to the postmenopausal
women who were just taking aplacebo or a dummy pill.
(10:16):
However, the increased risk ofheart disease were seen only in
women several years past the ageof menopause, after the age of
70.
Are seen only in women severalyears past the age of menopause,
after the age of 70.
And the risk of breast cancerwas rated in the rare category,
even less than what was in thepackage insert.
This was not a treatment studyof younger midlife women.
(10:37):
It was a study of predominantlyolder women.
Most of them were between theages of 63 and 67.
And they, by and large, didn'teven have menopausal symptoms
anymore.
And because it was a so-calledpreventive study and the bar was
set so low for accepting anyrisk, the WHI discontinued this
study in this subset of women,saying that the risks were just
(10:59):
too great to continue, notbecause more women taking
hormone therapy were dyingthat's very important to note
compared to placebo but becausesome risks were noted in the
treatment arm.
Well, there were also benefitsnoted, and that's really
important.
When you look at large studies,comparing some treatment option
to a placebo is the one thingyou absolutely cannot argue with
(11:20):
is death rates, and that's anabsolute outcome, and so you
never want the treatment arm tohave a higher risk of death, and
in the WHI there was not.
But clot was a risk, and therewas one in every thousand women
extra who took hormones for 10years were diagnosed with breast
(11:42):
cancer, didn't die from breastcancer, but were just diagnosed.
Now, another two years later,the NIH halted the other portion
of the WHI, which was thecomponent just investigating
Premarin 0.625, an estrogen-onlyoral option in women who had
already had a hysterectomy.
In this study, the participantswho were older than 60 had a
(12:06):
very slightly increased risk ofstroke one extra case per 1,000
women but they didn't show anyincrease in heart disease and
they actually had a marked 33%decrease in the risk of being
diagnosed with breast cancer,and that reduced risk persisted
into the 70s.
But by this time many women whohad undergone a hysterectomy
had already stopped takingestrogen therapy, spooked by all
(12:28):
the negative media reports in2002.
And it's so ironic that so muchof their fear centered around
the reported increased risk forbeing diagnosed with breast
cancer and heart disease, whichdid not materialize in the
estrogen-only arm.
Most women didn't realize thatthere's a risk in not taking
hormone therapy when it's needed.
The latest information from theWHI study is that for women who
(12:52):
are within 10 years ofmenopause, who've taken hormone
therapy for five or more yearswhether it's estrogen alone,
hysterectomized women orestrogen plus progesterone if
you have a uterus there is a 30%reduction in all-cause
mortality.
That's significant, significant.
There was reduced risk of death.
(13:14):
So what are we to believe abouthormone therapy?
In my opinion, misunderstandingsurrounding the WHI study has
designed unnecessary panic.
This was a prevention, not atreatment study, and two-thirds
of the women, as I mentioned,were over the age of 65, which
is a good 10 to 15 years laterthan most women would even start
hormone therapy, and thestudy's purpose was to see
(13:36):
whether hormone therapyprevented certain diseases, it
was not designed to measure theeffectiveness on treatment of
menopausal symptoms.
Furthermore, the AmericanCollege of Clinical
Endocrinologists announced in2008 that the benefits of
hormone therapy in women underage 60 far outweighs the risk.
This was based on a reanalysisof the data of the WHI in women
(14:00):
under 60.
It took several years for theWHI investigators to release the
age stratified risk andbenefits, and that again, is
important anytime you're lookingat any intervention for any
prevention or treatment arm,because age sex comorbidities
(14:21):
dramatically can changesomeone's risk for a condition.
So it's concerning to me thatthese WHI investigators withheld
this age stratified data fromthe beginning and they didn't
release it until years later.
So much of the increase incardiovascular risk that was
(14:42):
publicized in 2002 was just seenin those older women over age
70, who were so many years pastmenopause, who were starting
quote preventive hormone therapymore than a decade after being
exposed to any of these hormones.
And so we know from the timinghypothesis that if you start
with healthy arteries and ahealthy brain, the hormone
(15:04):
therapy does seem to have somebeneficial preventative effects.
But if it's been over a decadeor more and there's some
underlying disease of thearteries, of the neurons in the
brain that adding estrogen tothe mix may not at all be
helpful and in a very smallpercent may be harmful.
(15:24):
May not at all be helpful andin a very small percent may be
harmful.
So this is in contrast to olderwomen who have been on hormone
therapy since the beginning ofmenopause and done well and not
demonstrated any evidence ofblood clot.
So just because you're over 60or over 70 doesn't mean you
can't continue safely on hormonetherapy.
(15:54):
The biologic age and especiallythe age of actual menopause and
the time a person has gonewithout hormones those time
frames are very important inhelping your physician interpret
the benefit and risk.
And it's also important to knowthat in women without a uterus
taking estrogen under the age of60, even with oral estrogen,
there was no increased risk ofstroke.
In fact there were two lesscases per thousand compared to
(16:18):
placebo.
So I see women every day whosaid oh, my doctor said
increased risk of stroke.
That's the reason I should stopthe estrogen.
And you can mitigate this inwomen over 60 or 65 by simply
changing to transdermal orcutting the standard 0.625
conjugated estrogen down to 0.45or 0.3.
(16:40):
Or if someone's on a milligramof estradiol, cutting that down
to 0.5.
So the bottom line is hormonetherapy is still the absolute
best treatment for recentlymenopausal women who are having
significant symptoms.
Women have no reason to fearhormone therapy or doubt its
efficacy as a solution foruncomfortable and potentially
(17:02):
debilitating side effects.
The key is to tailor hormonetherapy to each woman's
individual needs, and with somany options available, let me
tell you this is so much easierthan it's been ever before.
Now one of the things that Irun into is just whether
insurance covers it, and that isa big hassle, and I will have
(17:24):
future podcasts on the speakingof women's healthcom uh regular
podcast going over um tips toreduce the cost of medicine,
because that's the one thingthat we end up dealing with most
, most of um the office visits,sadly.
(17:46):
So what the WHI study showed usis that in much, much older
women who don't have anysymptoms of menopause, they
should not only take hormonetherapy solely for just
prevention.
In fact, there isn't one pillthat we encourage all women to
take not aspirin, not vitamin E,certainly not a single
(18:10):
prescription medicine.
For instance, we advise womenat high risk for heart disease
and stroke potentially to takeaspirin to reduce the risk of
stroke, but it can increasehemorrhagic stroke and GI bleeds
.
We certainly don't tell allmenopausal women to take aspirin
(18:31):
.
We don't tell all people totake statins
cholesterol-lowering medicines.
The message is that one sizedoes not fit all.
All treatments have to beindividualized and periodically
assessed, and every medicine,prescription as well as
non-prescription supplements,carry potential risk and
(18:52):
potential benefits.
So don't throw the baby outwith the bathwater.
Statins and hormone therapy aninteresting comparison.
Like hormone therapy, manymedicines used for prevention,
such as using statins,cholesterol-lowering medicines,
have risks and side effects.
However, we certainly don'ttell all people with high
cholesterol just to throw outtheir statin because a small
(19:13):
number of them may have a sideeffect.
Yet this is exactly whathappened to millions of women
when the proverbial hormonetherapy rug was pulled out right
from underneath them.
Breast cancer rates with statintherapy are actually comparable
to breast cancer rates withhormone therapy.
Rug was pulled out right fromunderneath them.
Breast cancer rates with statintherapy are actually comparable
to breast cancer rates withhormone therapy.
And still, statin agents arethe most commonly prescribed
class of medication.
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Women on hormone therapyactually have a reduced risk of
death and cardiovascularmortality if they start hormone
therapy within 10 years ofmenopause, something that can't
be said for primary preventionsin women with statins.
Now men have some evidence ofprimary prevention with statins,
and both men and women whoalready have existing heart
disease have evidence of reducedrisk of heart disease with
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statins, but not primaryprevention for women in their
50s.
What's more is, statins haveonly been shown in women who
already have heart disease or atvery high risk for heart
disease, and so there's notreally good definitive
information on the usefulness ofusing statins in younger women
solely as prevention.
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In fact, statin use in womenincreases the risk of diabetes,
and diabetes is our worst riskfor women for cardiovascular
disease than diabetes is for men, and hormone therapy actually
reduces the risk of diabetestype 2 by 30 to 35%.
So no medicine or substance isperfectly risk-free.
(20:39):
But that doesn't mean we don'tuse agents.
We need perspective.
So that requires you and yourhealthcare clinician to provide
and perform an individualizedrisk-benefit assessment.
Don't let the media hype scareyou.
They're not your doctor andhave known heart disease.
(21:01):
Data from Tommy McCullough outof Finland shows that women that
are on statins and hormonetherapy have a lower risk of
heart attack and stroke comparedto women over 60 just on
statins or just on hormonetherapy.
So it's not that I don'trecommend statins in some women,
(21:22):
but this rush to use them andput them in the drinking water
when they don't improvemenopausal symptoms or help the
genitourinary atrophy or thesleep or reduce the risk of
fracture, when we know hormonetherapy does those items.
It's just helpful to make thatcomparison, so informing the
(21:47):
debate.
You've probably read plenty ofcontradictory reports by now,
leading you to question whetheryou should use hormone therapy
or, if you started, how long youshould continue.
I hope by listening to thispodcast, your anxiety is going
to be quelled.
Let's take a look at some of themost important questions
concerning hormone therapy.
Here are my conclusions, drawnfrom years of clinical practice,
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careful interpretation of manywell-designed scientific studies
, which includes observationaldata, randomized controlled
trials, meta-analysis, casereports, because all of those
have their role to play.
What exactly is hormone therapy?
Well, hormone therapy is whenthe body is given a bit of
(22:35):
estrogen plus minus progestogen,in the form of either a
synthetic progestin orprogesterone if one has a uterus
slash, an endometrium lining ofthe uterus.
So sometimes, even in womenwith hysterectomies who have
endometriosis, we still may useprogesterone.
The ovaries are responsible forproducing estrogen and
(22:55):
progesterone, and sometestosterone in women, but
during menopause and especiallyfollowing complete hysterectomy,
when both the ovaries areremoved, we might not produce
the amounts that we need toregulate several bodily
functions.
So, essentially, by replacingsome of these missing hormones
with a pill or a patch or gel orother forms we'll discuss in
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future chapters the body staysbalanced.
So estrogen relieves hotflashes, vaginal dryness and
other symptoms associated withmenopause, such as dry, itchy
skin, and, taken in combinationwith estrogen, progesterone
prevents the cell overgrowth inthe lining of the uterus, which
is very important at reducingendometrial hyperplasia and
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endometrial cancer.
Some women prefer estrogen inthe form of just human estradiol
, which is the same exact potentestrogen that's produced in the
egg.
Other women prefer conjugatedestrogens, which last for a
whole 24 hours, as opposed tooral estradiol, which needs to
(24:01):
be dosed at least twice a day,and conjugated estrogens are a
mixture of several estrogensthat are usually derived from
either horse urine orsynthesized in a lab.
