April 12, 2025 • 52 mins
The Dusty Muffins are cracking open the hormone therapy debate! Dr. Aoife O'Sullivan, Dr. Christine Hart Kress, and Dr. Rebbecca Hertel tackle the most persistent myths about menopausal hormone therapy that even some doctors still believe.
In this myth-busting episode, you'll discover:💊 Why hormone therapy is safer than you've been told🧠 The surprising benefits for your bones AND brain🩺 How to navigate insurance hurdles and find affordable options💡 The truth about different delivery methods (pills, patches, creams and more)
The Muffins share insider tips for making treatment accessible, including:• GoodRx coupons that can slash prescription costs• Affordable options through Mark Cuban's Cost Plus Drugs• How Amazon Pharmacy can help
With their signature blend of medical expertise and laugh-out-loud honesty, they're breaking down taboos about hormone therapy so you can make informed decisions about your health.
Remember: They're doctors, but not YOUR doctors - this episode arms you with knowledge to have better conversations with your healthcare provider about what's right for YOU.
Subscribe for more no-nonsense women's health advice that's equal parts enlightening and entertaining!
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:05):
Welcome to the Dusty Muffins, where menopause meets sisterhood and
strengths or three menopause specialists coming together to laugh, share,
and empower you through the wild ride of menopause, impaerimenopause.
Whether you're curious, confused, or just looking for real talk,
you're in the right place. We're here to answer your
burning questions, educate, and appocate all with a dash of
(00:26):
humor and a lot of heart. So pull up the
chair and join the conversation.
Speaker 2 (00:30):
Before we dive in, Please remember, while we're doctors, we're
not your doctors. This podcast is for educational purposes only
and is not a substitute for medical advice. We encourage
you to partner with your own medical clinician to address
your unique health needs. This is the Dusty Muffins.
Speaker 3 (00:47):
Welcome back to the Dusty Muffins podcast. Today's episode is
what are the menopausal hormone therapy medication Options? We're diving
into the different medication options available from menopausal hormone therapy.
Will break down the types, how do they work, and
want to consider when discussing them with your doctor. I'm
(01:07):
if O'Sullivan, a family medicine physician over in Oregon and
a Menopause Society Certified practitioner.
Speaker 4 (01:17):
Hi, I am a doctor Christine Hartcress. I am a
Board certified Women's Selt Nurse practitioner and Menopause Society Menopause
practitioner over here in Virginia.
Speaker 5 (01:30):
Hi, I'm doctor Rebecca Hurdle.
Speaker 6 (01:32):
I am a Board certified osthropathic family Medicine physician and
a Minipause Society Certified practitioner.
Speaker 5 (01:39):
And I'm in Pennsylvania.
Speaker 7 (01:42):
Awesome. Can you see you all?
Speaker 4 (01:46):
We've been on text messaging and just for the listeners,
you know, if you could have been here to watch
the theatrics of both Rebecca starting with having a HOF
and having to remove her socks, which then sent Ifa
into her hot flash, and they're both sitting here fanning themselves,
(02:08):
and our tech supports.
Speaker 7 (02:13):
Aaron is probably like what we love because is a
hot mess rolling up in here?
Speaker 6 (02:20):
Yeah?
Speaker 5 (02:20):
Yes, And this is what happens even behind the scenes.
Speaker 6 (02:23):
You remember, we're going through all of this with you,
and so as we're literally telling you, I'm going to
tell you about all the medications, I'm thinking, like, do
I need my increase because I can't think my words
are like stuck and I'm hot as hell.
Speaker 4 (02:38):
I say, certified menopause practitioner. I think the answer is
yes from just the three minutes of observation and the
weekend of crazy text messages, and.
Speaker 5 (02:51):
I'm going to have to invest in a lovely fan.
So when you see us on YouTube, I'm not with
my pad.
Speaker 3 (02:58):
Yeah here here are all right?
Speaker 6 (03:03):
All right, my darlings, we all want to start on
this lovely, lovely little journey of what medications.
Speaker 3 (03:11):
We use to treat. How about what menopausal hormone therapy is.
So it's called different things, right, So, when someone has
premature ovarian insufficiency, which is when you have your last
period before the age of forty or early menopause when
you have your last period before the age of forty five,
(03:32):
we call it hormone replacement therapy because we are truly
replacing something that your body really really needs, and we're
replacing it in proper.
Speaker 5 (03:42):
You know, large enough doses.
Speaker 3 (03:45):
But then when you go into perimenopause, and then after
your last period when your menopausal, we call it menopausal
hormone therapy because we're using much smaller doses.
Speaker 7 (03:56):
Right, yep, yep.
Speaker 6 (03:57):
So most people will say it with hormone replacement, and
really that we've trying, we're really trying to transition all
clinicians and just the buttzword away from that. Like doctor
O Sullivan said, to this to menopausal hormone therapy and
not hormone replacement therapy, because it really is two different things.
Speaker 4 (04:16):
And I think too, it's important for women to know
that the highest dose of menopausal hormone therapy that we use,
that estra dial, is lower lower than the lowest.
Speaker 7 (04:28):
Dose of birth control pills.
Speaker 4 (04:30):
And I've heard it said a couple different ways that
you know, the menopuzzle hormone therapy that we prescribe on
average is one quarter of one pill in a pill pack.
I've heard other people say that it's one tenth. I've
never personally, you know, done the math on it, but
it is such a low amount. And so the lots
(04:52):
of women around birth control pills for years and years
and don't blink an eye at the amount of estrogen
and that's synthetic estrogen at the nail estra dial, and
the amount we're giving you in hormone therapy is just
the amount to gap what the receptors from head to
toe are looking for so that we can put some
(05:13):
estra dile on those receptors and knock out the symptoms
that you're having.
Speaker 3 (05:17):
Yeah, sorry, Rebecca, We're trying to get your estrogen level
above your husband's.
Speaker 5 (05:23):
Yes, isn't it? Wouldn't that be nice?
Speaker 6 (05:25):
Because you know when we sit here and we talk
with women and we're like, listen, your husband right there
next to you. If you are female and male partner,
is you have none and he's got more than you, yeah,
like for forever, And they're like and the husband's like,
I'm like, yes, honey, you do. You know what I
(05:46):
like to do with my patients, and I don't know
if it's good or bad. I like to use my hand,
So I'm like, okay, if this is zero, then menopausal
keeps you like here at like fifty, your birth controls
here like one hundred and fifty, and then being pregnant
is like up.
Speaker 5 (06:04):
Here right or up and over.
Speaker 6 (06:06):
And sometimes that kind of gives them at least a
little graphic visualization when I'm like, okay, the tick here,
then it's here, and then it's here, and just seems
to kind of help.
Speaker 5 (06:16):
I like that.
Speaker 7 (06:17):
I haven't I have.
Speaker 4 (06:19):
I have not seen that in education, but I'm always
looking for something like that when I'm educating women because
I think it's really helpful to see something a graph,
a step.
Speaker 7 (06:30):
Yeah, it kind of gives something to compare to HM.
That's awesome. Yeah, I will be using that this week
in question. So thank you, Rebecca.
Speaker 5 (06:38):
You are very welcome. This is how we This is
called the collaboration.
Speaker 6 (06:41):
In case anybody wonders, like, we collaborate all the time
at all these little ideas.
Speaker 5 (06:46):
Remember, three brains are always better than one, especially.
Speaker 6 (06:49):
When you're perimen apostle and an apostle, because maybe some
estrogen receptors.
Speaker 5 (06:55):
Are more or more bound in one of us and
the other.
Speaker 3 (06:58):
I feel like between the three of us, we've one
really highly functioning brain.
Speaker 6 (07:02):
Oh pa gas brain.
Speaker 4 (07:08):
So so menopuzzle hormone therapy. So is FDA approved for
hot flashes, night sweats, vaginal dryness, and the prevention of osteoporosis.
But you don't have to have one of those things
in order to gain access. There's we you know, we
will use men I will use menopuzzle hormone therapy. I
(07:30):
mean usually everybody's got at least one symptom, I mean
most vaginity.
Speaker 5 (07:34):
You really ask the question, right, right?
Speaker 4 (07:36):
Yeah, but you know, really we know that you know
it'll help with the ringing in the ears, the heart palpitations,
the burning tongue, sleep mood.
Speaker 7 (07:48):
Is that the primary reason why we're using it.
Speaker 4 (07:50):
No, but do we know that when you're lacking those
hormones you have those symptoms? Yes, And you know there's
there should not be in twenty twenty five gateway of
you have to have one of those things. And everybody
needs to have prevention fasterio borosis.
Speaker 7 (08:07):
Everybody.
Speaker 4 (08:08):
Estrogen is the only thing that's going to keep your
bones together unless you're just really lucky. But you know,
most women will have some bone loss by the time
you know their average life expectancy for women now is
I think they're saying eighty two, you're.
Speaker 7 (08:22):
Going to have bone loss.
Speaker 4 (08:24):
You know that's inevitable to at least have thirty percent
bone loss by the time you're eighty even with good genetics.
Speaker 3 (08:32):
You know, Oh sorry, go ahead to Rebacca.
Speaker 6 (08:34):
No, I was just gonna say, and you know it's
okay to say to these women too, like, okay, so
it's FDA approved for this, and we technically use it
off label for this, just so there's not any confusion.
Speaker 5 (08:44):
But it doesn't mean that we use it all the.
Speaker 6 (08:46):
Time because they're you know, for brain fog and whatnot.
Just it just means that it was studied here and
we know we know this, but off label, just like
we use so many other things off label as well,
like birth control pills, like birth control felves, right, go ahead, Yeah, Oh, I.
Speaker 3 (09:03):
Was gonna make kind of the same point. Like I
being in primary care, you know, you take care of everything,
and so it's really obvious to me how differently we
treat women's midlife healthcare. Because when I am using psychiatric medications,
medications for cardiology meds, pulmonary meds, I don't sit down
(09:23):
and say to a patient, now, this is not FDA
approved for this, but we use it all the time.
I mean, I just go ahead and treat, you know.
And that's why specialists dy too. They don't sit down
and go back twenty years and explain the studies that we're.
Speaker 5 (09:36):
Done off this, you know, or what's a good point
we don't.
Speaker 3 (09:41):
Like you said, with the pill, like the pill is
not FDA approved for acne or menstrual cramps, and yet
we throw women on it all the time, and we
don't say, now, this is not FDA approved for menstrual cramps,
so here sign this consent form because it's not FDA. No,
we don't do that.
Speaker 4 (09:58):
That's ridiculous, right, arresting your cycles, which exactly everybody is right,
everybody's up on skipping some cycles in a year.
Speaker 6 (10:05):
Yeah, we don't even think about it twice. I don't
think twice about it.