If a woman's had a hysterectomyand is particularly concerned
about breast cancer risk, Iactually do recommend the
conjugated estrogen Premarin,because it's the estrogen that's
(24:22):
been studied in the longestformat in women with
hysterectomy up to 11 years andnot only has it not shown any
increase in breast cancer.
In fact, the Premarinestrogen-only arm of the WHI
showed a decreased risk ofbreast cancer in hysterectomized
women even into their 70s.
Now there's some women whodon't want to use an animal
source of estrogen.
(24:42):
So in the past there was asynthetic form of conjugated
estrogens called Injuvia on themarket, but it's not exactly
bioequivalent and I don't thinkit's commonly able to oogen.
(25:08):
So just as many women havepreferences regarding the type
and dose and route of estrogen,many women also have some strong
feelings about progestogens.
Again, one size does not fitall.
Some women prefer to takenatural progesterone in the form
of prometrium, but it's mixedin peanut oil so it's not
suitable for women allergic topeanuts.
Other women feel too sleepy orgroggy on prometrium, which has
(25:32):
to be taken at night with alittle bit of food.
Rarely the natural progesteronerelaxes the lower esophageal
sphincter and heartburn happens.
Some women may prefer aprogestin such as norethendrone
acetate.
It's in very many common birthcontrol pills such as low estrin
.
It's also in low-dose FemHeartand Activella or generic MIMV,
(25:56):
and comes in different doses,like Activella is one milligram
of estradiol and a 0.5 ofnorethadrone acetate, or the
low-dose activella or low-doseMIMV is only a half a milligram
of estradiol and the 0.1 ofnorethadrone acetate.
Now when you combine theestrogen with the progesterone
(26:19):
in a pill form or a patch form,it lasts longer If you separate
the two.
Oral estradiol has a very shorthalf-life.
Now there's a newer progestogen,drosperinone, which is actually
a derivative of spironolactone,and that's in birth control
pills like Yaz and Yasmin andSafral and B-Yaz.
(26:40):
But it's also found in amenopausal formulation of
estradiol, which is bioidenticalestrogen.
With drosperinone, and becauseit's similar to spironolactone,
it may give some benefits toskin and hair, especially if
women have had some negativeeffects from too much androgens
(27:01):
or testosterone, anddrosperinone is a mild diuretic
and it might lower bloodpressure and help cholesterol.
Some women cannot toleratesystemic progestogens and need
to use progesterone in the formof a gel, like a 4% vaginal gel.
Other women who've done well onPrempro are using it in lower
(27:22):
doses, with only 1.5 milligramsof medroxyprogesterone acetate,
which was well studied in theWomen's Hope trial.
Now I'm not a fan of usingmedroxyprogesterone acetate for
over five plus years becauseit's very anti-estrogenic and so
I think it's probably the worstone.
(27:43):
On the breast.
Most progestins don't haveindependent bone effects, but
there's some evidence thatnorethendrone acetate, which
sometimes we use alone in womenwith severe endometriosis, may
have some bone benefit.
Some women like the naturalsedating and anxiolytic effects
of natural progesterone.
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And there's only onecombination of oral estradiol
with natural progesterone in theform of bijuva, which we've now
had for about four years, butit only comes in one standard
dose.
I really wish we had threedoses.
So it comes in one milligram ofestradiol with 100 milligrams
(28:24):
of progesterone, but instead ofbeing mixed in peanut oil it's
micronized in coconut oil, sothis is taken after dinner.
Other women who don't want totake a pill, maybe because they
have nausea or gallstones orthey've had a history of a blood
clot or they've not ever usedhormones and they want to use
the lowest risk option mightwant to use a weekly patch of
(28:47):
ClimeraPro, which is estradiol,bioidentical and levonorgestrel
in a fixed combination of 0.45of estrogen.
Now women who are concernedabout low testosterone might
want to use transdermal orvaginal hormones which don't
increase sex hormone bindingglobulin, because that protein
(29:11):
is increased in the liver whenyou take oral estrogen, which
then lowers testosterone.
So women with hair loss andacne actually may prefer oral
over transdermal transdermal.
(29:31):
There is a twice a weekestrogen progesterone patch with
0.05 estradiol and twodifferent doses of norethadrone
acetate 0.14 and a higher dose,0.25.
And that's changed every 84,which is 3.5 days.
So there are plain genericestrogen patches and generic and
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brand name twice a week patches.
In women who spend lots of timein the water or humid climates
they might find that the patchesdon't stick well and they might
want to use a transdermalestradiol but don't want to be
marked with a patch.
E4 is being studied and it'sanother natural estrogen and
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it's in a current birth controlpill, nexstellis, and it is
being studied in postmenopausalwomen as well, but at the time
of the taping, which is March of2023, we don't have that
available.
In the past we had thiswonderful soybean-based estrogen
oil called Estrazor, but that'snot on the market anymore.
(30:40):
We do have a couple ofquick-drying alcohol-based gels
DiviGel, which comes in threelittle packets in three
different sizes 0.25, which isuber low dose, 0.5, and 0.1.
And even the 0.1 dose, thehighest strength dose, is a
pretty low dose.
(31:01):
There is Estrogel one squirt aday to the skin, or elesterin,
which is up to two squirts, andthere's one spray of estrogen
called Evamist and itinterestingly peaks the estrogen
level around two or three inthe morning if you apply it in
the morning, and certainly sleepdisturbances can occur.
(31:22):
So it's kind of nice, nice, youget that little boost at night
and each container has 60squirts or sprays after you
prime it once and so for womenwho don't want to rub things on
their hand, the spray is a niceoption.
There are some research studieslooking at intranasal estrogen,
but that's not standardlyavailable.
(31:46):
And there is vaginal estrogen.
Most of that's local, but thereare the formulations of the
femoring in two doses, 0.5 and0.100.
So, for all the reasons thatwe've discussed so far in this
podcast, many women willcontinue to turn to hormone
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therapy as a safe, effectiveoption.
Are older women who takehormone therapy at greater risk,
you may ask.
Well, starting hormone therapy10 to 20 years after the onset
of menopause generally issomething that we don't
routinely do if you're solelytaking it for prevention or just
to promote general health.
(32:27):
But that being said, women whoare, say, 65 years old can take
hormone therapy to relieve hotflashes, treat genital dryness,
sexual dysfunction and preventosteoporosis, particularly if
they started it and they've donewell on it and they just want
to continue.
But in order to reduce strokerisk in women over 65, I usually
reduce the dose of estrogen bythe time a woman is 65.
(32:49):
And that's certainly when weassess further for heart disease
risk.
If the blood pressure iscreeping up, that may need to be
treated, and it's always theright time to talk about weight
reduction, intermittent fasting,smoking cessation, improving
cholesterol ratios, gettingadequate sleep, maybe having a
blood pressure cuff at home andchecking your blood pressure
(33:11):
more frequently, as well asdiabetes prevention or treatment
.
As for younger women, the risksfound in the WHI do not apply
to them, so a 25-year-old womanwho finds herself in premature
menopause should not identifywith the results of research
that was done in60-plus-year-old women, and that
is just a devastating mistakethat I see too many people make.
(33:36):
Are low doses of hormone therapyjust as effective as previous
standard doses?
Many times, the answer is yes.
Low doses of hormone therapyare generally effective at
treating hot flashes, and thehope is that lower doses will
assure women that it's okay tostart and continue hormone
therapy, as well as give themmore options and dosage ranges.
(33:57):
But there's no pat answers thatapply to all women at all
phases of life, and women withsevere menopausal symptoms may
not benefit from a low dose asmuch as they would from a higher
dose, which, I remind you, isnot even that high a dose and it
is FDA approved and safe.
For example, a woman whosuffers from debilitating
anxiety attacks coupled withserious hot flashes and thin
(34:20):
bones might fare better with ahigher dose of hormones.
So would younger women, womenwith faster metabolisms, women
who've lost their ovaries.
Furthermore, an average doseprescribed for one woman with a
fast metabolism may be way toolow for another woman who has a
slower metabolism or who's older.
(34:40):
Most of the studies that showimpressive reductions in
osteoporosis and bone breakagehave not used the uber uber low
doses.
So if you're going to use uberlow doses, you still may need to
use something extra for thevagina and for the bones, and
then I find that you're just,you know, increasing the time
and the expense.
But each woman's needs aredifferent and the same woman can
(35:04):
metabolize the same dose ofestrogen differently.
And because each woman's needsare different, you must have a
health assessment to determinewhere you are, whether you're at
risk for hormonal loss, even ifyou have no menopausal symptoms
and what dose to begin with,and if it's beneficial to you,
and we'll discuss more of thisin the podcast on Chapter 11.
(35:26):
And at least once a year thisshould be assessed by your
physician and if you're stable,a women's health nurse
practitioner can certainlyexamine you and give you refills
if all is the same.
But if you've got a new problembleeding or a new medical
diagnosis or you're approachingyour 65th birthday and about to
(35:49):
go on Medicare, where a lot oftimes the coverage of these
hormones also change, it's goodto maybe touch base again with
your physician and we're goingto have future podcasts on
reducing the cost of medicinesand what things you should look
for when you're looking forsecondary insurance when you
become of Medicare age.
(36:09):
Will hormone therapy protect myheart?
Well, observations from studiessuch as the Nurses' Health
Study show a lower incidence ofheart disease in women who took
hormone therapy.
Other studies have found thathormone therapy favorably
affects cholesterol ratios,improving the good HDL
cholesterol with oral hormonesand reducing the LDL cholesterol
.
But oral estrogen can increasetriglycerides, so I usually
(36:33):
avoid oral estrogen if a womanhas had a triglyceride level
over 400 or is diabetic withoutgood control, or in someone who
has any risk for blood clotcontrol or in someone who has
any risk for blood clot.
But in the heart and estrogenprogestin HERS trial women who
already had existing coronaryheart disease did not have a
lower rate of cardiac eventswhen taking PremPro, and the
(36:55):
American Heart Association hasissued various guidelines and
they basically state youshouldn't use it to treat or
prevent heart disease.
But you can certainly take itfor other indications, and the
most recent American HeartAssociation guidelines actually
acknowledge menopause andestrogen deficiency as a risk
for cardiovascular disease, andwe'll go into that in much more
(37:17):
details in a future podcast.
So a 30-year-old woman whosmokes and is overweight is not
at immediate risk for heartattack, but her lifetime risk is
very high and it should beaddressed then.
And even a 50 year old womanwho only has one risk factor for
heart disease still has anincreased absolute lifetime risk
for heart disease and a shorterduration of life.
(37:39):
So that needs to be addressed.
So we don't use hormone therapyspecifically to prevent heart
disease.
Cirms, which are selectiveestrogen receptor modulators,
such as avista, raloxifin andantioxidant vitamins, are also
not specifically recommended forthe prevention of heart disease
.
So women at the very highestrisk for heart disease should
(38:01):
certainly aim to reduce theirLDL cholesterol under 70, to
stop all forms of nicotine, tocontrol blood pressure and blood
sugar and also be assessed fordepression, which is a risk for
heart disease.
Whi findings did discourage theuse of just broad spectrum
(38:23):
hormone therapy as just a broadspectrum heart protection.
But hormone therapy is notdamaging to the heart per se and
if you take it for five to 10years within 10 years of
menopause, starting under age 65, generally there's actually
less cardiovascular disease andless diabetes.
(38:46):
So this is so much informationto process and consider and I
think that the biggest risk withhormone therapy is the rare
risk of blood clot, particularlywith oral estrogen, and oral
estrogen with progestins furtherincrease that risk.
So knowing your family historyand your personal history is
important and if you're someonewho's had blood clots or has
(39:10):
genetic risk for blood clots,such as prothrombin G mutation,
factor V, leiden, we generallydon't use oral estrogen In the
menopausal state.
We use transdermal.
So don't plan on solely takinghormone therapy for anti-aging,
even though there are probablysome anti-aging benefits, but
(39:32):
certainly in younger women withpremature menopause.
Definitely consider it stronglyand you're probably going to
have some benefit incardiovascular risk and
anti-aging if you start hormonetherapy and you already start
with healthy arteries Becauseestrogen has so many complex
effects on nitric oxide it's acalcium channel blocker.
(39:55):
It improves blood flow.
It has effects on cholesterol,some antioxidant effects and
certainly in diseased arteriesit can promote clot disruption.
So it's got a lot of complexeffects.
Do take hormone therapy fortherapeutic effects if you need
(40:18):
it and you're being monitored,and stay tuned for further
research.
And how will hormone therapyaffect by blood pressure, you
might ask.
Hormone therapy generally doesnot have a negative effect on
blood pressure.
In fact, sometimes the bloodpressure actually increases less
over time in women who takehormone therapy than in those
who don't.
It generally increases with allpeople with age.
(40:40):
Certainly, higher doses ofsynthetic pharmacologic doses of
estrogen, such as in birthcontrol pills or hormonal
contraception, can increaseblood pressure and affect the
run in angiotensin system.
Does hormone therapy improvedepression, feel-good
(41:00):
neurotransmitters in the brain,serotonin, dopamine or
epinephrine?
Because the replacement of lostestrogen and occasionally
progesterone or androgens canimprove a woman's self-image and
comfort level and sleep.
And so it's reasonable toconclude that hormone therapy
can positively affect the moodin many, but certainly not all,
(41:22):
women, and some progestogensnegatively affect women's mood.
But many medications, whetherthey're mood medicines, blood
pressure medicines, cholesterolmedicines, actually seem to work
better when there's adequateestrogen.
Hormone therapy might exertbenefits beyond helping women
regain their even mood byeliminating the unpleasant
(41:43):
symptoms of menopause.
When women who've beenprescribed estradiol stop their
therapy, their hot flashes canreturn, but sometimes the
depression does not.
The jury's out regarding whyestrogen has exact
antidepressant effects in somewomen.
We know it's effective inkeeping depression at bay in
some women, while also reducingsevere menopausal symptoms.
(42:04):
But estrogen in general is notrepeat, is not a standalone
treatment for major depression,and women who've never had
depression, anxiety or panic butwho all of a sudden develop
these symptoms during menopausecertainly needs to see a women's
health specialist whounderstands the connection in
the brain between hormones andneurotransmitters.
(42:27):
Does hormone therapy improvecognitive function, both memory
and thought processes?
The answer to thiscontroversial question seems to
depend on the timing.
Some studies show long-termusers of hormone therapy who
started hormone therapy at thebeginning of menopause show
better memory function later inlife than women who began it
much later.
Other studies show thatstarting hormone therapy long
(42:49):
after menopause actually maycause some cognitive decline,
and that might be in women,because over age 65, oral
estrogen can increase the riskof stroke.
Clearly more research is neededbefore we can better define the
role of hormone therapy incognitive functioning.
Can breast cancer survivors usehormone therapy?
If you're a breast cancersurvivor or receiving treatments
(43:12):
for cancer, you would have todefinitely discuss hormone
therapy with an expert.
Generally it's not prescribedfor women in active treatment,
since some breast cancers maygrow when exposed to estrogen.
But there's lots ofalternatives and survivors who
have debilitating symptoms ofmenopause may want to explore
low-dose hormone therapy.
The HABITS trial HormoneReplacement After Breast Cancer
(43:36):
Is it Safe?
Study showed an increased riskof breast cancer recurrence if
hormone therapy was used,particularly with high doses of
progestins, but other studieshave shown no increased risk and
perhaps survival benefit, andthis could be due to the bias of
patient selection and or fordifferent effects, as the trials
that used more progestins didseem to have worse outcomes.
(43:58):
Certainly, most breast cancersurvivors can use the vaginal
string, vaginal local estrogencreams or vaginal DHEA to
restore the integrity of thevagina, and many women who are
receiving therapies that wipeout estrogen need bone agents
like zolendronic acid, known asReclast, or denosumab, also
(44:20):
known as the brand name Prolia.
And certainly, if a young womanundergoes breast cancer and is
done with her breast cancertreatment, we we do not.
We no longer prevent thatperson from deciding about
whether she wants to becomepregnant naturally or through
(44:40):
assisted techniques, and womenwho have had breast cancer and
have a pregnancy which is veryhigh levels of hormones
afterwards have the same or, insome cases better, outcomes than
women who have not beenpregnant after their breast
cancer diagnosis.
So, as you can see, it's verycomplicated.
Can we predict who will benefitfrom hormone therapy and who
(45:04):
are the small portion of peoplewho might be harmed from hormone
therapy?
And who are the small portionof people who might be harmed?
I think genetic testing andevolving research will probably
allow us to further determine inthe future, more fine tuning,
who are the people that are thebest candidates for long-term
therapy, as well as those fewwomen who are predisposed to
clots or could be potentiallyharmed.
But what we do know now is thatshort-term therapy is safe and
(45:25):
effective for the vast majorityof women within 10 years of
menopause and it's not ahigh-risk proposition for those
who have discussed the optionwith their physician and found
to be suitable candidates.
But individualization,monitoring and re-evaluation are
critical and while there's notime limit to feeling well and
(45:46):
no specific time limit tohormone therapy contrary to the
urban myth that it's only fiveyears periodic reassessment is
needed and some peopleerroneously tell women oh, after
five years you have to stopflashes and you've been on
(46:07):
hormone therapy and your hormonetherapies are stopped and
you're under the age of 60, even65, you have a higher risk of
stroke and heart attack becauseof the resultant hot flashes
than someone who continues ontherapy.
So there are risks in stoppingtherapy.
Hormone therapy it works.
The WHI study found that 77% ofthe women in the study who
complained to hot flashes saidtheir hot flashes significantly
(46:28):
diminished when they were onhormone therapy.
Bear in mind that women withsevere hot flashes were not
included in the study becausethey would have known right away
if they were taking the drug orplacebo, although we do know
that the brain is powerful andplacebos have about a 30% effect
.
There are other options fortreating hot flashes.
You can go back and listen topodcast chapter seven, as well
(46:50):
as the medical CME free podcastthat talk about the candy neuron
inhibitors and non-hormonaloptions for hot flashes, but
none is as effective and broadas hormone therapy.
Weighing the risk and benefits,again, I stress that hormone
therapy is still the besttherapy for treating symptoms
and menopause.
All women should determinetheir risk profile with a
(47:13):
knowledgeable clinician beforestarting any prescription
treatment.
Having said that, let's look ata summary of the risk and
benefits.
Hormone therapy benefits Treatshot flashes.
Helps prevent and treatosteoporosis.
Prevents vaginal changes fromthinning tissue.
May improve the skin appearanceand hair.
Reduces the risk of diabetes.
(47:33):
Might reduce the risk for coloncancer.
We need further studies.
Now.
What are the risks?
The biggest risk is the rarerisk of blood clot, dvt,
especially with oral hormonetherapy.
Oral hormone therapy is alsoassociated with some increase in
gallbladder disease, a need forgallbladder removal.
(47:54):
There is an increased risk ofstroke, primarily in older women
with higher oral doses.
For women with a uterus who havenot had a complete hysterectomy
of removal of their uterus,estrogen alone can increase the
risk of uterine hyperplasia anduterine cancer.
But if you take estrogen withprogestogen, you reduce this
risk lower to the risk ofplacebo, but you still can get
(48:19):
uterine cancer even being onhormone therapy.
Hormone therapy has no apparenteffect on the risk of ovarian
cancer.
So don't forget to put theserisks and benefits into context,
because there is a risk in nottreating your symptoms.
A lot of women can't functionand go to work, they have
multiple doctor visits, theirpersonal relationships fall
(48:42):
apart and they are not as activebecause they don't feel as well
, which then promotes furtherweight gain, which promotes
further medical problems.
So you have to look at thewhole picture.
So you ask is hormone therapyright for me?
First of all, if you don't feelcomfortable about taking
hormone therapy, remember,throughout this podcast we have
(49:05):
so many descriptions ofalternative therapies lifestyle
changes, food, vitamins, stressreduction, exercise, other
non-hormonal pharmacologicagents.
Some are proven, others are not.
As we've seen for women withsevere menopausal symptoms,
sometimes alternatives are notenough, and you certainly don't
(49:25):
have to suffer before youconsider hormone therapy.
I mean, every day I see someonewho's just suffered so long and
they thought that they had tohave the worst symptoms ever,
which is not the case.
So you should be asked thesequestions, though, before being
prescribed hormone therapy Doyou have abnormal vaginal
(49:47):
bleeding, heavy periods,postmenopausal bleeding,
spotting after intercourse orwhen wiping yourself?
Is there a history of cancer inyour family?
Early heart disease, bloodclots?
Have you personally had anyendometrial or uterine cancer?
Have you personally had bloodclots in the veins, superficial
or deep, especially duringpregnancy or when taking birth
(50:10):
control pills?
If you've never had blood clotsand you've had pregnancies,
perhaps a C-section, or takenoral birth control pills or
hormonal contraception, becausethere is a hormonal birth
control patch and a couplevaginal rings NuvaRing and the
one-year Anavera ring.
If you've used these agents andhaven't had a blood clot,
(50:31):
chances are you're probably nota clotter.
Do you have chronic liverdisease, because oral hormone
therapy does go through theliver.
Do you smoke?
Certainly, women who are overthe age of 35 who smoke even one
cigarette a week cannot takehormonal contraception and we
don't want our menopausalpatients and postmenopausal
patients to smoke.
(50:52):
But if you do smoke, that isnot an absolute contraindication
to menopausal hormone therapylike it is for hormonal
contraception.
There's a big difference.
Do you have any activegallbladder disease?
So if you answer yes to any ofthese questions, you might need
to further individuate yourtherapy and you might not be the
(51:12):
best candidate for hormonetherapy or it may need to be
adjusted.
So for women with liver diseaseor increased risk of blood
clots, high triglycerides,gallbladder problems in those
women, it's probably moreprudent to use a low-dose
hormone therapy or go thetransdermal route.