Speaker 3 (10:09):
You're right, you know, it's very expensive to get FDA approval,
and so drug companies pick and choose what they will
get FDA approval for things that will be really obviously
fixed by their medication, and they get FDA approval for that.
And we use medications off label all the time. Off
label is when you're not using it for that FDA
approved indication, Like the pill for acne, still.
Speaker 5 (10:30):
Means it's safe.
Speaker 6 (10:31):
It doesn't mean that it's not safe. That's a big,
big distinction I think we need to make. It doesn't
mean that it's not safe.
Speaker 3 (10:38):
So exactly. Yeah, And I think you know, for some reason,
clinicians have clung onto these FDA approvals for hormones like
binging on for dear life. I don't understand it. It's
like it's FDA approved for these conditions if they're extremely severe.
Like who am I to say my patient flashes are
(11:01):
severe or not.
Speaker 7 (11:02):
You know, it's not our.
Speaker 4 (11:03):
It's not our place to judge too many too often,
you know. And you know because like one of the
things that I've been hearing this week, when I've been
talking about hot flashes, especially women who wake up in
the middle of the night, you know, they'll say, oh,
I'm not I don't have nights. I don't have night sweats.
And I say, okay, explain that to me. They're like, well,
(11:25):
I'm not waking up in a pool of sweat. And
you know, even when I have my hot flashes, you know,
I'm it's not the movies where I get red and
start dripping.
Speaker 7 (11:34):
And I'm like, well, you don't have to like.
Speaker 5 (11:37):
That is just it's not that bad. That's what they say, right,
It's not that bad. It's okay.
Speaker 6 (11:43):
It still makes changes in your brain and it still
affects your heart, honey, you know, like, and it doesn't
have to be that.
Speaker 5 (11:50):
And I think you're right to that point.
Speaker 6 (11:52):
We've made it seem that you have to be drenched
and sweat and you know, and and steam coming off
your head and in a pool of sweat at night,
to where you're not sure what happened to you in
order to seek treatment. And I think that is so
unfair because what I had just had was really uncomfortable.
(12:14):
And when you had that happen multiple times during the day,
or not even multiple times, but just throughout your day,
or I mean, that was very disruptive, you know, yes,
like it's very disruptive. And then I'm not thinking and
my you know, I'm I'm not focused on what I'm doing.
And so that not that bad is a way for
women to say it, like, well, you know, it's just
(12:34):
it's not that bad.
Speaker 5 (12:35):
I'm okay.
Speaker 7 (12:36):
Even one is one?
Speaker 5 (12:37):
Even one?
Speaker 3 (12:38):
Yeah, I just made a note there for an episode idea.
So we'll go into vaso motor symptoms someday. Suit.
Speaker 6 (12:44):
Yeah.
Speaker 4 (12:45):
Yeah.
Speaker 3 (12:46):
So let's move on to the types of hormone therapy.
Let's talk about who could use estrogen alone and why
we might do that.
Speaker 7 (12:57):
Quizzing, No, just throw.
Speaker 6 (13:00):
That idea, Yes, yes, so I see, So aftrogen alone
would be just would be a woman who either has
an IUD for uterine protection or a woman who does
not have a uterus.
Speaker 3 (13:16):
Yeah, because we're using that gesterone usually because estrogen is
such a good growth factor. It helps everything grow, which
is wonderful. But if you make the lining of the
womb the uterus grow too much, that can actually be
a problem. You can get a thing called uterine hyperplasia,
which down the line can sometimes increase your risk of
(13:36):
uterine cancer. So we don't want to go there. So
that's why we give to women with a uterus progesterone.
It's not the only reason, but definitely if you have
a uterus, you're going to get progesterone in some form,
whether it be a tablet or the IUD.
Speaker 5 (13:52):
YEP YEP or a combined pat mm hm.
Speaker 4 (13:55):
So I think we probably all kind of have our
favorite of how we prescribe, right, I tend to I
tend to prescribe a lot more gel estradial gel for
the simple fact that I like estra dial. I I
(14:18):
like because it doesn't matter what I like, it matters
what the patients want. I do present all of the options,
but I one of the things that I find really
helpful of estradial gel because you're applying it every twenty
four hours, you get really nice, steady states. You apply
it to your inner thigh or the top of your
thigh is where I tell my patients to apply it.
(14:40):
I have them do it at night because I find
it covers night sweats really really well and helps tremendously
with sleep.
Speaker 7 (14:49):
I also like to do it.
Speaker 4 (14:51):
It comes in little packets, and you know, sometimes especially
impairmentopuzal women, right before or during their cycle, when they're
s strogen levels are particularly low, that you might need
just a little bit more. And so you know, I
will tell my patients, you know, you can use one
and a half of these or one in a quarter.
(15:12):
In someone who's perimenopauzle, we don't need to worry because
they're making their progesterone, and they're probably already.
Speaker 7 (15:19):
On a progesterone.
Speaker 4 (15:20):
But I don't have to worry about them taking more
than a milligram of estradil, which then requires more progesterone
if you are menopauseal.
Speaker 7 (15:30):
So this is the.
Speaker 4 (15:31):
One that I think I probably prescribe the most, or
that people switch to eventually. The only thing that's kind
of a nuisance about it is that it does take,
especially when you have you know, a standard dose would
be zero point five milligrams, So when you're when you
(15:52):
have zero point seventy five or one milligram, it's a
lot of volume in.
Speaker 7 (15:56):
These little packets, and so it takes.
Speaker 4 (15:58):
A long time to dry. And so that's the other
reason why I like it at night is inevitably, if
you're in a hurry in the morning, you put your
pants on, the first time you sit on the toilet,
you go to pull your pants down and they're stuck
because your pants have stuck to your gel and you
know what, it feels a lot like, will you use
your imagination?
Speaker 7 (16:18):
It's really not a great feeling when you do that.
Speaker 4 (16:21):
So I like it at night because then you can
let your let your leg dry. So that's my that's
my that's I will say, that's my probably number one.
Speaker 5 (16:30):
That way, nothing's getting stuck to your leg.
Speaker 4 (16:32):
No, And that's in yes. So go ahead, what's your
favorite ladies? Anybody my my.
Speaker 3 (16:39):
Go to in general, because well you know yourself. Every
woman is so different and we talk about during the
appointment what would suit them, So we have this whole discussion.
But I find a lot of my patients and me
myself go with the patch. This one is you change
it twice a week. And here it is there, so.
Speaker 7 (17:04):
An estradle alone patch.
Speaker 3 (17:06):
Yeah, estradle on its own, and then you tend to
put that on maybe your lower tummy, your upper thigh,
lower back, or your buttock. I've tried putting it on
my lower back and it's like when you get a
bit of tape and it folds over on itself. That
happens to me every time I try it, So I
always end up putting mine just on the lower part
(17:27):
of my tummy. And I find that if you invest
a minute just putting it on properly, so you make
sure there's no moisturizer or lotion on there because you
want really dry skin. Put it on and then put
your hand over it for a minute because all the
estrogen is in the adhesive, and so you need to
get a really good bond to your skin and the
(17:48):
heat of your hand will warm up the adhesive and
get a really good bond, and then it should stay on,
you know, through your swimming or your showering or bathing
or whatever. And then you change it twice a week.
It's got about three and a half to four days
worth of Madison And another great option I find for
women who have migraines that are sensitive to estrogen, because
(18:09):
you really are getting that nice steady state.
Speaker 6 (18:12):
Yeah.
Speaker 3 (18:12):
I find that if I use the once a week patch,
they tend to complain of women will say they get
migraines towards the end of the week.
Speaker 7 (18:19):
Yeah.
Speaker 3 (18:19):
So I definitely don't feel like you get that steady
state with the once a week patch you back, can.
Speaker 4 (18:26):
I I just want to say I had a patient
with the once a week patch that she came in
and she was having some irritation and redness from that patch,
and I had her lifted up. I'm like, well, show
me your I wanted to see the area and that
patch was like it's huge big, It's like it's faith
I mean yeah, I mean what is that like four
(18:47):
or three inches across?
Speaker 5 (18:50):
Yeah?
Speaker 7 (18:50):
Yeah, it was really big.
Speaker 5 (18:52):
And I was like, there's no hide in that.
Speaker 7 (18:53):
I was like, that thing off. I'm like that looks.
Speaker 4 (18:56):
I mean, it's like five times the size of your
belly button. And I'm like that's too me. And apparently
some of the brands are that big. And then some
of the brands of the once a week are smaller,
but you don't know until you get home, and you
don't and you know, what about side effects at all?
What have you had patients say as far as side effects, Rebecca,
(19:19):
with the patches, I've.
Speaker 6 (19:22):
Had them usually two things, and I my go to
is typically the patch with the jow depending on the patient,
I have. Most of my patients try the patch first
and then I can talk about the ring.
Speaker 5 (19:33):
I have that here too.
Speaker 6 (19:34):
But most of the side effects that I hear is
either they get that like nausea and maybe the start
of a migraine at first, so I feel like they're
getting this like release of estrogen, and especially if they're
postman apostlem haven't seen estrogen for a while, it's almost
like the receptors are like, oh my gosh, we're so excited,
like here it comes girls, you know. And then or
(19:55):
they're getting it at the end before or they get
their new patch on, they're starting to get a little low,
and so sometimes you know, every three days is a
little bit better, or sometimes I'll have them use the
gel to supplement when they're growing low. But but I
will tell you too that you know that I agree
(20:18):
with with efon this that that patch at least to
twice a week.
Speaker 5 (20:23):
One. If you put that thing on, it's it's like wax.
And when you take that thing off.
Speaker 4 (20:29):
Yeah, that's a good analogy.
Speaker 5 (20:31):
Yeah, I mean I usually have the brace. I'm like,
all right, here we go.
Speaker 6 (20:35):
Yeah, And I've like saw on a hot tub swim,
you know, and I know we've I don't know if
you guys have heard from your patients, like you know,
and I actually think I had a pharmacist tell one
of my patients like, you can't go in the hot
tub with this, and you can't go swimming with us.
Speaker 5 (20:50):
It's going to release all the estrogen at once.
Speaker 7 (20:52):
And I'm like all the water sports, all the things.
Speaker 3 (20:56):
And the thing, you know.
Speaker 7 (20:58):
Yeah, yeah, every.
Speaker 4 (20:59):
And now and then I'll patients get the irritation, the
redness and the ishing and a cave very rarely hived,
very very very rarely hives. And that's you know, usually
when will switch to something else. But I think, you know,
I tell women all the time, it doesn't you know,
we love transnermal But it doesn't matter what you do.
(21:20):
All that matters is what you can you remember to do.
So that's what you got to pick that's going to
work for your life.
Speaker 3 (21:27):
Yeah, and can I give a tip for the just
in case anyone is listening who gets that little rash
when they're you know, a day or two into the
patch and the over the counter flown aise or flute
take a zone. You can buy that over the counter.
Spray the skin that you're going to put the patch
on with one spray. Let it air drive for a
(21:47):
minute and then put your patch on. And that works
really well for a lot of women.
Speaker 7 (21:52):
That's a great tip. That's a great We love our tips. Again.
One brain, three people, really good brain.
Speaker 3 (22:01):
Let's talk about well, the other kind of options that
aren't oral, and then we could do oral. So maybe
the ring you got actually hands, yeah.
Speaker 5 (22:11):
I do.
Speaker 6 (22:11):
This is called the femme ring, not to be confused
with the E string, which is just for bagile and
we'll we'll do that another podcast.
Speaker 5 (22:18):
But this is the fem ring.
Speaker 6 (22:20):
This is is almost like if anybody remembers the new
are the new ring? Yeah, that's my brain fog right there,
right there, ladies, and so I know that you can't
see it.
Speaker 5 (22:31):
Who are listening to the podcast? Yes, the crickets, thank you.
That was awesome. That was the brain fog because I
couldn't remember never ring.
Speaker 6 (22:43):
But those of you that are watching us, like on
YouTube or you'll be able to see this.
Speaker 5 (22:47):
So this is a new are the fem ring.
Speaker 6 (22:50):
And you just squeeze this little bad boy and then
you insert it intro vaginally and that stays for three months,
and it's really great.
Speaker 5 (22:59):
It slowly releases.
Speaker 6 (23:00):
A certain amount of estrogen every single day, and then
after three months you take that take it out.
Speaker 5 (23:06):
If it comes out, you wash it, you put it
back in.
Speaker 6 (23:10):
For those with male partners, some can't feel it, some
can and like it, so.
Speaker 5 (23:16):
Have a great time. It's fine. What I've heard with this.
Speaker 6 (23:22):
Not with everyone, is it can lose some of its
efficacy before you're due to change it.
Speaker 5 (23:28):
So I would keep maybe some gel.
Speaker 6 (23:32):
On hand, and you know, in case that happens before
you get your refail, then you can either put a
patch on or you can put some at some gel
if you find that that's happening before you get your
ring to change.
Speaker 5 (23:43):
I'm talking like maybe a week or two before.
Speaker 3 (23:46):
So what about pricing, we're back here for that.
Speaker 6 (23:49):
Yeah, so this thing's extremely expensive. Some I think Christine,
you were saying it was covered by Try insurance, Trycare,
Try Care as an unformulay.
Speaker 5 (24:01):
Oh random, it's so random.
Speaker 6 (24:03):
They have all the otherwise stuff on formulay. It's very
expensive to get this through the pharmacy. There is a
different pharmacy, Transition pharmacy, about one hundred and eighty dollars
for three months. Yeah. I think that's really really reasonable,
So let your clinician know Transition.
Speaker 3 (24:18):
Yeah, and if it's not covered by your insurance, it's
six hundred, so that's two hundred a month, and then
Transitions Pharmacy one hundred and eighty. So definitely better. But
we shouldn't have to be paying for this, you know.
But that's another's correct, yeah, correct.
Speaker 4 (24:35):
And then the other patch that I have here is
circular compared to the little postage stamp one that IFA showed.
This is a Comby patch and so this is Estra
dial in northindron acetate. This is the Comby patch comes
in two different doses, a zero point one four and
(24:58):
a zero point Let me see, let me remember that
for correct in a minute. Zero point Yeah, it's a
zero point one four milligram progesterone or a zero point
two five milligram progesterone most women unless they're I'm gonna
just throw this out five years menopausal. On the zero
(25:19):
point one four milligram, we'll usually have unscheduled bleeding with it.
So if I prescribe it, which sometimes I will, the
zero point two five milligrams, but it's the synthetic progestogen
norphendron acetate as compared to the progesterone, which is more
like what you're ovar is we're producing, and but it
(25:42):
is an option for you.
Speaker 5 (25:44):
You know, we just.
Speaker 4 (25:45):
Prefer progesterone because there's no there hasn't been any associated
increased risk of breast cancer with progesterone as compared to
the synthetic progestogens. But they are not evil and sometimes
we do need to use them, and it is okay
to use them. You still need to keep getting your mammograms,
(26:06):
but you know, it's and it's an option if you
just want one patch and be one and done and
change it twice a week.
Speaker 5 (26:14):
M hmm, Well you can use those levels.
Speaker 3 (26:17):
Right, yeah, Astro, you've brought us on to the combined
therapy then with that, Christine, that's great. Yeah, So the
combined estrogen and progesterone therapy, which we use for women
who do.
Speaker 5 (26:31):
Have a uterress mm hmmm.
Speaker 3 (26:35):
That progesterone, the progestine in that Comby patch. I have
very few women that that will control their bleeding. I
get so many complaints of naginal bleeding on that Comby patch.
So if you're on a Comby patch at home and
it's working for you and you're not having vaginal bleeding,
that is wonderful. Yeah, but I have not hid greads.
Speaker 5 (26:55):
Drop us a line.
Speaker 3 (26:56):
Yeah.
Speaker 4 (26:56):
They have to either have an ablation, you know, the
ablated uteruses do really well on it, or like five
plus years menopausal on the higher dose. Otherwise, I see
so many people on the lowered dose progestogen and they
do not do well. And we use that Northindron acetape
(27:17):
for women who orally for women who can can't take progesterone,
and the five milligrams they do not bleed at all.
It's the low low dose in that patch.
Speaker 3 (27:30):
Yeah.
Speaker 6 (27:31):
Yeah, which is which is interesting because there's not an
oral equivalent to that, which you know, would would be nice.
I had I had someone retouch to me asking me
about that, you know, and I was like, I know,
it's not you've got the you know the five or
half a five.
Speaker 7 (27:46):
Yeah, that's it.
Speaker 3 (27:47):
Let's talk more about the oral options for progestogens than
which includes progesterone, natural, micronized projecrotize. Yeah, and then the
synthetic progestins. We could talk those for a minute.
Speaker 5 (28:01):
Yes, yeah, do you want me? You probably have the micronized.
Speaker 6 (28:04):
Progesterone so you can show people.
Speaker 5 (28:09):
But the micronized progesterone is you.
Speaker 6 (28:11):
Know that that bioidentical body, identical equal twitch or ovaries
make works on the GABA receptors of the brain, helps
to help you sleep, It can decrease your anxiety, and
then it protects your uterus from the estrogen causing that
lining to grow. Comes to to one hundred or two hundred.
(28:33):
I believe most of the data that I have read
that usually anything over three hundred you're not getting much
more of a benefit out of maybe more just of
your sedation and things like that. I do have some
that do need do need three hundred, and they do
do really well with sleep and anxiety and not having
any side effects. But it can come with some of
(28:54):
those side effects like water retention, some reflux, some bloating,
a lot of times that will go away over time
for women. Sometimes some gas as well. But there is
this there is a percentage of women that don't do
well on it, and so then we need to move
on to the synthetic ones. Or instead of taking it orally,
(29:15):
there are some other ways that we will do it.
We'll do it intervationally as well off label.
Speaker 3 (29:20):
And the women who love the micronized progesterone really love
the micronized project like put We talked about that in
a previous episode, how that micronized progesterone gets converted to
alopregnanolone in the brain which acts on the GABA receptors
which stimulates rest and relaxation. And women will say it's
really helped with their anxiety, and it's really helped me
(29:43):
get to sleep at night. And then there's some other
women who do not love it at all, who are really.
Speaker 5 (29:49):
Right, they feel terrible yep yep.
Speaker 4 (29:52):
And if you have a penut allergy, you cannot be
on the progesterone that we get in the pharmacy. That's
when we have to compound it or you at a
compounding pharmacy because it is slung. I always say slung,
slung in peanut oil. Yeah, yeah, so that progesterone. And
the other thing I tell women is, you know, sometimes
(30:13):
women will walk away from a provider with a whole
stack of hormones.
Speaker 7 (30:17):
Occasionally they get really lucky and they're like.
Speaker 4 (30:20):
Here's some estrogen, here's some progesterone, here's some testosterone. Not
that very often, but then nobody tells them how to
take it. And that progesterone you need to take before
you go to bed, because the reason why we love
it is it makes you sleepy.
Speaker 5 (30:32):
It's sedating.
Speaker 7 (30:34):
So many women are like, this progesterone.
Speaker 4 (30:36):
I've been so tired since I started to take it.
And I'm like, when are you taking it? They're like
in the morning. I'm like, no, take it at night
so you get.
Speaker 7 (30:45):
Those sleep benefits.
Speaker 4 (30:47):
And I then tell women, don't take it before you're
gonna watch a movie with your family, because you're gonna
be crashed out on the couch.
Speaker 7 (30:54):
It won't take long for you to feel really sleepy
and fall asleep.
Speaker 5 (30:58):
Yeah.
Speaker 6 (30:58):
Yeah. Or their providers will start them too high of
a dose, and these poor women are like knocking into
the walls and you know, passing out and ending up
in the er. Because they started on like two hundred
right out the bat, you know, so at least for me,
I like one hormone at a time, and I like
a low and slow.
Speaker 3 (31:15):
Yeah, and I just and if anyone's having problems with
it orally, my next suggestion is to insert it vaginally
or rectally at bedtime. And it's that same capsule, the
same one you were taken by mouth. You can pop
it into the vagina or the rectum and see if
that suits you. Because for a lot of women, if
(31:37):
they're I've had a few patients recently tell me it
really like what makes them feel wired for some reason.
Speaker 6 (31:45):
I know I have a couple and they actually take
it in the morning instead.
Speaker 3 (31:49):
Yeah, and so I know you have to try different things, right,
So my first thing is try it. If that doesn't work,
then I'll say try it in the morning. And if
that doesn't work, then I know we need change.
Speaker 5 (32:00):
Is Yeah.
Speaker 6 (32:01):
Yeah, we're all a little special unicorn time. Yeah, you
tell I tell every patient that, like you, just I'm
going to tell you what what it's supposed to do,
and then you're gonna tell me what it actually does
to you.
Speaker 3 (32:13):
Nisen, You're like a little Ferrari, you know, with the
le engine and we're just tinkering under the hood and
we're trying to find exactly what works for you.
Speaker 4 (32:21):
M I like that and other progestogens. I think maybe
we kind of talked about Northendron or the mini pills,
the pops, the ones that most women are familiar with
that they have when they're breastfeeding or they can't take
estrogen and they do a progestine only birth control, so
(32:41):
that Northin drone is an option. The northindrone acetate, which
a lot of women if you have had, if you
go into your guy N and you're having really heavy bleeding,
will give you five milligrams of northindrone acetate to shut
your bleeding down. So some women may be familiar with that.
And then slind is really good. You know, we like
(33:04):
slind uh josperinone and people are familiar with that for
being in yeas birth control and a lot less bleeding
on drosperinone than on the norah thin drone.