Now, remember this podcast isnot medical advice and it's just
(51:34):
a form of some information tohelp arm you to be ready to
discuss these issues with yourpersonal physician.
If your answer to everyquestion, though, is no, then
you're probably a good candidatefor hormone therapy, and you
have to just try it for at leastthree months and see how you
feel.
(51:54):
The lower the dose, the longerit takes to feel better.
So if you go with some uber lowdose, it may take up to six
months.
If you go with a standard dose,some women feel better within a
few weeks, certainly within 12weeks.
Am I better off with analternative?
Some women choose not to starthormone therapy for personal
reasons.
Maybe they don't have hotflashes, their bone density is
(52:15):
normal.
They don't want to take anypharmaceutical agent.
If you're a breast cancer withhot flashes, certainly look into
the candineuron inhibitors ifthey've hit the market
Venlafaxine or desvenlafaxine,which is a Fexor, or Pristique.
(52:36):
We discussed those options inprior podcasts and we'll be
talking about them also incustomizing therapy for more
details.
And don't forget to get yourbone density checked and get
periodic vaginal and vulvarexams to see if there's any
signs of thinning.
If you're a current breastcancer patient and you're taking
(52:57):
tamoxifen or an aromataseinhibitor, in general those
women are completely discouragedfrom using any systemic
estrogen use, and that alsoincludes oral DHEA, which I have
seen some integrative andfunctional medicine doctors
prescribe.
The vaginal DHEA is fine, butnot oral.
What about if you're a woman whodoesn't have breast cancer, but
(53:19):
you just have an increased risk?
If you don't have hot flashesbut are at risk for spine
fractures thin bones in thespine you may really want to
consider the prescriptionmedicine raloxifin, also known
as Avista for five years becauseit's FDA approved to reduce the
diagnosis of invasiveestrogen-positive breast cancer
(53:40):
as well as reduce fracture risk.
Similar to menopausal hormonetherapy, avista has a slight
increased risk of blood clots,particularly if you're
immobilized, but does notincrease the risk of stroke in
older women like oral estrogendoes.
However, older women with heartdisease who have a stroke while
they're on raloxifin may have aslightly higher risk of stroke
(54:02):
death.
So, as with any medicine,there's benefits and risks and
it has to be individuated.
What if you're a woman with ahistory of stroke or heart
attack?
Well, certainly you need thestandard cardiovascular
evaluation and treatmentlowering the LDL cholesterol,
treating the blood pressure,stopping smoking, treating
(54:23):
diabetes, discussing whether youneed to be on aspirin or a
blood thinner as well as astatin in the evening,
discussions on whether babyaspirin is appropriate, doing
cardiac rehab with appropriateexercise, being on a
Mediterranean diet.
So we don't use hormone therapyor roloxifin or antioxidants to
(54:44):
prevent a heart attack orstroke in someone who's had the
disease.
But if your cardiac status isstable and you have other
indications for hormone therapy,you certainly can be continued
on these hormone therapy andmany women function better.
So if you are a heart attacksurvivor and having menopausal
(55:10):
symptoms, just like if you're acancer survivor or you've had
blood clots, those specialgroups of women do benefit from
seeking out a menopausespecialist as opposed to just a
women's health doctor, and youmay want to go on our website,
speakingofwomenshealthcom, or onmenopauseorg.
So if you have had a heartattack or stroke or even a
(55:37):
carotid dissection, which may bemore common in pregnancy or in
some women on hormone therapy,once you're medically stable and
if your symptoms are severe,you still may consider hormone
therapy.
But it's critical first tostabilize your status, work with
your cardiologist or women'shealth specialist and evaluate
all the risks before beginningany treatment.
(55:58):
Paradoxically, though, womenwho do have a heart attack while
on hormone therapy actuallytend to respond better to
treatment than women who've hada heart attack and who are not
on hormone therapy theCalifornia teacher study showed
this Less ventriculararrhythmias.
For someone experiencingmoderate to severe hot flashes,
hormone therapy is truly thebest option for your hot flashes
(56:22):
.
Though women may tryover-the-counter products such
as black cohosh remifemin,they're generally not that much
more effective than a placeboand may help more with sweats
than with flashes.
For preventing osteoporosis,many women, when they stop,
rapidly lose bone, typical ofperimenopause and early
postmenopause.
(56:43):
So if the only reason you'reusing hormone therapy is to help
your bones, you can certainlyuse other bone agents, but
estrogen is the only optionshown to reduce all types of
fracture in women who have anormal bone density as well as
it reduces fractures in womenwith osteopenia and women with
osteoporosis.
(57:03):
Please tune in to our podcast,chapter 12, to go into bone
detail, and we're also going tohave an upcoming CME podcast on
bone health.
A final word on hormone therapyand choice.
I'm often discouraged by themedia warnings that continue
about hormone therapy, although20 years post-WHI the tides
(57:27):
turned a little bit.
I had so many women recentlysend me links to a New York
Times article about how you knowthey had gotten it so wrong 20
years ago.
I'm like, yeah, tell me aboutit.
I've known about this since thebeginning, but it's so bad that
the media has really affectedso many women's psyche because
(57:49):
it's really dealt a direct blowto symptomatic, suffering women.
Of course, all therapies,including hormone therapy,
should be scrutinized foreffectiveness and risk, and all
women should be listened to andno one should disregard their
concerns or symptoms.
Just like with any biologicpharmaceutical agent,
(58:13):
understanding risk associatedwith any therapy is critical
before the woman and herhealthcare clinician can make
educated decisions together.
The problem occurs whenscientific studies are just
misrepresented for clicks andblown up into national headlines
that don't address the fullpicture, don't address the facts
(58:35):
underlying a particular study.
This happens too often andthese mixed messages confuse
women who are very busy, and itdoes a great disservice to them.
So we feel as if our choicesare limited and that our safety
is at risk.
And if you want to controlsomeone, you make them fearful.
So anytime you become fearful,your antenna should go up that
(58:59):
someone's trying to control you.
So if you're suffering fromsevere menopausal symptoms,
don't be a martyr.
Please Don't allow yourself tolive each day feeling like less
of a person because of yourdiscomfort and distress.
There are so many options andhormone therapy is one of them.
It's not the only one, but it'san important one, and it's a
(59:23):
solution that is FDA approved,has been used for over 70 years
and certainly has benefitedmillions of women and has been
shown to be safe and effectivein numerous well-designed
studies.
So thank you for joining me backin the Sunflower House.
(59:43):
This is your host and author.
Sunflower House.
This is your host and author,dr Holly Thacker.
I'm the executive director ofNational Speaking of Women's
Health and you can catch us onanywhere you get your podcast
Apple Podcasts, google Podcasts,amazon Music, podcast, addict,
iheartradio, cashbox, overcast,spotify.
(01:00:05):
Please give us a five-starrating Helps us move up in the
rankings, and please join meback in the Sunflower House for
Chapter 11, customizing HormoneTherapy.
Welcome to the Speaking of Women's Health
podcast.
I'm Dr Holly Thacker, your hostand author, and thanks for
joining me back in the SunflowerHouse for Chapter 10, the Risk
and Benefits of Hormone Therapy.
Hormone therapy is still thebest available treatment to
(00:27):
treat menopausal symptoms andthe case is far from closed
regarding its long-term effectsin terms of helping blood
pressure, reducing heart disease, colon cancer, potentially
reducing Alzheimer's disease,depression, parkinson's,
arthritis and even maculardegeneration.
We do need more study.
(00:48):
Furthermore, lower doses ofhormones than previously studied
may provide some of the samebenefits while reducing side
effects, particularly on theuterus and breast.
The use of progestogens, whichare synthetic progestins or
natural progesterone, may bepart of the equation that
(01:08):
affects the risk of breastcancer while protecting the
uterus.
Using estrogen transdermally,as in a weekly patch, like
Climera or Climera Pro orVivelle Dot or Minivel twice a
week, or a daily estrogen gel orlotion or spray, may reduce the
risk of blood clots, but it maynot raise the HDL cholesterol
(01:34):
as well as oral estrogen.
In short, we always need moreresearch, but in the meantime we
have more options for treatingmenopausal symptoms than ever
before.
This should be the best time formidlife women and beyond, but
instead many suffer needlessly.
Take Anne-Marie, for instance.
Anne-marie, I didn't know whatto believe.
(01:55):
One said he said don't take anyhormones.
Another one said estrogen useby older women could increase
their risk of stroke.
Every day there's a newheadline with a different
warning.
Ah, you'd think I was treatingmy menopausal symptoms with
illegal drugs.
I took PremPro for several yearswithout a problem before I
discovered that I thought I wasrisking my life, at least
(02:17):
according to the media reports.
My doctor suggested I taperdown the dosage, but I insisted
on just stopping it completely.
So I quit cold turkey.
Well, the result of my rashdecision was disastrous.
I felt as if someone had pulledthe rug from right out
underneath me.
I was anxious and extremelyuncomfortable all the time.
(02:39):
My hot flashes were so severe Isometimes wondered whether I
could leave the house to runerrands.
I had never realized how muchthe hormone therapy had been
helping me until I stopped.
I tried some alternatives blackcohosh in the form of remifemin
for hot flashes, vitamin E oilfor vaginal discomfort, but
(03:01):
nothing worked quite as well asmy original therapy.
And to add insult to injury, Ilost an inch of height and I
found out on bone density, I hadosteopenia, bone thinning.
With so many misleading reportsabout what's good for women.
Today it just seems as ifbreathing is a risk.
But I decided I had to feelcomfortable.
So I went back on hormonetherapy.
(03:23):
I went on low dose PremPro andfinally I felt normal again
Taking hormone therapy.
Millions of women have done verywell on hormone therapy,
finding relief from the worst oftheir symptoms without
increasing any other health risk.
Hormone therapy was and stillis the only FDA-approved
(03:46):
treatment for the symptoms ofmenopause, including vaginal
atrophy and the management ofpostmenopausal osteoporosis.
Now we do have indications fornon-hormonal treatments of
vaginal atrophy, such as Asfina,aspemafen, asermirm, a
selective estrogen receptoragonist antagonist.
(04:06):
We have several options thatare FDA approved to treat
osteoporosis, to prevent andtreat and we are going to go
over that in a future chapter onboosting bone health.
And we do have FDA-approvednon-hormonal treatments to treat
hot flashes in the form ofBrisdell paroxetine and
(04:30):
hopefully soon to be some candyneuron antagonist.
So the FDA and most physiciansregard hormones as having
potential benefits.
As, like with anything,potential risk.
Nothing is 100% safe andeffective with no risk, nothing,
not even water.
(04:50):
So unfortunately, the risk manytimes get completely
overshadowed by fearful mediahype.
So where do all thesemisconceptions and fears come
from?
Well, the Women's HealthInitiative, which was a large
randomized trial that changedthe way women, as well as much
of the media and medicalcommunity, view hormone therapy,
(05:12):
and this change was not for thebetter.
My fifth podcast in thespeakingofwomenshealthcom
website podcast series was onthe 20th anniversary of the WHI.
Fear, anxiety, fewer choicesfor women resulted from
misinterpretations of sectionsof the study that focused on
(05:35):
hormone therapy in much olderwomen who were several years
past the age of the onset ofmenopause.
Ironically, these studies hadbeen initially designed to help
women better understand the riskand benefits.
So, unfortunately, the mediafriends, even some of our
doctors and nurses, areinappropriately waving
accusatory fingers at hormonetherapy as a treatment for
(05:57):
menopausal symptoms, and thisshould infuriate women and spark
a new debate that asks somevery pointed questions about the
treatment of modern, maturewomen in modern America.
For example, some might wonderhow accurate are randomized
studies when applied todifferent groups of women for
different reasons?
Why does the media scare womeninto thinking that they don't
(06:21):
have options, and why otherwisegood doctors into thinking that
they don't have options, and whyotherwise good doctors
misinterpreted these studies andjust followed what the media
said?
Hmm, where else have.
We have seen that.
What about the quality of lifeand sexual function for midlife
women?
How can women fairly assesswhat hormone therapy truly
represents for their ownindividual case?
In this chapter about the riskand benefits of hormone therapy,
(06:45):
I'll discuss the facts thatwomen absolutely must know.
These are details that you'renot going to read in the
newspaper, because so manyarticles for the lay public just
skim the surface, and there'sfar too much at stake with your
health for research to beinterpreted in such a glib and
superficial way.
Millions of women have donewell on hormone therapy, finding
(07:07):
relief from the worst of theirsymptoms without increasing
other health risk.
The FDA and most physiciansregard hormones as having
significant potential benefitsas well as potential risk, just
like with any prescriptionmedicine and even
non-prescription therapies.
I mean, my goodness, there aredeaths from acetaminophen
Tylenol, which is over thecounter.
(07:29):
So just because something isoff the shelf or available
without a prescription doesn'tmean that it's safer than
prescription medicines.
Women's Health Initiative thehard facts.
In 2002, researchers haltedpart of the WHI, and this was a
large preventive study funded bythe National Institute of
(07:51):
Health, nih, to focus onstrategies for preventing heart
disease, breast cancer,colorectal cancer and
osteoporosis in postmenopausalwomen.
It was a 15-year multi-milliondollar project.
The WHI involved over 161,000women that ranged from ages 50
(08:11):
to 79.
The segment of the study thatwas halted had been assessing
the long-term use of hormonetherapy as a prevention tool for
chronic illness, and that'sbecause a preventive agent can
essentially have no side effects.
It's important that this was nota menopausal treatment trial,
(08:34):
so when you're using somethingto prevent something in a
healthy person, the bar is setextremely high.
It really can have no sideeffects or risk.
When you're using something totreat an existing condition, you
have to accept some amount ofside effects and risk because
you're treating a problem.
And this is important toseparate, because some women use
(08:55):
hormone therapy just fortreatment.
Some women use it for bothtreatment and prevention and
there's some women who just useit for prevention.
And it's very important toclarify your goals and it's so
important to understand that theWHI was not a menopausal
treatment trial and inretrospect it actually really
(09:15):
wasn't a very good preventivetrial because most of the women
were an entire decade past theage of menopause and within that
decade you lose some of theeffects on the estrogen receptor
with methylation and many womenget subclinical disease.
Even if they're not diagnosedwith heart disease, they may
have some existing plaques.
(09:35):
So it truly wasn't thepreventive trial that we had
thought it was, and earlyinformation indicated that women
who are postmenopausal andusing the combination
prescription drug which wascommonly prescribed at that time
, called Prempro, which was acombination of 0.625 of
conjugated estrogens and 2.5milligrams of
(09:56):
medroxyprogesterone acetate, or5 milligrams of
medroxyprogesterone acetate orfive milligrams of
medroxyprogesterone acetate thatthey faced a slightly increased
risk of just being diagnosedwith breast cancer, heart
disease, stroke and blood clots,compared to the postmenopausal
women who were just taking aplacebo or a dummy pill.
(10:16):
However, the increased risk ofheart disease were seen only in
women several years past the ageof menopause, after the age of
70.
Are seen only in women severalyears past the age of menopause,
after the age of 70.
And the risk of breast cancerwas rated in the rare category,
even less than what was in thepackage insert.
This was not a treatment studyof younger midlife women.
(10:37):
It was a study of predominantlyolder women.
Most of them were between theages of 63 and 67.
And they, by and large, didn'teven have menopausal symptoms
anymore.
And because it was a so-calledpreventive study and the bar was
set so low for accepting anyrisk, the WHI discontinued this
study in this subset of women,saying that the risks were just
(10:59):
too great to continue, notbecause more women taking
hormone therapy were dyingthat's very important to note
compared to placebo but becausesome risks were noted in the
treatment arm.
Well, there were also benefitsnoted, and that's really
important.
When you look at large studies,comparing some treatment option
to a placebo is the one thingyou absolutely cannot argue with
(11:20):
is death rates, and that's anabsolute outcome, and so you
never want the treatment arm tohave a higher risk of death, and
in the WHI there was not.
But clot was a risk, and therewas one in every thousand women
extra who took hormones for 10years were diagnosed with breast
(11:42):
cancer, didn't die from breastcancer, but were just diagnosed.
Now, another two years later,the NIH halted the other portion
of the WHI, which was thecomponent just investigating
Premarin 0.625, an estrogen-onlyoral option in women who had
already had a hysterectomy.
In this study, the participantswho were older than 60 had a
(12:06):
very slightly increased risk ofstroke one extra case per 1,000
women but they didn't show anyincrease in heart disease and
they actually had a marked 33%decrease in the risk of being
diagnosed with breast cancer,and that reduced risk persisted
into the 70s.
But by this time many women whohad undergone a hysterectomy
had already stopped takingestrogen therapy, spooked by all
(12:28):
the negative media reports in2002.
And it's so ironic that so muchof their fear centered around
the reported increased risk forbeing diagnosed with breast
cancer and heart disease, whichdid not materialize in the
estrogen-only arm.
Most women didn't realize thatthere's a risk in not taking
hormone therapy when it's needed.
The latest information from theWHI study is that for women who
(12:52):
are within 10 years ofmenopause, who've taken hormone
therapy for five or more yearswhether it's estrogen alone,
hysterectomized women orestrogen plus progesterone if
you have a uterus there is a 30%reduction in all-cause
mortality.
That's significant, significant.
There was reduced risk of death.
(13:14):
So what are we to believe abouthormone therapy?
In my opinion, misunderstandingsurrounding the WHI study has
designed unnecessary panic.
This was a prevention, not atreatment study, and two-thirds
of the women, as I mentioned,were over the age of 65, which
is a good 10 to 15 years laterthan most women would even start
hormone therapy, and thestudy's purpose was to see
(13:36):
whether hormone therapyprevented certain diseases, it
was not designed to measure theeffectiveness on treatment of
menopausal symptoms.
Furthermore, the AmericanCollege of Clinical
Endocrinologists announced in2008 that the benefits of
hormone therapy in women underage 60 far outweighs the risk.
This was based on a reanalysisof the data of the WHI in women
(14:00):
under 60.
It took several years for theWHI investigators to release the
age stratified risk andbenefits, and that again, is
important anytime you're lookingat any intervention for any
prevention or treatment arm,because age sex comorbidities
(14:21):
dramatically can changesomeone's risk for a condition.
So it's concerning to me thatthese WHI investigators withheld
this age stratified data fromthe beginning and they didn't
release it until years later.
So much of the increase incardiovascular risk that was
(14:42):
publicized in 2002 was just seenin those older women over age
70, who were so many years pastmenopause, who were starting
quote preventive hormone therapymore than a decade after being
exposed to any of these hormones.
And so we know from the timinghypothesis that if you start
with healthy arteries and ahealthy brain, the hormone
(15:04):
therapy does seem to have somebeneficial preventative effects.
But if it's been over a decadeor more and there's some
underlying disease of thearteries, of the neurons in the
brain that adding estrogen tothe mix may not at all be
helpful and in a very smallpercent may be harmful.
(15:24):
May not at all be helpful andin a very small percent may be
harmful.
So this is in contrast to olderwomen who have been on hormone
therapy since the beginning ofmenopause and done well and not
demonstrated any evidence ofblood clot.
So just because you're over 60or over 70 doesn't mean you
can't continue safely on hormonetherapy.
(15:54):
The biologic age and especiallythe age of actual menopause and
the time a person has gonewithout hormones those time
frames are very important inhelping your physician interpret
the benefit and risk.
And it's also important to knowthat in women without a uterus
taking estrogen under the age of60, even with oral estrogen,
there was no increased risk ofstroke.
In fact there were two lesscases per thousand compared to
(16:18):
placebo.
So I see women every day whosaid oh, my doctor said
increased risk of stroke.
That's the reason I should stopthe estrogen.
And you can mitigate this inwomen over 60 or 65 by simply
changing to transdermal orcutting the standard 0.625
conjugated estrogen down to 0.45or 0.3.
(16:40):
Or if someone's on a milligramof estradiol, cutting that down
to 0.5.
So the bottom line is hormonetherapy is still the absolute
best treatment for recentlymenopausal women who are having
significant symptoms.
Women have no reason to fearhormone therapy or doubt its
efficacy as a solution foruncomfortable and potentially
(17:02):
debilitating side effects.
The key is to tailor hormonetherapy to each woman's
individual needs, and with somany options available, let me
tell you this is so much easierthan it's been ever before.
Now one of the things that Irun into is just whether
insurance covers it, and that isa big hassle, and I will have
(17:24):
future podcasts on the speakingof women's healthcom uh regular
podcast going over um tips toreduce the cost of medicine,
because that's the one thingthat we end up dealing with most
, most of um the office visits,sadly.
(17:46):
So what the WHI study showed usis that in much, much older
women who don't have anysymptoms of menopause, they
should not only take hormonetherapy solely for just
prevention.
In fact, there isn't one pillthat we encourage all women to
take not aspirin, not vitamin E,certainly not a single
(18:10):
prescription medicine.
For instance, we advise womenat high risk for heart disease
and stroke potentially to takeaspirin to reduce the risk of
stroke, but it can increasehemorrhagic stroke and GI bleeds
.
We certainly don't tell allmenopausal women to take aspirin
(18:31):
.
We don't tell all people totake statins
cholesterol-lowering medicines.
The message is that one sizedoes not fit all.
All treatments have to beindividualized and periodically
assessed, and every medicine,prescription as well as
non-prescription supplements,carry potential risk and
(18:52):
potential benefits.
So don't throw the baby outwith the bathwater.
Statins and hormone therapy aninteresting comparison.
Like hormone therapy, manymedicines used for prevention,
such as using statins,cholesterol-lowering medicines,
have risks and side effects.
However, we certainly don'ttell all people with high
cholesterol just to throw outtheir statin because a small
(19:13):
number of them may have a sideeffect.