Speaker 7 (33:20):
And then of course the IUD as well.
Speaker 4 (33:24):
And then there is there is a gel called ye
but I haven't heard very good. People say it's messy
and oily, but there is a gel. I've never prescribed
it me neither.
Speaker 5 (33:38):
I haven't either.
Speaker 3 (33:40):
With the progestins, a lot of them are from kind
of testosterone based. So if you have a woman who
already has had some excess testosterone issues throughout her life,
if you have polycystic ovarian syndrome, for instance, then those
women tend to love the drosperonone the slint because it's
(34:00):
not from a testosterone kind of base. That's good point,
and I can't think of anything else helpful really. The
iu D, like the Marina, the Kylina, the Lalletta that
those are. We do use them as part of menopausal
hormone therapy. But they're another thing that aren't FDA approved
for use in the menopausal hormone therapy. But the marina
(34:22):
is in Europe yep. So we use all your So
we use the offlabel.
Speaker 5 (34:28):
Yeah, we use it.
Speaker 4 (34:30):
And that The good thing I mentioned about that i
u D is that you can add progesterone to the
iu D because the iu D is just to protect
the uterus, so you're not going to get sleep benefits
out of it.
Speaker 5 (34:40):
So I hear.
Speaker 4 (34:42):
You know, sometimes patients will come and say, I really
want that progesterone, but nobody will give it to me.
You can use progesterone with a with a progestine I D.
Speaker 5 (34:51):
And the sleep right point and the other synthetic progestins.
Speaker 6 (34:54):
Don't do that if we think about that, right, because
all those yeah on those pop pops would be sleeping.
Speaker 3 (35:00):
Yeah, and don't say one more thing about those sorry
before if we're moving on, I just okay, So the
mental gymnastics of this drives me crazy, so I would
love to bring it up. Doctors are terrified of giving
women hormone therapy for menopausal symptoms because of the progestins.
(35:20):
They say, the progestine is what increases your risk of
breast cancer. Okay, now, if we could just please break
that down, because the progestins that we are using are
the exact same progestins that your doctor is pumping you
full of in the birth control pill exactly. Both control
pill is very safe. It's a wonderful medication. It does
(35:42):
have some risks and benefits, just like other medications. It's
been life changing for women on this planet. We've been
able to have careers and put off having children, not
have children. You know, it's been incredible. But these are
the same progestins that doctor and become terrified of once
you call it hormone therapy. How what how did they
(36:06):
convince us of this?
Speaker 4 (36:08):
How have we even studied all of the progestigens. We've
only studied majroxity progesterone in the w HI, So I
mean we don't have studies on every single other progestagen.
Speaker 3 (36:24):
From France from the E three. Yeah, and there's a
slightly increased incidence of breast cancer. It may have to
do with the progestine causing the breast tissue become a
little more dense and it being harder, harder mammogram, Yeah,
but really low risk, like the same as being overweight
(36:46):
or sedentry, having a big glass of wine every night. Yeah,
but that risk. Those are the same progestins that you've
been taking all these years in the birth control pill,
and no one has mentioned breast cancer to you. So
nothing magically happens when you come off the pill and go.
Speaker 4 (37:02):
On to.
Speaker 3 (37:04):
Your menopausal hormone therapy. If it's a synthetics progestin, it's
the same medication. I just don't understand how we've all
been so brainwashed to not use our brains and think
that through you know.
Speaker 5 (37:16):
Yeah, you're right, So I had to.
Speaker 3 (37:19):
Get that off my chest. Sorry, No, very frustrating.
Speaker 5 (37:22):
I find it very really great point. Mm hmmm.
Speaker 3 (37:26):
So we don't need to be scared of these things.
I'm a primary care doctor. I've been in medicine for
thirty years, and these are the safest medicines I've ever prescribed.
Save I've never had a patient end up in the
emergency room with these medicines. I have when I've had
datins or blood pressure medications or diabetes medications, I've had
patients end up in the emergency room with side effects.
(37:47):
Never once touchwood from a hormone. So we have to pass.
We have to get past this fear. Okay, I'll get
off a little bit time.
Speaker 5 (37:57):
No, it was a good soapbox enjoyed testosterol. It was
really good. Do we want to say anything about basidoxapine.
Speaker 3 (38:06):
Basic doxaphene, Yes, Dovie, I love it.
Speaker 7 (38:11):
Stevie, I love it too, Yes I do.
Speaker 6 (38:14):
I haven't used it a whole lot, so you ladies
may have better experience with it. I really I actually
took a patient wanted off of that and and to
go on really, I mean, yeah, yeah, whoever the provider
was just I guess was comfortable with it and so
put her on that not for any like, you know,
(38:37):
any reason at all.
Speaker 3 (38:38):
Let's tell's what it is.
Speaker 6 (38:41):
Yeah, So BASI is a selective estrogen receptor modulator or
a ser estrogen agnes. It has so combined with conjugated
equin estrogen deforma tissue selective estrogen complex.
Speaker 3 (38:55):
Yeah. That sounds smart, sounds really smart, and nobody will
know what we're saying.
Speaker 5 (39:04):
So I supposed to medicine, yes, yeah, yes.
Speaker 4 (39:11):
Right, the conjugated aquine estrogen, equin estrogen and the trimarin.
Speaker 6 (39:15):
So and that works on that uterus so that it
doesn't grow the uterine lining because of the conjugated equine estrogen. Right,
it makes the uterine lining thick, and the bes of
dox think keeps that lining thin.
Speaker 4 (39:30):
Yeah.
Speaker 3 (39:30):
We didn't talk about combine aquin estrogen when we were
back doing our first.
Speaker 7 (39:34):
No, but we haven't talked about orals. Yeah yeah, yeah,
and so let'sten so do.
Speaker 4 (39:40):
The other reason why we like it is that there's
no stimulation to the breast tissue and there's not stimulation
to the uterine lining, so you don't need a progestogen
with that, we like it for women who are concerned
about breast cancer. You know, some women, you know, they
(40:00):
may have a braca. They may be braca one, braca two.
You know, maybe they have a family history, neither of
which are contraindications for being on hormone therapy. But this
makes them more comfortable because there's no stimulation to that tissue.
Speaker 3 (40:15):
We might need to explain the combined neck one estrogen then,
So that's from pregnant mayor's urine and the drug name
is Premarin pre pregnant mayor mayors And you're, yeah, so or,
And that is a big concoction of different estrogens. There's
(40:39):
like I think there's even been a testosterone in there.
There's some progestins in there. It's a big concoction of stuff.
But it turns out synthetic and it's very panthetic. Yeah,
and it's synthetic as in, you know, it's from pregnant
mayor's urine, but it's put together in natural into a tap.
Speaker 6 (40:58):
Yeah.
Speaker 3 (40:58):
So that was study in the Women's Health Initiative twenty
years ago, and when they looked at women who were
taking the estrogen on its own, so without any progestine
synthetic progestine, those women actually have a decreased incidence of
breast cancer. It seemed to be really protective of breast tissue.
And what it seems to do is cause something called
apoptosis of abnormal cells. So if a cell is growing
(41:23):
and it's going through quality control and they pick up
on it, the combined aquanic estrogen can help kill that cell.
And then so actually we know that that is good
for women who haven't increased risk of breast cancer, right, yeah,
it can actually.
Speaker 6 (41:43):
Even and I think the data was even more so
than the than the estradyl I remember correctly, right.
Speaker 3 (41:50):
Oh, yeah, maybe that was Yeah, it was even more
so than definitely. Yeah, I don't even know if we
can say that estradil.
Speaker 7 (41:58):
Definitely increasing risk.
Speaker 4 (42:02):
Yeah yeah, right, so then the way strapolate that all
the time, but yes, you're in correct.
Speaker 7 (42:07):
Yeah.
Speaker 3 (42:09):
And then the basidoxaviene is not licensed for use on
its own over here. They only use it in that
mixture pill, the dewav And that's almost like tomoxifen, right,
the same family, yeahsta, yeah, And so really good for
your bones, really good for the lining of the uterus,
and really good for the breast. So you've got this
(42:31):
double it's like a booster book, which should be really
protect me or the breast. Yeah. And there's a study
going on at the moment called the Promise Study, and
it's in women who have dcis of the breast, which
is not breast cancer, it's like pre cancer. And they're
(42:53):
giving women do a VY for five or six weeks
before their surgery, and they're looking at you know, the
biopsy results from before the medicine, and then they look
at the tissue again after the surgery. And so I
think there might be some really exciting results from that study.
I can't wait to hear.
Speaker 5 (43:11):
Yeah, I am too.
Speaker 3 (43:13):
Yeah, how hopeful for women maybe who've had breast cancer.
And instead of saying to them, okay, we want you
to be on tomoxivan for five years or an aromatase inhibitor,
we say, here's your duave. It's got estrogen innits, you
don't get all the side effects, it's press breast protective,
and it's got a sister of tomoxivin in it, which
is Yeah, doing that.
Speaker 7 (43:32):
Work, that'll be really nice.
Speaker 6 (43:34):
I know.
Speaker 3 (43:34):
I can't wait for that day.
Speaker 5 (43:36):
Oh, that would be fantastic.
Speaker 4 (43:38):
I know, and then we don't prescribe very often the
oral estradial or like the synthetic you know, premarin, you know,
but you know it's I think we've villainized the orals,
but you know, not we did need to.
Speaker 7 (43:57):
You know, there are women that we will put oral
estra dial.
Speaker 4 (44:01):
I think one of the things that's just important to
know is that baseline risk for women between the ages
of fifty to fifty nine, there are five cases of
having a blood clot for every thousand women. And then
when we add you know, oral estrogen only over five years,
(44:23):
it's one and a half more cases. When we combine
oral estrogen with a synthetic progestin, then it's five five
more cases, so a total you know of ten ten,
ten women out of one thousand and so, you know,
I think, you know, we try to avoid risk when
(44:45):
we can, but the risk of oral of being on
oral estrogen for blood clots increases for the first six
to twelve months and then goes back down to baseline.
I like it for women who have high cholesterol, you know,
trying to get their LDLs down. I find it to
be helpful to get their LDLs down. But I do
(45:10):
know that their sex hormone binding globulin tends to go up.
And if it's more than one seventy and we're trying
to put you on testosterone, then you won't get the
same benefits because all the hormones are just going to
bind bind up, and you're not going to have any
free and available to use. But and you know, there's
some women who just want to take oral, and there
(45:31):
are some combination you know, there is a combination pill
that is, you know, estra dial with progesterone and women
like that as well. And so again, I think it
depends on what works for your life.
Speaker 7 (45:43):
And if you're.
Speaker 4 (45:44):
Someone who's healthy and doesn't have high cholesterol and you're
not worried about a blood clot, you've been on birth
control pills, you've been pregnant without any problems, and you
want to be on oral, then do your thing.