Yet this is exactly whathappened to millions of women
when the proverbial hormonetherapy rug was pulled out right
from underneath them.
Breast cancer rates with statintherapy are actually comparable
to breast cancer rates withhormone therapy.
Rug was pulled out right fromunderneath them.
Breast cancer rates with statintherapy are actually comparable
to breast cancer rates withhormone therapy.
And still, statin agents arethe most commonly prescribed
class of medication.
(19:35):
Women on hormone therapyactually have a reduced risk of
death and cardiovascularmortality if they start hormone
therapy within 10 years ofmenopause, something that can't
be said for primary preventionsin women with statins.
Now men have some evidence ofprimary prevention with statins,
and both men and women whoalready have existing heart
disease have evidence of reducedrisk of heart disease with
(19:57):
statins, but not primaryprevention for women in their
50s.
What's more is, statins haveonly been shown in women who
already have heart disease or atvery high risk for heart
disease, and so there's notreally good definitive
information on the usefulness ofusing statins in younger women
solely as prevention.
(20:17):
In fact, statin use in womenincreases the risk of diabetes,
and diabetes is our worst riskfor women for cardiovascular
disease than diabetes is for men, and hormone therapy actually
reduces the risk of diabetestype 2 by 30 to 35%.
So no medicine or substance isperfectly risk-free.
(20:39):
But that doesn't mean we don'tuse agents.
We need perspective.
So that requires you and yourhealthcare clinician to provide
and perform an individualizedrisk-benefit assessment.
Don't let the media hype scareyou.
They're not your doctor andhave known heart disease.
(21:01):
Data from Tommy McCullough outof Finland shows that women that
are on statins and hormonetherapy have a lower risk of
heart attack and stroke comparedto women over 60 just on
statins or just on hormonetherapy.
So it's not that I don'trecommend statins in some women,
(21:22):
but this rush to use them andput them in the drinking water
when they don't improvemenopausal symptoms or help the
genitourinary atrophy or thesleep or reduce the risk of
fracture, when we know hormonetherapy does those items.
It's just helpful to make thatcomparison, so informing the
(21:47):
debate.
You've probably read plenty ofcontradictory reports by now,
leading you to question whetheryou should use hormone therapy
or, if you started, how long youshould continue.
I hope by listening to thispodcast, your anxiety is going
to be quelled.
Let's take a look at some of themost important questions
concerning hormone therapy.
Here are my conclusions, drawnfrom years of clinical practice,
(22:11):
careful interpretation of manywell-designed scientific studies
, which includes observationaldata, randomized controlled
trials, meta-analysis, casereports, because all of those
have their role to play.
What exactly is hormone therapy?
Well, hormone therapy is whenthe body is given a bit of
(22:35):
estrogen plus minus progestogen,in the form of either a
synthetic progestin orprogesterone if one has a uterus
slash, an endometrium lining ofthe uterus.
So sometimes, even in womenwith hysterectomies who have
endometriosis, we still may useprogesterone.
The ovaries are responsible forproducing estrogen and
(22:55):
progesterone, and sometestosterone in women, but
during menopause and especiallyfollowing complete hysterectomy,
when both the ovaries areremoved, we might not produce
the amounts that we need toregulate several bodily
functions.
So, essentially, by replacingsome of these missing hormones
with a pill or a patch or gel orother forms we'll discuss in
(23:18):
future chapters the body staysbalanced.
So estrogen relieves hotflashes, vaginal dryness and
other symptoms associated withmenopause, such as dry, itchy
skin, and, taken in combinationwith estrogen, progesterone
prevents the cell overgrowth inthe lining of the uterus, which
is very important at reducingendometrial hyperplasia and
(23:38):
endometrial cancer.
Some women prefer estrogen inthe form of just human estradiol
, which is the same exact potentestrogen that's produced in the
egg.
Other women prefer conjugatedestrogens, which last for a
whole 24 hours, as opposed tooral estradiol, which needs to
(24:01):
be dosed at least twice a day,and conjugated estrogens are a
mixture of several estrogensthat are usually derived from
either horse urine orsynthesized in a lab.
If a woman's had a hysterectomyand is particularly concerned
about breast cancer risk, Iactually do recommend the
conjugated estrogen Premarin,because it's the estrogen that's
(24:22):
been studied in the longestformat in women with
hysterectomy up to 11 years andnot only has it not shown any
increase in breast cancer.
In fact, the Premarinestrogen-only arm of the WHI
showed a decreased risk ofbreast cancer in hysterectomized
women even into their 70s.
Now there's some women whodon't want to use an animal
source of estrogen.
(24:42):
So in the past there was asynthetic form of conjugated
estrogens called Injuvia on themarket, but it's not exactly
bioequivalent and I don't thinkit's commonly able to oogen.
(25:08):
So just as many women havepreferences regarding the type
and dose and route of estrogen,many women also have some strong
feelings about progestogens.
Again, one size does not fitall.
Some women prefer to takenatural progesterone in the form
of prometrium, but it's mixedin peanut oil so it's not
suitable for women allergic topeanuts.
Other women feel too sleepy orgroggy on prometrium, which has
(25:32):
to be taken at night with alittle bit of food.
Rarely the natural progesteronerelaxes the lower esophageal
sphincter and heartburn happens.
Some women may prefer aprogestin such as norethendrone
acetate.
It's in very many common birthcontrol pills such as low estrin
.
It's also in low-dose FemHeartand Activella or generic MIMV,
(25:56):
and comes in different doses,like Activella is one milligram
of estradiol and a 0.5 ofnorethadrone acetate, or the
low-dose activella or low-doseMIMV is only a half a milligram
of estradiol and the 0.1 ofnorethadrone acetate.
Now when you combine theestrogen with the progesterone
(26:19):
in a pill form or a patch form,it lasts longer If you separate
the two.
Oral estradiol has a very shorthalf-life.
Now there's a newer progestogen,drosperinone, which is actually
a derivative of spironolactone,and that's in birth control
pills like Yaz and Yasmin andSafral and B-Yaz.
(26:40):
But it's also found in amenopausal formulation of
estradiol, which is bioidenticalestrogen.
With drosperinone, and becauseit's similar to spironolactone,
it may give some benefits toskin and hair, especially if
women have had some negativeeffects from too much androgens
(27:01):
or testosterone, anddrosperinone is a mild diuretic
and it might lower bloodpressure and help cholesterol.
Some women cannot toleratesystemic progestogens and need
to use progesterone in the formof a gel, like a 4% vaginal gel.
Other women who've done well onPrempro are using it in lower
(27:22):
doses, with only 1.5 milligramsof medroxyprogesterone acetate,
which was well studied in theWomen's Hope trial.
Now I'm not a fan of usingmedroxyprogesterone acetate for
over five plus years becauseit's very anti-estrogenic and so
I think it's probably the worstone.
(27:43):
On the breast.
Most progestins don't haveindependent bone effects, but
there's some evidence thatnorethendrone acetate, which
sometimes we use alone in womenwith severe endometriosis, may
have some bone benefit.
Some women like the naturalsedating and anxiolytic effects
of natural progesterone.
(28:03):
And there's only onecombination of oral estradiol
with natural progesterone in theform of bijuva, which we've now
had for about four years, butit only comes in one standard
dose.
I really wish we had threedoses.
So it comes in one milligram ofestradiol with 100 milligrams
(28:24):
of progesterone, but instead ofbeing mixed in peanut oil it's
micronized in coconut oil, sothis is taken after dinner.
Other women who don't want totake a pill, maybe because they
have nausea or gallstones orthey've had a history of a blood
clot or they've not ever usedhormones and they want to use
the lowest risk option mightwant to use a weekly patch of
(28:47):
ClimeraPro, which is estradiol,bioidentical and levonorgestrel
in a fixed combination of 0.45of estrogen.
Now women who are concernedabout low testosterone might
want to use transdermal orvaginal hormones which don't
increase sex hormone bindingglobulin, because that protein
(29:11):
is increased in the liver whenyou take oral estrogen, which
then lowers testosterone.
So women with hair loss andacne actually may prefer oral
over transdermal transdermal.
(29:31):
There is a twice a weekestrogen progesterone patch with
0.05 estradiol and twodifferent doses of norethadrone
acetate 0.14 and a higher dose,0.25.
And that's changed every 84,which is 3.5 days.
So there are plain genericestrogen patches and generic and
(29:54):
brand name twice a week patches.
In women who spend lots of timein the water or humid climates
they might find that the patchesdon't stick well and they might
want to use a transdermalestradiol but don't want to be
marked with a patch.
E4 is being studied and it'sanother natural estrogen and
(30:17):
it's in a current birth controlpill, nexstellis, and it is
being studied in postmenopausalwomen as well, but at the time
of the taping, which is March of2023, we don't have that
available.
In the past we had thiswonderful soybean-based estrogen
oil called Estrazor, but that'snot on the market anymore.
(30:40):
We do have a couple ofquick-drying alcohol-based gels
DiviGel, which comes in threelittle packets in three
different sizes 0.25, which isuber low dose, 0.5, and 0.1.
And even the 0.1 dose, thehighest strength dose, is a
pretty low dose.
(31:01):
There is Estrogel one squirt aday to the skin, or elesterin,
which is up to two squirts, andthere's one spray of estrogen
called Evamist and itinterestingly peaks the estrogen
level around two or three inthe morning if you apply it in
the morning, and certainly sleepdisturbances can occur.
(31:22):
So it's kind of nice, nice, youget that little boost at night
and each container has 60squirts or sprays after you
prime it once and so for womenwho don't want to rub things on
their hand, the spray is a niceoption.
There are some research studieslooking at intranasal estrogen,
but that's not standardlyavailable.
(31:46):
And there is vaginal estrogen.
Most of that's local, but thereare the formulations of the
femoring in two doses, 0.5 and0.100.
So, for all the reasons thatwe've discussed so far in this
podcast, many women willcontinue to turn to hormone
(32:06):
therapy as a safe, effectiveoption.
Are older women who takehormone therapy at greater risk,
you may ask.
Well, starting hormone therapy10 to 20 years after the onset
of menopause generally issomething that we don't
routinely do if you're solelytaking it for prevention or just
to promote general health.
(32:27):
But that being said, women whoare, say, 65 years old can take
hormone therapy to relieve hotflashes, treat genital dryness,
sexual dysfunction and preventosteoporosis, particularly if
they started it and they've donewell on it and they just want
to continue.
But in order to reduce strokerisk in women over 65, I usually
reduce the dose of estrogen bythe time a woman is 65.
(32:49):
And that's certainly when weassess further for heart disease
risk.
If the blood pressure iscreeping up, that may need to be
treated, and it's always theright time to talk about weight
reduction, intermittent fasting,smoking cessation, improving
cholesterol ratios, gettingadequate sleep, maybe having a
blood pressure cuff at home andchecking your blood pressure
(33:11):
more frequently, as well asdiabetes prevention or treatment
.
As for younger women, the risksfound in the WHI do not apply
to them, so a 25-year-old womanwho finds herself in premature
menopause should not identifywith the results of research
that was done in60-plus-year-old women, and that
is just a devastating mistakethat I see too many people make.
(33:36):
Are low doses of hormone therapyjust as effective as previous
standard doses?
Many times, the answer is yes.
Low doses of hormone therapyare generally effective at
treating hot flashes, and thehope is that lower doses will
assure women that it's okay tostart and continue hormone
therapy, as well as give themmore options and dosage ranges.
(33:57):
But there's no pat answers thatapply to all women at all
phases of life, and women withsevere menopausal symptoms may
not benefit from a low dose asmuch as they would from a higher
dose, which, I remind you, isnot even that high a dose and it
is FDA approved and safe.
For example, a woman whosuffers from debilitating
anxiety attacks coupled withserious hot flashes and thin
(34:20):
bones might fare better with ahigher dose of hormones.
So would younger women, womenwith faster metabolisms, women
who've lost their ovaries.
Furthermore, an average doseprescribed for one woman with a
fast metabolism may be way toolow for another woman who has a
slower metabolism or who's older.
(34:40):
Most of the studies that showimpressive reductions in
osteoporosis and bone breakagehave not used the uber uber low
doses.
So if you're going to use uberlow doses, you still may need to
use something extra for thevagina and for the bones, and
then I find that you're just,you know, increasing the time
and the expense.
But each woman's needs aredifferent and the same woman can
(35:04):
metabolize the same dose ofestrogen differently.
And because each woman's needsare different, you must have a
health assessment to determinewhere you are, whether you're at
risk for hormonal loss, even ifyou have no menopausal symptoms
and what dose to begin with,and if it's beneficial to you,
and we'll discuss more of thisin the podcast on Chapter 11.
(35:26):
And at least once a year thisshould be assessed by your
physician and if you're stable,a women's health nurse
practitioner can certainlyexamine you and give you refills
if all is the same.
But if you've got a new problembleeding or a new medical
diagnosis or you're approachingyour 65th birthday and about to
(35:49):
go on Medicare, where a lot oftimes the coverage of these
hormones also change, it's goodto maybe touch base again with
your physician and we're goingto have future podcasts on
reducing the cost of medicinesand what things you should look
for when you're looking forsecondary insurance when you
become of Medicare age.
(36:09):
Will hormone therapy protect myheart?
Well, observations from studiessuch as the Nurses' Health
Study show a lower incidence ofheart disease in women who took
hormone therapy.
Other studies have found thathormone therapy favorably
affects cholesterol ratios,improving the good HDL
cholesterol with oral hormonesand reducing the LDL cholesterol
.
But oral estrogen can increasetriglycerides, so I usually
(36:33):
avoid oral estrogen if a womanhas had a triglyceride level
over 400 or is diabetic withoutgood control, or in someone who
has any risk for blood clotcontrol or in someone who has
any risk for blood clot.
But in the heart and estrogenprogestin HERS trial women who
already had existing coronaryheart disease did not have a
lower rate of cardiac eventswhen taking PremPro, and the
(36:55):
American Heart Association hasissued various guidelines and
they basically state youshouldn't use it to treat or
prevent heart disease.
But you can certainly take itfor other indications, and the
most recent American HeartAssociation guidelines actually
acknowledge menopause andestrogen deficiency as a risk
for cardiovascular disease, andwe'll go into that in much more
(37:17):
details in a future podcast.
So a 30-year-old woman whosmokes and is overweight is not
at immediate risk for heartattack, but her lifetime risk is
very high and it should beaddressed then.
And even a 50 year old womanwho only has one risk factor for
heart disease still has anincreased absolute lifetime risk
for heart disease and a shorterduration of life.
(37:39):
So that needs to be addressed.
So we don't use hormone therapyspecifically to prevent heart
disease.
Cirms, which are selectiveestrogen receptor modulators,
such as avista, raloxifin andantioxidant vitamins, are also
not specifically recommended forthe prevention of heart disease
.
So women at the very highestrisk for heart disease should
(38:01):
certainly aim to reduce theirLDL cholesterol under 70, to
stop all forms of nicotine, tocontrol blood pressure and blood
sugar and also be assessed fordepression, which is a risk for
heart disease.
Whi findings did discourage theuse of just broad spectrum
(38:23):
hormone therapy as just a broadspectrum heart protection.
But hormone therapy is notdamaging to the heart per se and
if you take it for five to 10years within 10 years of
menopause, starting under age 65, generally there's actually
less cardiovascular disease andless diabetes.
(38:46):
So this is so much informationto process and consider and I
think that the biggest risk withhormone therapy is the rare
risk of blood clot, particularlywith oral estrogen, and oral
estrogen with progestins furtherincrease that risk.
So knowing your family historyand your personal history is
important and if you're someonewho's had blood clots or has
(39:10):
genetic risk for blood clots,such as prothrombin G mutation,
factor V, leiden, we generallydon't use oral estrogen In the
menopausal state.
We use transdermal.
So don't plan on solely takinghormone therapy for anti-aging,
even though there are probablysome anti-aging benefits, but
(39:32):
certainly in younger women withpremature menopause.
Definitely consider it stronglyand you're probably going to
have some benefit incardiovascular risk and
anti-aging if you start hormonetherapy and you already start
with healthy arteries Becauseestrogen has so many complex
effects on nitric oxide it's acalcium channel blocker.
(39:55):
It improves blood flow.
It has effects on cholesterol,some antioxidant effects and
certainly in diseased arteriesit can promote clot disruption.
So it's got a lot of complexeffects.
Do take hormone therapy fortherapeutic effects if you need
(40:18):
it and you're being monitored,and stay tuned for further
research.
And how will hormone therapyaffect by blood pressure, you
might ask.
Hormone therapy generally doesnot have a negative effect on
blood pressure.
In fact, sometimes the bloodpressure actually increases less
over time in women who takehormone therapy than in those
who don't.
It generally increases with allpeople with age.
(40:40):
Certainly, higher doses ofsynthetic pharmacologic doses of
estrogen, such as in birthcontrol pills or hormonal
contraception, can increaseblood pressure and affect the
run in angiotensin system.
Does hormone therapy improvedepression, feel-good
(41:00):
neurotransmitters in the brain,serotonin, dopamine or
epinephrine?
Because the replacement of lostestrogen and occasionally
progesterone or androgens canimprove a woman's self-image and
comfort level and sleep.
And so it's reasonable toconclude that hormone therapy
can positively affect the moodin many, but certainly not all,
(41:22):
women, and some progestogensnegatively affect women's mood.
But many medications, whetherthey're mood medicines, blood
pressure medicines, cholesterolmedicines, actually seem to work
better when there's adequateestrogen.
Hormone therapy might exertbenefits beyond helping women
regain their even mood byeliminating the unpleasant
(41:43):
symptoms of menopause.
When women who've beenprescribed estradiol stop their
therapy, their hot flashes canreturn, but sometimes the
depression does not.
The jury's out regarding whyestrogen has exact
antidepressant effects in somewomen.
We know it's effective inkeeping depression at bay in
some women, while also reducingsevere menopausal symptoms.
(42:04):
But estrogen in general is notrepeat, is not a standalone
treatment for major depression,and women who've never had
depression, anxiety or panic butwho all of a sudden develop
these symptoms during menopausecertainly needs to see a women's
health specialist whounderstands the connection in
the brain between hormones andneurotransmitters.
(42:27):
Does hormone therapy improvecognitive function, both memory
and thought processes?
The answer to thiscontroversial question seems to
depend on the timing.
Some studies show long-termusers of hormone therapy who
started hormone therapy at thebeginning of menopause show
better memory function later inlife than women who began it
much later.
Other studies show thatstarting hormone therapy long
(42:49):
after menopause actually maycause some cognitive decline,
and that might be in women,because over age 65, oral
estrogen can increase the riskof stroke.
Clearly more research is neededbefore we can better define the
role of hormone therapy incognitive functioning.
Can breast cancer survivors usehormone therapy?
If you're a breast cancersurvivor or receiving treatments
(43:12):
for cancer, you would have todefinitely discuss hormone
therapy with an expert.
Generally it's not prescribedfor women in active treatment,
since some breast cancers maygrow when exposed to estrogen.
But there's lots ofalternatives and survivors who
have debilitating symptoms ofmenopause may want to explore
low-dose hormone therapy.
The HABITS trial HormoneReplacement After Breast Cancer
(43:36):
Is it Safe?
Study showed an increased riskof breast cancer recurrence if
hormone therapy was used,particularly with high doses of
progestins, but other studieshave shown no increased risk and
perhaps survival benefit, andthis could be due to the bias of
patient selection and or fordifferent effects, as the trials
that used more progestins didseem to have worse outcomes.
(43:58):
Certainly, most breast cancersurvivors can use the vaginal
string, vaginal local estrogencreams or vaginal DHEA to
restore the integrity of thevagina, and many women who are
receiving therapies that wipeout estrogen need bone agents
like zolendronic acid, known asReclast, or denosumab, also
(44:20):
known as the brand name Prolia.
And certainly, if a young womanundergoes breast cancer and is
done with her breast cancertreatment, we we do not.
We no longer prevent thatperson from deciding about
whether she wants to becomepregnant naturally or through
(44:40):
assisted techniques, and womenwho have had breast cancer and
have a pregnancy which is veryhigh levels of hormones
afterwards have the same or, insome cases better, outcomes than
women who have not beenpregnant after their breast
cancer diagnosis.
So, as you can see, it's verycomplicated.
Can we predict who will benefitfrom hormone therapy and who
(45:04):
are the small portion of peoplewho might be harmed from hormone
therapy?
And who are the small portionof people who might be harmed?
I think genetic testing andevolving research will probably
allow us to further determine inthe future, more fine tuning,
who are the people that are thebest candidates for long-term
therapy, as well as those fewwomen who are predisposed to
clots or could be potentiallyharmed.
But what we do know now is thatshort-term therapy is safe and
(45:25):
effective for the vast majorityof women within 10 years of
menopause and it's not ahigh-risk proposition for those
who have discussed the optionwith their physician and found
to be suitable candidates.
But individualization,monitoring and re-evaluation are
critical and while there's notime limit to feeling well and
(45:46):
no specific time limit tohormone therapy contrary to the
urban myth that it's only fiveyears periodic reassessment is
needed and some peopleerroneously tell women oh, after
five years you have to stopflashes and you've been on
(46:07):
hormone therapy and your hormonetherapies are stopped and
you're under the age of 60, even65, you have a higher risk of
stroke and heart attack becauseof the resultant hot flashes
than someone who continues ontherapy.
So there are risks in stoppingtherapy.
Hormone therapy it works.
The WHI study found that 77% ofthe women in the study who
complained to hot flashes saidtheir hot flashes significantly
(46:28):
diminished when they were onhormone therapy.
Bear in mind that women withsevere hot flashes were not
included in the study becausethey would have known right away
if they were taking the drug orplacebo, although we do know
that the brain is powerful andplacebos have about a 30% effect
.