Speaker 6 (45:55):
Yeah, yep, I think as long as you know those contraindications,
you know, high blood pressure, things like that thyroid, you know,
because those can interfere and sometimes oral estrogen synthetic and
non I have found will increase can increase the bloo
pressure in some women, even those that haven't had hypertension,
(46:16):
and then obviously those that do have hypertension, So we're
careful with that thybroid just because it combined the thybroid
modulin and can interfere with that.
Speaker 7 (46:24):
So those more thyroid hormone you need to adjust.
Speaker 5 (46:29):
Yeah, yep.
Speaker 3 (46:31):
Sometimes with oral estrogen, some of it gets a lot
of it gets converted to esterone, which is more inflammatory.
Estradiol is quite anti inflammatory.
Speaker 7 (46:42):
So that's another good point.
Speaker 3 (46:44):
Yeah, and also can increase kind of gall bladder disease
like gallstone. Right, So I would say negatives for the
old oral estrogen would be you get your increased esterrone.
It competes with your thyroid medication if you're taking the
can cause gallstones, can increase your risk, and it increases
(47:06):
your sex harmal binding globulin which can decrease your testosterone
in your libido. But like you said, if you're a
healthy woman and you don't have any issues going on,
you're probably going to be very safe taken oral estrogen.
Speaker 6 (47:20):
Yep.
Speaker 5 (47:21):
Yeah, I agree.
Speaker 6 (47:21):
I think you have some of those patients or at
least I do, where you know they're just like I
don't want any risk, I want to decrease any risk
and then that's where we're just like, listen, we have
a plethora of transformal options.
Speaker 5 (47:34):
Yeah, that's fine too.
Speaker 4 (47:36):
So personally, one transformal option we didn't talk about was
the the spray in your forearm, one to three sprays
daily some women.
Speaker 7 (47:51):
I've had a.
Speaker 4 (47:52):
Couple of patients on it, and I don't know, they
just decided they didn't like it. I don't know why
they didn't like the spray on their arm, and we
just we just wound up switching them.
Speaker 3 (48:04):
Yeah, insurance, that's a nice one for timed insurance can
be a bit tricky as well with THEMS.
Speaker 6 (48:09):
Yeah, and sometimes the gel too, Yes, but those are
both the gel and the spray I find are so
nice for timed dosing in those patients, like you're saying, Christine,
they have, you know, more flashes at night or during
the day, or they're doing great on their patch, they
can't go up to their next dose because it's too much,
but they're still having flashes at night.
Speaker 5 (48:30):
Then a gel er spray is nice to add. Let's
add a little spray at night and pretty good to go. Yeah.
Speaker 4 (48:37):
And I think the other thing that sometimes I will
see is this speaking more to the clinicians confusion about
that patch, and so just remember that the dose on
the patch times two is what it's equal to an
oral estrogen. And so if you're over one milligram of
(48:58):
oral estrogen, which is zero point zero seven five patch
would be your uterus needs more progesterone.
Speaker 7 (49:07):
You need the two hundred milligrams.
Speaker 4 (49:09):
You definitely need the five milligrams of a northendron acetate
just to make sure you're protecting protecting that lining and
keeping the woman from bleeding. So, and you know, gel
and oral are equal to each other, but that patch,
you know, and women get confused too when we switch
(49:31):
them from gel to patches as they think we're dropping
their dose, but we're actually not.
Speaker 5 (49:38):
Yeah, and you can absorb it a little differently too.
Speaker 6 (49:40):
You might not be absorbing the patch the same as
you do the gel or the spray, So sometimes we
may have to still adjust even though we think it's
the same.
Speaker 3 (49:48):
So, yeah, we may have to skip testosterone and give
that gel.
Speaker 6 (49:54):
I think it needs it's an own episode, It deserves
its own.
Speaker 5 (49:58):
It's so beautiful you want to run.
Speaker 7 (50:00):
You're going to do our wrap ups since if.
Speaker 3 (50:04):
Yeah, yeah, you have secretary stary Okay, so let's pull
this all together with some takeaway tips. So, first of all,
menopausal hormone therapy is so so safe, please don't be
scared of it. And hopefully by listening to our podcast
(50:25):
you are becoming more comfortable thinking about it and talking
about it. And we also want to get rid of
the myth that it's only for severe symptoms. You know,
we need it for our bones, our brain, are all
our organs, and to stay in good health. And there
was another one I thought of there if you want
(50:48):
to go on a certain type of hormone therapy and
you're finding that your insurance is not covering it, we
know some tips for that, so make sure you check
good or X website to see if there's a coupon
for that. Mark Cuban's cost plus website is very helpful,
(51:08):
especially for vaginal estrogen cream. It's so much cheaper there
than a lot of insurances. And then there's the hort Club,
which I think is part of Transitions Pharmacy, So you
can join that for ninety nine dollars a year, I think,
and then you can order your hormones through there, and
for a lot of women because they're on maybe the
(51:30):
gel or something that's not covered by their insurance that
works out much deeper than the big copas from their
pharmacy an Amazon.
Speaker 4 (51:38):
Oh, Amazon right now is the lowest vaginal estrogen cream?
Is it?
Speaker 6 (51:44):
Oh?
Speaker 4 (51:44):
That's good.
Speaker 6 (51:45):
I don't know.
Speaker 3 (51:47):
All right, I've tried. Remember you're not alone in this journey.
Be informed, be empowered, and keep thriving through midlife. Until
next time, stay fabulous,
Welcome to the Dusty Muffins, where menopause meets sisterhood and
strengths or three menopause specialists coming together to laugh, share,
and empower you through the wild ride of menopause, impaerimenopause.
Whether you're curious, confused, or just looking for real talk,
you're in the right place. We're here to answer your
burning questions, educate, and appocate all with a dash of
(00:26):
humor and a lot of heart. So pull up the
chair and join the conversation.
Speaker 2 (00:30):
Before we dive in, Please remember, while we're doctors, we're
not your doctors. This podcast is for educational purposes only
and is not a substitute for medical advice. We encourage
you to partner with your own medical clinician to address
your unique health needs. This is the Dusty Muffins.
Speaker 3 (00:47):
Welcome back to the Dusty Muffins podcast. Today's episode is
what are the menopausal hormone therapy medication Options? We're diving
into the different medication options available from menopausal hormone therapy.
Will break down the types, how do they work, and
want to consider when discussing them with your doctor. I'm
(01:07):
if O'Sullivan, a family medicine physician over in Oregon and
a Menopause Society Certified practitioner.
Speaker 4 (01:17):
Hi, I am a doctor Christine Hartcress. I am a
Board certified Women's Selt Nurse practitioner and Menopause Society Menopause
practitioner over here in Virginia.
Speaker 5 (01:30):
Hi, I'm doctor Rebecca Hurdle.
Speaker 6 (01:32):
I am a Board certified osthropathic family Medicine physician and
a Minipause Society Certified practitioner.
Speaker 5 (01:39):
And I'm in Pennsylvania.
Speaker 7 (01:42):
Awesome. Can you see you all?
Speaker 4 (01:46):
We've been on text messaging and just for the listeners,
you know, if you could have been here to watch
the theatrics of both Rebecca starting with having a HOF
and having to remove her socks, which then sent Ifa
into her hot flash, and they're both sitting here fanning themselves,
(02:08):
and our tech supports.
Speaker 7 (02:13):
Aaron is probably like what we love because is a
hot mess rolling up in here?
Speaker 6 (02:20):
Yeah?
Speaker 5 (02:20):
Yes, And this is what happens even behind the scenes.
Speaker 6 (02:23):
You remember, we're going through all of this with you,
and so as we're literally telling you, I'm going to
tell you about all the medications, I'm thinking, like, do
I need my increase because I can't think my words
are like stuck and I'm hot as hell.
Speaker 4 (02:38):
I say, certified menopause practitioner. I think the answer is
yes from just the three minutes of observation and the
weekend of crazy text messages, and.
Speaker 5 (02:51):
I'm going to have to invest in a lovely fan.
So when you see us on YouTube, I'm not with
my pad.
Speaker 3 (02:58):
Yeah here here are all right?
Speaker 6 (03:03):
All right, my darlings, we all want to start on
this lovely, lovely little journey of what medications.
Speaker 3 (03:11):
We use to treat. How about what menopausal hormone therapy is.
So it's called different things, right, So, when someone has
premature ovarian insufficiency, which is when you have your last
period before the age of forty or early menopause when
you have your last period before the age of forty five,
(03:32):
we call it hormone replacement therapy because we are truly
replacing something that your body really really needs, and we're
replacing it in proper.
Speaker 5 (03:42):
You know, large enough doses.
Speaker 3 (03:45):
But then when you go into perimenopause, and then after
your last period when your menopausal, we call it menopausal
hormone therapy because we're using much smaller doses.
Speaker 7 (03:56):
Right, yep, yep.
Speaker 6 (03:57):
So most people will say it with hormone replacement, and
really that we've trying, we're really trying to transition all
clinicians and just the buttzword away from that. Like doctor
O Sullivan said, to this to menopausal hormone therapy and
not hormone replacement therapy, because it really is two different things.
Speaker 4 (04:16):
And I think too, it's important for women to know
that the highest dose of menopausal hormone therapy that we use,
that estra dial, is lower lower than the lowest.
Speaker 7 (04:28):
Dose of birth control pills.
Speaker 4 (04:30):
And I've heard it said a couple different ways that
you know, the menopuzzle hormone therapy that we prescribe on
average is one quarter of one pill in a pill pack.
I've heard other people say that it's one tenth. I've
never personally, you know, done the math on it, but
it is such a low amount. And so the lots
(04:52):
of women around birth control pills for years and years
and don't blink an eye at the amount of estrogen
and that's synthetic estrogen at the nail estra dial, and
the amount we're giving you in hormone therapy is just
the amount to gap what the receptors from head to
toe are looking for so that we can put some
(05:13):
estra dile on those receptors and knock out the symptoms
that you're having.
Speaker 3 (05:17):
Yeah, sorry, Rebecca, We're trying to get your estrogen level
above your husband's.
Speaker 5 (05:23):
Yes, isn't it? Wouldn't that be nice?
Speaker 6 (05:25):
Because you know when we sit here and we talk
with women and we're like, listen, your husband right there
next to you. If you are female and male partner,
is you have none and he's got more than you, yeah,
like for forever, And they're like and the husband's like,
I'm like, yes, honey, you do. You know what I
(05:46):
like to do with my patients, and I don't know
if it's good or bad. I like to use my hand,
So I'm like, okay, if this is zero, then menopausal
keeps you like here at like fifty, your birth controls
here like one hundred and fifty, and then being pregnant
is like up.
Speaker 5 (06:04):
Here right or up and over.
Speaker 6 (06:06):
And sometimes that kind of gives them at least a
little graphic visualization when I'm like, okay, the tick here,
then it's here, and then it's here, and just seems
to kind of help.
Speaker 5 (06:16):
I like that.
Speaker 7 (06:17):
I haven't I have.
Speaker 4 (06:19):
I have not seen that in education, but I'm always
looking for something like that when I'm educating women because
I think it's really helpful to see something a graph,
a step.
Speaker 7 (06:30):
Yeah, it kind of gives something to compare to HM.
That's awesome. Yeah, I will be using that this week
in question. So thank you, Rebecca.
Speaker 5 (06:38):
You are very welcome. This is how we This is
called the collaboration.
Speaker 6 (06:41):
In case anybody wonders, like, we collaborate all the time
at all these little ideas.
Speaker 5 (06:46):
Remember, three brains are always better than one, especially.
Speaker 6 (06:49):
When you're perimen apostle and an apostle, because maybe some
estrogen receptors.
Speaker 5 (06:55):
Are more or more bound in one of us and
the other.
Speaker 3 (06:58):
I feel like between the three of us, we've one
really highly functioning brain.
Speaker 6 (07:02):
Oh pa gas brain.
Speaker 4 (07:08):
So so menopuzzle hormone therapy. So is FDA approved for
hot flashes, night sweats, vaginal dryness, and the prevention of osteoporosis.
But you don't have to have one of those things
in order to gain access. There's we you know, we
will use men I will use menopuzzle hormone therapy. I
(07:30):
mean usually everybody's got at least one symptom, I mean
most vaginity.
Speaker 5 (07:34):
You really ask the question, right, right?
Speaker 4 (07:36):
Yeah, but you know, really we know that you know
it'll help with the ringing in the ears, the heart palpitations,
the burning tongue, sleep mood.
Speaker 7 (07:48):
Is that the primary reason why we're using it.
Speaker 4 (07:50):
No, but do we know that when you're lacking those
hormones you have those symptoms? Yes, And you know there's
there should not be in twenty twenty five gateway of
you have to have one of those things. And everybody
needs to have prevention fasterio borosis.
Speaker 7 (08:07):
Everybody.
Speaker 4 (08:08):
Estrogen is the only thing that's going to keep your
bones together unless you're just really lucky. But you know,
most women will have some bone loss by the time
you know their average life expectancy for women now is
I think they're saying eighty two, you're.
Speaker 7 (08:22):
Going to have bone loss.
Speaker 4 (08:24):
You know that's inevitable to at least have thirty percent
bone loss by the time you're eighty even with good genetics.
Speaker 3 (08:32):
You know, Oh sorry, go ahead to Rebacca.
Speaker 6 (08:34):
No, I was just gonna say, and you know it's
okay to say to these women too, like, okay, so
it's FDA approved for this, and we technically use it
off label for this, just so there's not any confusion.
Speaker 5 (08:44):
But it doesn't mean that we use it all the.
Speaker 6 (08:46):
Time because they're you know, for brain fog and whatnot.
Just it just means that it was studied here and
we know we know this, but off label, just like
we use so many other things off label as well,
like birth control pills, like birth control felves, right, go ahead, Yeah, Oh, I.
Speaker 3 (09:03):
Was gonna make kind of the same point. Like I
being in primary care, you know, you take care of everything,
and so it's really obvious to me how differently we
treat women's midlife healthcare. Because when I am using psychiatric medications,
medications for cardiology meds, pulmonary meds, I don't sit down
(09:23):
and say to a patient, now, this is not FDA
approved for this, but we use it all the time.
I mean, I just go ahead and treat, you know.
And that's why specialists dy too. They don't sit down
and go back twenty years and explain the studies that we're.
Speaker 5 (09:36):
Done off this, you know, or what's a good point
we don't.
Speaker 3 (09:41):
Like you said, with the pill, like the pill is
not FDA approved for acne or menstrual cramps, and yet
we throw women on it all the time, and we
don't say, now, this is not FDA approved for menstrual cramps,
so here sign this consent form because it's not FDA. No,
we don't do that.
Speaker 4 (09:58):
That's ridiculous, right, arresting your cycles, which exactly everybody is right,
everybody's up on skipping some cycles in a year.
Speaker 6 (10:05):
Yeah, we don't even think about it twice. I don't
think twice about it.
Speaker 3 (10:09):
You're right, you know, it's very expensive to get FDA approval,
and so drug companies pick and choose what they will
get FDA approval for things that will be really obviously
fixed by their medication, and they get FDA approval for that.
And we use medications off label all the time. Off
label is when you're not using it for that FDA
approved indication, Like the pill for acne, still.
Speaker 5 (10:30):
Means it's safe.
Speaker 6 (10:31):
It doesn't mean that it's not safe. That's a big,
big distinction I think we need to make. It doesn't
mean that it's not safe.
Speaker 3 (10:38):
So exactly. Yeah, And I think you know, for some reason,
clinicians have clung onto these FDA approvals for hormones like
binging on for dear life. I don't understand it. It's
like it's FDA approved for these conditions if they're extremely severe.
Like who am I to say my patient flashes are
(11:01):
severe or not.
Speaker 7 (11:02):
You know, it's not our.
Speaker 4 (11:03):
It's not our place to judge too many too often,
you know. And you know because like one of the
things that I've been hearing this week, when I've been
talking about hot flashes, especially women who wake up in
the middle of the night, you know, they'll say, oh,
I'm not I don't have nights. I don't have night sweats.
And I say, okay, explain that to me. They're like, well,
(11:25):
I'm not waking up in a pool of sweat. And
you know, even when I have my hot flashes, you know,
I'm it's not the movies where I get red and
start dripping.
Speaker 7 (11:34):
And I'm like, well, you don't have to like.
Speaker 5 (11:37):
That is just it's not that bad. That's what they say, right,
It's not that bad. It's okay.
Speaker 6 (11:43):
It still makes changes in your brain and it still
affects your heart, honey, you know, like, and it doesn't
have to be that.
Speaker 5 (11:50):
And I think you're right to that point.
Speaker 6 (11:52):
We've made it seem that you have to be drenched
and sweat and you know, and and steam coming off
your head and in a pool of sweat at night,
to where you're not sure what happened to you in
order to seek treatment. And I think that is so
unfair because what I had just had was really uncomfortable.
(12:14):
And when you had that happen multiple times during the day,
or not even multiple times, but just throughout your day,
or I mean, that was very disruptive, you know, yes,
like it's very disruptive. And then I'm not thinking and
my you know, I'm I'm not focused on what I'm doing.
And so that not that bad is a way for
women to say it, like, well, you know, it's just
(12:34):
it's not that bad.
Speaker 5 (12:35):
I'm okay.
Speaker 7 (12:36):
Even one is one?
Speaker 5 (12:37):
Even one?
Speaker 3 (12:38):
Yeah, I just made a note there for an episode idea.
So we'll go into vaso motor symptoms someday. Suit.
Speaker 6 (12:44):
Yeah.
Speaker 4 (12:45):
Yeah.
Speaker 3 (12:46):
So let's move on to the types of hormone therapy.
Let's talk about who could use estrogen alone and why
we might do that.
Speaker 7 (12:57):
Quizzing, No, just throw.
Speaker 6 (13:00):
That idea, Yes, yes, so I see, So aftrogen alone
would be just would be a woman who either has
an IUD for uterine protection or a woman who does
not have a uterus.
Speaker 3 (13:16):
Yeah, because we're using that gesterone usually because estrogen is
such a good growth factor. It helps everything grow, which
is wonderful. But if you make the lining of the
womb the uterus grow too much, that can actually be
a problem. You can get a thing called uterine hyperplasia,
which down the line can sometimes increase your risk of
(13:36):
uterine cancer. So we don't want to go there. So
that's why we give to women with a uterus progesterone.
It's not the only reason, but definitely if you have
a uterus, you're going to get progesterone in some form,
whether it be a tablet or the IUD.
Speaker 5 (13:52):
YEP YEP or a combined pat mm hm.
Speaker 4 (13:55):
So I think we probably all kind of have our
favorite of how we prescribe, right, I tend to I
tend to prescribe a lot more gel estradial gel for
the simple fact that I like estra dial. I I
(14:18):
like because it doesn't matter what I like, it matters
what the patients want. I do present all of the options,
but I one of the things that I find really
helpful of estradial gel because you're applying it every twenty
four hours, you get really nice, steady states. You apply
it to your inner thigh or the top of your
thigh is where I tell my patients to apply it.
(14:40):
I have them do it at night because I find
it covers night sweats really really well and helps tremendously
with sleep.
Speaker 7 (14:49):
I also like to do it.
Speaker 4 (14:51):
It comes in little packets, and you know, sometimes especially
impairmentopuzal women, right before or during their cycle, when they're
s strogen levels are particularly low, that you might need
just a little bit more. And so you know, I
will tell my patients, you know, you can use one
and a half of these or one in a quarter.
(15:12):
In someone who's perimenopauzle, we don't need to worry because
they're making their progesterone, and they're probably already.
Speaker 7 (15:19):
On a progesterone.
Speaker 4 (15:20):
But I don't have to worry about them taking more
than a milligram of estradil, which then requires more progesterone
if you are menopauseal.
Speaker 7 (15:30):
So this is the.
Speaker 4 (15:31):
One that I think I probably prescribe the most, or
that people switch to eventually. The only thing that's kind
of a nuisance about it is that it does take,
especially when you have you know, a standard dose would
be zero point five milligrams, So when you're when you
(15:52):
have zero point seventy five or one milligram, it's a
lot of volume in.
Speaker 7 (15:56):
These little packets, and so it takes.
Speaker 4 (15:58):
A long time to dry. And so that's the other
reason why I like it at night is inevitably, if
you're in a hurry in the morning, you put your
pants on, the first time you sit on the toilet,
you go to pull your pants down and they're stuck
because your pants have stuck to your gel and you
know what, it feels a lot like, will you use
your imagination?
Speaker 7 (16:18):
It's really not a great feeling when you do that.
Speaker 4 (16:21):
So I like it at night because then you can
let your let your leg dry. So that's my that's
my that's I will say, that's my probably number one.
Speaker 5 (16:30):
That way, nothing's getting stuck to your leg.
Speaker 4 (16:32):
No, And that's in yes. So go ahead, what's your
favorite ladies? Anybody my my.
Speaker 3 (16:39):
Go to in general, because well you know yourself. Every
woman is so different and we talk about during the
appointment what would suit them, So we have this whole discussion.
But I find a lot of my patients and me
myself go with the patch. This one is you change
it twice a week. And here it is there, so.
Speaker 7 (17:04):
An estradle alone patch.