There are other options fortreating hot flashes.
You can go back and listen topodcast chapter seven, as well
(46:50):
as the medical CME free podcastthat talk about the candy neuron
inhibitors and non-hormonaloptions for hot flashes, but
none is as effective and broadas hormone therapy.
Weighing the risk and benefits,again, I stress that hormone
therapy is still the besttherapy for treating symptoms
and menopause.
All women should determinetheir risk profile with a
(47:13):
knowledgeable clinician beforestarting any prescription
treatment.
Having said that, let's look ata summary of the risk and
benefits.
Hormone therapy benefits Treatshot flashes.
Helps prevent and treatosteoporosis.
Prevents vaginal changes fromthinning tissue.
May improve the skin appearanceand hair.
Reduces the risk of diabetes.
(47:33):
Might reduce the risk for coloncancer.
We need further studies.
Now.
What are the risks?
The biggest risk is the rarerisk of blood clot, dvt,
especially with oral hormonetherapy.
Oral hormone therapy is alsoassociated with some increase in
gallbladder disease, a need forgallbladder removal.
(47:54):
There is an increased risk ofstroke, primarily in older women
with higher oral doses.
For women with a uterus who havenot had a complete hysterectomy
of removal of their uterus,estrogen alone can increase the
risk of uterine hyperplasia anduterine cancer.
But if you take estrogen withprogestogen, you reduce this
risk lower to the risk ofplacebo, but you still can get
(48:19):
uterine cancer even being onhormone therapy.
Hormone therapy has no apparenteffect on the risk of ovarian
cancer.
So don't forget to put theserisks and benefits into context,
because there is a risk in nottreating your symptoms.
A lot of women can't functionand go to work, they have
multiple doctor visits, theirpersonal relationships fall
(48:42):
apart and they are not as activebecause they don't feel as well
, which then promotes furtherweight gain, which promotes
further medical problems.
So you have to look at thewhole picture.
So you ask is hormone therapyright for me?
First of all, if you don't feelcomfortable about taking
hormone therapy, remember,throughout this podcast we have
(49:05):
so many descriptions ofalternative therapies lifestyle
changes, food, vitamins, stressreduction, exercise, other
non-hormonal pharmacologicagents.
Some are proven, others are not.
As we've seen for women withsevere menopausal symptoms,
sometimes alternatives are notenough, and you certainly don't
(49:25):
have to suffer before youconsider hormone therapy.
I mean, every day I see someonewho's just suffered so long and
they thought that they had tohave the worst symptoms ever,
which is not the case.
So you should be asked thesequestions, though, before being
prescribed hormone therapy Doyou have abnormal vaginal
(49:47):
bleeding, heavy periods,postmenopausal bleeding,
spotting after intercourse orwhen wiping yourself?
Is there a history of cancer inyour family?
Early heart disease, bloodclots?
Have you personally had anyendometrial or uterine cancer?
Have you personally had bloodclots in the veins, superficial
or deep, especially duringpregnancy or when taking birth
(50:10):
control pills?
If you've never had blood clotsand you've had pregnancies,
perhaps a C-section, or takenoral birth control pills or
hormonal contraception, becausethere is a hormonal birth
control patch and a couplevaginal rings NuvaRing and the
one-year Anavera ring.
If you've used these agents andhaven't had a blood clot,
(50:31):
chances are you're probably nota clotter.
Do you have chronic liverdisease, because oral hormone
therapy does go through theliver.
Do you smoke?
Certainly, women who are overthe age of 35 who smoke even one
cigarette a week cannot takehormonal contraception and we
don't want our menopausalpatients and postmenopausal
patients to smoke.
(50:52):
But if you do smoke, that isnot an absolute contraindication
to menopausal hormone therapylike it is for hormonal
contraception.
There's a big difference.
Do you have any activegallbladder disease?
So if you answer yes to any ofthese questions, you might need
to further individuate yourtherapy and you might not be the
(51:12):
best candidate for hormonetherapy or it may need to be
adjusted.
So for women with liver diseaseor increased risk of blood
clots, high triglycerides,gallbladder problems in those
women, it's probably moreprudent to use a low-dose
hormone therapy or go thetransdermal route.
Now, remember this podcast isnot medical advice and it's just
(51:34):
a form of some information tohelp arm you to be ready to
discuss these issues with yourpersonal physician.
If your answer to everyquestion, though, is no, then
you're probably a good candidatefor hormone therapy, and you
have to just try it for at leastthree months and see how you
feel.
(51:54):
The lower the dose, the longerit takes to feel better.
So if you go with some uber lowdose, it may take up to six
months.
If you go with a standard dose,some women feel better within a
few weeks, certainly within 12weeks.
Am I better off with analternative?
Some women choose not to starthormone therapy for personal
reasons.
Maybe they don't have hotflashes, their bone density is
(52:15):
normal.
They don't want to take anypharmaceutical agent.
If you're a breast cancer withhot flashes, certainly look into
the candineuron inhibitors ifthey've hit the market
Venlafaxine or desvenlafaxine,which is a Fexor, or Pristique.
(52:36):
We discussed those options inprior podcasts and we'll be
talking about them also incustomizing therapy for more
details.
And don't forget to get yourbone density checked and get
periodic vaginal and vulvarexams to see if there's any
signs of thinning.
If you're a current breastcancer patient and you're taking
(52:57):
tamoxifen or an aromataseinhibitor, in general those
women are completely discouragedfrom using any systemic
estrogen use, and that alsoincludes oral DHEA, which I have
seen some integrative andfunctional medicine doctors
prescribe.
The vaginal DHEA is fine, butnot oral.
What about if you're a woman whodoesn't have breast cancer, but
(53:19):
you just have an increased risk?
If you don't have hot flashesbut are at risk for spine
fractures thin bones in thespine you may really want to
consider the prescriptionmedicine raloxifin, also known
as Avista for five years becauseit's FDA approved to reduce the
diagnosis of invasiveestrogen-positive breast cancer
(53:40):
as well as reduce fracture risk.
Similar to menopausal hormonetherapy, avista has a slight
increased risk of blood clots,particularly if you're
immobilized, but does notincrease the risk of stroke in
older women like oral estrogendoes.
However, older women with heartdisease who have a stroke while
they're on raloxifin may have aslightly higher risk of stroke
(54:02):
death.
So, as with any medicine,there's benefits and risks and
it has to be individuated.
What if you're a woman with ahistory of stroke or heart
attack?
Well, certainly you need thestandard cardiovascular
evaluation and treatmentlowering the LDL cholesterol,
treating the blood pressure,stopping smoking, treating
(54:23):
diabetes, discussing whether youneed to be on aspirin or a
blood thinner as well as astatin in the evening,
discussions on whether babyaspirin is appropriate, doing
cardiac rehab with appropriateexercise, being on a
Mediterranean diet.
So we don't use hormone therapyor roloxifin or antioxidants to
(54:44):
prevent a heart attack orstroke in someone who's had the
disease.
But if your cardiac status isstable and you have other
indications for hormone therapy,you certainly can be continued
on these hormone therapy andmany women function better.
So if you are a heart attacksurvivor and having menopausal
(55:10):
symptoms, just like if you're acancer survivor or you've had
blood clots, those specialgroups of women do benefit from
seeking out a menopausespecialist as opposed to just a
women's health doctor, and youmay want to go on our website,
speakingofwomenshealthcom, or onmenopauseorg.
So if you have had a heartattack or stroke or even a
(55:37):
carotid dissection, which may bemore common in pregnancy or in
some women on hormone therapy,once you're medically stable and
if your symptoms are severe,you still may consider hormone
therapy.
But it's critical first tostabilize your status, work with
your cardiologist or women'shealth specialist and evaluate
all the risks before beginningany treatment.
(55:58):
Paradoxically, though, womenwho do have a heart attack while
on hormone therapy actuallytend to respond better to
treatment than women who've hada heart attack and who are not
on hormone therapy theCalifornia teacher study showed
this Less ventriculararrhythmias.
For someone experiencingmoderate to severe hot flashes,
hormone therapy is truly thebest option for your hot flashes
(56:22):
.
Though women may tryover-the-counter products such
as black cohosh remifemin,they're generally not that much
more effective than a placeboand may help more with sweats
than with flashes.
For preventing osteoporosis,many women, when they stop,
rapidly lose bone, typical ofperimenopause and early
postmenopause.
(56:43):
So if the only reason you'reusing hormone therapy is to help
your bones, you can certainlyuse other bone agents, but
estrogen is the only optionshown to reduce all types of
fracture in women who have anormal bone density as well as
it reduces fractures in womenwith osteopenia and women with
osteoporosis.
(57:03):
Please tune in to our podcast,chapter 12, to go into bone
detail, and we're also going tohave an upcoming CME podcast on
bone health.
A final word on hormone therapyand choice.
I'm often discouraged by themedia warnings that continue
about hormone therapy, although20 years post-WHI the tides
(57:27):
turned a little bit.
I had so many women recentlysend me links to a New York
Times article about how you knowthey had gotten it so wrong 20
years ago.
I'm like, yeah, tell me aboutit.
I've known about this since thebeginning, but it's so bad that
the media has really affectedso many women's psyche because
(57:49):
it's really dealt a direct blowto symptomatic, suffering women.
Of course, all therapies,including hormone therapy,
should be scrutinized foreffectiveness and risk, and all
women should be listened to andno one should disregard their
concerns or symptoms.
Just like with any biologicpharmaceutical agent,
(58:13):
understanding risk associatedwith any therapy is critical
before the woman and herhealthcare clinician can make
educated decisions together.
The problem occurs whenscientific studies are just
misrepresented for clicks andblown up into national headlines
that don't address the fullpicture, don't address the facts
(58:35):
underlying a particular study.
This happens too often andthese mixed messages confuse
women who are very busy, and itdoes a great disservice to them.
So we feel as if our choicesare limited and that our safety
is at risk.
And if you want to controlsomeone, you make them fearful.
So anytime you become fearful,your antenna should go up that
(58:59):
someone's trying to control you.
So if you're suffering fromsevere menopausal symptoms,
don't be a martyr.
Please Don't allow yourself tolive each day feeling like less
of a person because of yourdiscomfort and distress.
There are so many options andhormone therapy is one of them.
It's not the only one, but it'san important one, and it's a
(59:23):
solution that is FDA approved,has been used for over 70 years
and certainly has benefitedmillions of women and has been
shown to be safe and effectivein numerous well-designed
studies.
So thank you for joining me backin the Sunflower House.
(59:43):
This is your host and author.
Sunflower House.
This is your host and author,dr Holly Thacker.
I'm the executive director ofNational Speaking of Women's
Health and you can catch us onanywhere you get your podcast
Apple Podcasts, google Podcasts,amazon Music, podcast, addict,
iheartradio, cashbox, overcast,spotify.
(01:00:05):
Please give us a five-starrating Helps us move up in the
rankings, and please join meback in the Sunflower House for
Chapter 11, customizing HormoneTherapy.
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