Speaker 3 (17:06):
Yeah, estradle on its own, and then you tend to
put that on maybe your lower tummy, your upper thigh,
lower back, or your buttock. I've tried putting it on
my lower back and it's like when you get a
bit of tape and it folds over on itself. That
happens to me every time I try it, So I
always end up putting mine just on the lower part
(17:27):
of my tummy. And I find that if you invest
a minute just putting it on properly, so you make
sure there's no moisturizer or lotion on there because you
want really dry skin. Put it on and then put
your hand over it for a minute because all the
estrogen is in the adhesive, and so you need to
get a really good bond to your skin and the
(17:48):
heat of your hand will warm up the adhesive and
get a really good bond, and then it should stay on,
you know, through your swimming or your showering or bathing
or whatever. And then you change it twice a week.
It's got about three and a half to four days
worth of Madison And another great option I find for
women who have migraines that are sensitive to estrogen, because
(18:09):
you really are getting that nice steady state.
Speaker 6 (18:12):
Yeah.
Speaker 3 (18:12):
I find that if I use the once a week patch,
they tend to complain of women will say they get
migraines towards the end of the week.
Speaker 7 (18:19):
Yeah.
Speaker 3 (18:19):
So I definitely don't feel like you get that steady
state with the once a week patch you back, can.
Speaker 4 (18:26):
I I just want to say I had a patient
with the once a week patch that she came in
and she was having some irritation and redness from that patch,
and I had her lifted up. I'm like, well, show
me your I wanted to see the area and that
patch was like it's huge big, It's like it's faith
I mean yeah, I mean what is that like four
(18:47):
or three inches across?
Speaker 5 (18:50):
Yeah?
Speaker 7 (18:50):
Yeah, it was really big.
Speaker 5 (18:52):
And I was like, there's no hide in that.
Speaker 7 (18:53):
I was like, that thing off. I'm like that looks.
Speaker 4 (18:56):
I mean, it's like five times the size of your
belly button. And I'm like that's too me. And apparently
some of the brands are that big. And then some
of the brands of the once a week are smaller,
but you don't know until you get home, and you
don't and you know, what about side effects at all?
What have you had patients say as far as side effects, Rebecca,
(19:19):
with the patches, I've.
Speaker 6 (19:22):
Had them usually two things, and I my go to
is typically the patch with the jow depending on the patient,
I have. Most of my patients try the patch first
and then I can talk about the ring.
Speaker 5 (19:33):
I have that here too.
Speaker 6 (19:34):
But most of the side effects that I hear is
either they get that like nausea and maybe the start
of a migraine at first, so I feel like they're
getting this like release of estrogen, and especially if they're
postman apostlem haven't seen estrogen for a while, it's almost
like the receptors are like, oh my gosh, we're so excited,
like here it comes girls, you know. And then or
(19:55):
they're getting it at the end before or they get
their new patch on, they're starting to get a little low,
and so sometimes you know, every three days is a
little bit better, or sometimes I'll have them use the
gel to supplement when they're growing low. But but I
will tell you too that you know that I agree
(20:18):
with with efon this that that patch at least to
twice a week.
Speaker 5 (20:23):
One. If you put that thing on, it's it's like wax.
And when you take that thing off.
Speaker 4 (20:29):
Yeah, that's a good analogy.
Speaker 5 (20:31):
Yeah, I mean I usually have the brace. I'm like,
all right, here we go.
Speaker 6 (20:35):
Yeah, And I've like saw on a hot tub swim,
you know, and I know we've I don't know if
you guys have heard from your patients, like you know,
and I actually think I had a pharmacist tell one
of my patients like, you can't go in the hot
tub with this, and you can't go swimming with us.
Speaker 5 (20:50):
It's going to release all the estrogen at once.
Speaker 7 (20:52):
And I'm like all the water sports, all the things.
Speaker 3 (20:56):
And the thing, you know.
Speaker 7 (20:58):
Yeah, yeah, every.
Speaker 4 (20:59):
And now and then I'll patients get the irritation, the
redness and the ishing and a cave very rarely hived,
very very very rarely hives. And that's you know, usually
when will switch to something else. But I think, you know,
I tell women all the time, it doesn't you know,
we love transnermal But it doesn't matter what you do.
(21:20):
All that matters is what you can you remember to do.
So that's what you got to pick that's going to
work for your life.
Speaker 3 (21:27):
Yeah, and can I give a tip for the just
in case anyone is listening who gets that little rash
when they're you know, a day or two into the
patch and the over the counter flown aise or flute
take a zone. You can buy that over the counter.
Spray the skin that you're going to put the patch
on with one spray. Let it air drive for a
(21:47):
minute and then put your patch on. And that works
really well for a lot of women.
Speaker 7 (21:52):
That's a great tip. That's a great We love our tips. Again.
One brain, three people, really good brain.
Speaker 3 (22:01):
Let's talk about well, the other kind of options that
aren't oral, and then we could do oral. So maybe
the ring you got actually hands, yeah.
Speaker 5 (22:11):
I do.
Speaker 6 (22:11):
This is called the femme ring, not to be confused
with the E string, which is just for bagile and
we'll we'll do that another podcast.
Speaker 5 (22:18):
But this is the fem ring.
Speaker 6 (22:20):
This is is almost like if anybody remembers the new
are the new ring? Yeah, that's my brain fog right there,
right there, ladies, and so I know that you can't
see it.
Speaker 5 (22:31):
Who are listening to the podcast? Yes, the crickets, thank you.
That was awesome. That was the brain fog because I
couldn't remember never ring.
Speaker 6 (22:43):
But those of you that are watching us, like on
YouTube or you'll be able to see this.
Speaker 5 (22:47):
So this is a new are the fem ring.
Speaker 6 (22:50):
And you just squeeze this little bad boy and then
you insert it intro vaginally and that stays for three months,
and it's really great.
Speaker 5 (22:59):
It slowly releases.
Speaker 6 (23:00):
A certain amount of estrogen every single day, and then
after three months you take that take it out.
Speaker 5 (23:06):
If it comes out, you wash it, you put it
back in.
Speaker 6 (23:10):
For those with male partners, some can't feel it, some
can and like it, so.
Speaker 5 (23:16):
Have a great time. It's fine. What I've heard with this.
Speaker 6 (23:22):
Not with everyone, is it can lose some of its
efficacy before you're due to change it.
Speaker 5 (23:28):
So I would keep maybe some gel.
Speaker 6 (23:32):
On hand, and you know, in case that happens before
you get your refail, then you can either put a
patch on or you can put some at some gel
if you find that that's happening before you get your
ring to change.
Speaker 5 (23:43):
I'm talking like maybe a week or two before.
Speaker 3 (23:46):
So what about pricing, we're back here for that.
Speaker 6 (23:49):
Yeah, so this thing's extremely expensive. Some I think Christine,
you were saying it was covered by Try insurance, Trycare,
Try Care as an unformulay.
Speaker 5 (24:01):
Oh random, it's so random.
Speaker 6 (24:03):
They have all the otherwise stuff on formulay. It's very
expensive to get this through the pharmacy. There is a
different pharmacy, Transition pharmacy, about one hundred and eighty dollars
for three months. Yeah. I think that's really really reasonable,
So let your clinician know Transition.
Speaker 3 (24:18):
Yeah, and if it's not covered by your insurance, it's
six hundred, so that's two hundred a month, and then
Transitions Pharmacy one hundred and eighty. So definitely better. But
we shouldn't have to be paying for this, you know.
But that's another's correct, yeah, correct.
Speaker 4 (24:35):
And then the other patch that I have here is
circular compared to the little postage stamp one that IFA showed.
This is a Comby patch and so this is Estra
dial in northindron acetate. This is the Comby patch comes
in two different doses, a zero point one four and
(24:58):
a zero point Let me see, let me remember that
for correct in a minute. Zero point Yeah, it's a
zero point one four milligram progesterone or a zero point
two five milligram progesterone most women unless they're I'm gonna
just throw this out five years menopausal. On the zero
(25:19):
point one four milligram, we'll usually have unscheduled bleeding with it.
So if I prescribe it, which sometimes I will, the
zero point two five milligrams, but it's the synthetic progestogen
norphendron acetate as compared to the progesterone, which is more
like what you're ovar is we're producing, and but it
(25:42):
is an option for you.
Speaker 5 (25:44):
You know, we just.
Speaker 4 (25:45):
Prefer progesterone because there's no there hasn't been any associated
increased risk of breast cancer with progesterone as compared to
the synthetic progestogens. But they are not evil and sometimes
we do need to use them, and it is okay
to use them. You still need to keep getting your mammograms,
(26:06):
but you know, it's and it's an option if you
just want one patch and be one and done and
change it twice a week.
Speaker 5 (26:14):
M hmm, Well you can use those levels.
Speaker 3 (26:17):
Right, yeah, Astro, you've brought us on to the combined
therapy then with that, Christine, that's great. Yeah, So the
combined estrogen and progesterone therapy, which we use for women
who do.
Speaker 5 (26:31):
Have a uterress mm hmmm.
Speaker 3 (26:35):
That progesterone, the progestine in that Comby patch. I have
very few women that that will control their bleeding. I
get so many complaints of naginal bleeding on that Comby patch.
So if you're on a Comby patch at home and
it's working for you and you're not having vaginal bleeding,
that is wonderful. Yeah, but I have not hid greads.
Speaker 5 (26:55):
Drop us a line.
Speaker 3 (26:56):
Yeah.
Speaker 4 (26:56):
They have to either have an ablation, you know, the
ablated uteruses do really well on it, or like five
plus years menopausal on the higher dose. Otherwise, I see
so many people on the lowered dose progestogen and they
do not do well. And we use that Northindron acetape
(27:17):
for women who orally for women who can can't take progesterone,
and the five milligrams they do not bleed at all.
It's the low low dose in that patch.
Speaker 3 (27:30):
Yeah.
Speaker 6 (27:31):
Yeah, which is which is interesting because there's not an
oral equivalent to that, which you know, would would be nice.
I had I had someone retouch to me asking me
about that, you know, and I was like, I know,
it's not you've got the you know the five or
half a five.
Speaker 7 (27:46):
Yeah, that's it.
Speaker 3 (27:47):
Let's talk more about the oral options for progestogens than
which includes progesterone, natural, micronized projecrotize. Yeah, and then the
synthetic progestins. We could talk those for a minute.
Speaker 5 (28:01):
Yes, yeah, do you want me? You probably have the micronized.
Speaker 6 (28:04):
Progesterone so you can show people.
Speaker 5 (28:09):
But the micronized progesterone is you.
Speaker 6 (28:11):
Know that that bioidentical body, identical equal twitch or ovaries
make works on the GABA receptors of the brain, helps
to help you sleep, It can decrease your anxiety, and
then it protects your uterus from the estrogen causing that
lining to grow. Comes to to one hundred or two hundred.
(28:33):
I believe most of the data that I have read
that usually anything over three hundred you're not getting much
more of a benefit out of maybe more just of
your sedation and things like that. I do have some
that do need do need three hundred, and they do
do really well with sleep and anxiety and not having
any side effects. But it can come with some of
(28:54):
those side effects like water retention, some reflux, some bloating,
a lot of times that will go away over time
for women. Sometimes some gas as well. But there is
this there is a percentage of women that don't do
well on it, and so then we need to move
on to the synthetic ones. Or instead of taking it orally,
(29:15):
there are some other ways that we will do it.
We'll do it intervationally as well off label.
Speaker 3 (29:20):
And the women who love the micronized progesterone really love
the micronized project like put We talked about that in
a previous episode, how that micronized progesterone gets converted to
alopregnanolone in the brain which acts on the GABA receptors
which stimulates rest and relaxation. And women will say it's
really helped with their anxiety, and it's really helped me
(29:43):
get to sleep at night. And then there's some other
women who do not love it at all, who are really.
Speaker 5 (29:49):
Right, they feel terrible yep yep.
Speaker 4 (29:52):
And if you have a penut allergy, you cannot be
on the progesterone that we get in the pharmacy. That's
when we have to compound it or you at a
compounding pharmacy because it is slung. I always say slung,
slung in peanut oil. Yeah, yeah, so that progesterone. And
the other thing I tell women is, you know, sometimes
(30:13):
women will walk away from a provider with a whole
stack of hormones.
Speaker 7 (30:17):
Occasionally they get really lucky and they're like.
Speaker 4 (30:20):
Here's some estrogen, here's some progesterone, here's some testosterone. Not
that very often, but then nobody tells them how to
take it. And that progesterone you need to take before
you go to bed, because the reason why we love
it is it makes you sleepy.
Speaker 5 (30:32):
It's sedating.
Speaker 7 (30:34):
So many women are like, this progesterone.
Speaker 4 (30:36):
I've been so tired since I started to take it.
And I'm like, when are you taking it? They're like
in the morning. I'm like, no, take it at night
so you get.
Speaker 7 (30:45):
Those sleep benefits.
Speaker 4 (30:47):
And I then tell women, don't take it before you're
gonna watch a movie with your family, because you're gonna
be crashed out on the couch.
Speaker 7 (30:54):
It won't take long for you to feel really sleepy
and fall asleep.
Speaker 5 (30:58):
Yeah.
Speaker 6 (30:58):
Yeah. Or their providers will start them too high of
a dose, and these poor women are like knocking into
the walls and you know, passing out and ending up
in the er. Because they started on like two hundred
right out the bat, you know, so at least for me,
I like one hormone at a time, and I like
a low and slow.
Speaker 3 (31:15):
Yeah, and I just and if anyone's having problems with
it orally, my next suggestion is to insert it vaginally
or rectally at bedtime. And it's that same capsule, the
same one you were taken by mouth. You can pop
it into the vagina or the rectum and see if
that suits you. Because for a lot of women, if
(31:37):
they're I've had a few patients recently tell me it
really like what makes them feel wired for some reason.
Speaker 6 (31:45):
I know I have a couple and they actually take
it in the morning instead.
Speaker 3 (31:49):
Yeah, and so I know you have to try different things, right,
So my first thing is try it. If that doesn't work,
then I'll say try it in the morning. And if
that doesn't work, then I know we need change.
Speaker 5 (32:00):
Is Yeah.
Speaker 6 (32:01):
Yeah, we're all a little special unicorn time. Yeah, you
tell I tell every patient that, like you, just I'm
going to tell you what what it's supposed to do,
and then you're gonna tell me what it actually does
to you.
Speaker 3 (32:13):
Nisen, You're like a little Ferrari, you know, with the
le engine and we're just tinkering under the hood and
we're trying to find exactly what works for you.
Speaker 4 (32:21):
M I like that and other progestogens. I think maybe
we kind of talked about Northendron or the mini pills,
the pops, the ones that most women are familiar with
that they have when they're breastfeeding or they can't take
estrogen and they do a progestine only birth control, so
(32:41):
that Northin drone is an option. The northindrone acetate, which
a lot of women if you have had, if you
go into your guy N and you're having really heavy bleeding,
will give you five milligrams of northindrone acetate to shut
your bleeding down. So some women may be familiar with that.
And then slind is really good. You know, we like
(33:04):
slind uh josperinone and people are familiar with that for
being in yeas birth control and a lot less bleeding
on drosperinone than on the norah thin drone.
Speaker 7 (33:20):
And then of course the IUD as well.
Speaker 4 (33:24):
And then there is there is a gel called ye
but I haven't heard very good. People say it's messy
and oily, but there is a gel. I've never prescribed
it me neither.
Speaker 5 (33:38):
I haven't either.
Speaker 3 (33:40):
With the progestins, a lot of them are from kind
of testosterone based. So if you have a woman who
already has had some excess testosterone issues throughout her life,
if you have polycystic ovarian syndrome, for instance, then those
women tend to love the drosperonone the slint because it's
(34:00):
not from a testosterone kind of base. That's good point,
and I can't think of anything else helpful really. The
iu D, like the Marina, the Kylina, the Lalletta that
those are. We do use them as part of menopausal
hormone therapy. But they're another thing that aren't FDA approved
for use in the menopausal hormone therapy. But the marina
(34:22):
is in Europe yep. So we use all your So
we use the offlabel.
Speaker 5 (34:28):
Yeah, we use it.
Speaker 4 (34:30):
And that The good thing I mentioned about that i
u D is that you can add progesterone to the
iu D because the iu D is just to protect
the uterus, so you're not going to get sleep benefits
out of it.
Speaker 5 (34:40):
So I hear.
Speaker 4 (34:42):
You know, sometimes patients will come and say, I really
want that progesterone, but nobody will give it to me.
You can use progesterone with a with a progestine I D.
Speaker 5 (34:51):
And the sleep right point and the other synthetic progestins.
Speaker 6 (34:54):
Don't do that if we think about that, right, because
all those yeah on those pop pops would be sleeping.
Speaker 3 (35:00):
Yeah, and don't say one more thing about those sorry
before if we're moving on, I just okay, So the
mental gymnastics of this drives me crazy, so I would
love to bring it up. Doctors are terrified of giving
women hormone therapy for menopausal symptoms because of the progestins.
(35:20):
They say, the progestine is what increases your risk of
breast cancer. Okay, now, if we could just please break
that down, because the progestins that we are using are
the exact same progestins that your doctor is pumping you
full of in the birth control pill exactly. Both control
pill is very safe. It's a wonderful medication. It does
(35:42):
have some risks and benefits, just like other medications. It's
been life changing for women on this planet. We've been
able to have careers and put off having children, not
have children. You know, it's been incredible. But these are
the same progestins that doctor and become terrified of once
you call it hormone therapy. How what how did they
(36:06):
convince us of this?
Speaker 4 (36:08):
How have we even studied all of the progestigens. We've
only studied majroxity progesterone in the w HI, So I
mean we don't have studies on every single other progestagen.
Speaker 3 (36:24):
From France from the E three. Yeah, and there's a
slightly increased incidence of breast cancer. It may have to
do with the progestine causing the breast tissue become a
little more dense and it being harder, harder mammogram, Yeah,
but really low risk, like the same as being overweight
(36:46):
or sedentry, having a big glass of wine every night. Yeah,
but that risk. Those are the same progestins that you've
been taking all these years in the birth control pill,
and no one has mentioned breast cancer to you. So
nothing magically happens when you come off the pill and go.
Speaker 4 (37:02):
On to.
Speaker 3 (37:04):
Your menopausal hormone therapy. If it's a synthetics progestin, it's
the same medication. I just don't understand how we've all
been so brainwashed to not use our brains and think
that through you know.
Speaker 5 (37:16):
Yeah, you're right, So I had to.
Speaker 3 (37:19):
Get that off my chest. Sorry, No, very frustrating.
Speaker 5 (37:22):
I find it very really great point. Mm hmmm.
Speaker 3 (37:26):
So we don't need to be scared of these things.
I'm a primary care doctor. I've been in medicine for
thirty years, and these are the safest medicines I've ever prescribed.
Save I've never had a patient end up in the
emergency room with these medicines. I have when I've had
datins or blood pressure medications or diabetes medications, I've had
patients end up in the emergency room with side effects.
(37:47):
Never once touchwood from a hormone. So we have to pass.
We have to get past this fear. Okay, I'll get
off a little bit time.
Speaker 5 (37:57):
No, it was a good soapbox enjoyed testosterol. It was
really good. Do we want to say anything about basidoxapine.
Speaker 3 (38:06):
Basic doxaphene, Yes, Dovie, I love it.
Speaker 7 (38:11):
Stevie, I love it too, Yes I do.
Speaker 6 (38:14):
I haven't used it a whole lot, so you ladies
may have better experience with it. I really I actually
took a patient wanted off of that and and to
go on really, I mean, yeah, yeah, whoever the provider
was just I guess was comfortable with it and so
put her on that not for any like, you know,
(38:37):
any reason at all.
Speaker 3 (38:38):
Let's tell's what it is.
Speaker 6 (38:41):
Yeah, So BASI is a selective estrogen receptor modulator or
a ser estrogen agnes. It has so combined with conjugated
equin estrogen deforma tissue selective estrogen complex.
Speaker 3 (38:55):
Yeah. That sounds smart, sounds really smart, and nobody will
know what we're saying.
Speaker 5 (39:04):
So I supposed to medicine, yes, yeah, yes.
Speaker 4 (39:11):
Right, the conjugated aquine estrogen, equin estrogen and the trimarin.
Speaker 6 (39:15):
So and that works on that uterus so that it
doesn't grow the uterine lining because of the conjugated equine estrogen. Right,
it makes the uterine lining thick, and the bes of
dox think keeps that lining thin.
Speaker 4 (39:30):
Yeah.
Speaker 3 (39:30):
We didn't talk about combine aquin estrogen when we were
back doing our first.
Speaker 7 (39:34):
No, but we haven't talked about orals. Yeah yeah, yeah,
and so let'sten so do.
Speaker 4 (39:40):
The other reason why we like it is that there's
no stimulation to the breast tissue and there's not stimulation
to the uterine lining, so you don't need a progestogen
with that, we like it for women who are concerned
about breast cancer. You know, some women, you know, they
(40:00):
may have a braca. They may be braca one, braca two.
You know, maybe they have a family history, neither of
which are contraindications for being on hormone therapy. But this
makes them more comfortable because there's no stimulation to that tissue.
Speaker 3 (40:15):
We might need to explain the combined neck one estrogen then,
So that's from pregnant mayor's urine and the drug name
is Premarin pre pregnant mayor mayors And you're, yeah, so or,
And that is a big concoction of different estrogens. There's
(40:39):
like I think there's even been a testosterone in there.
There's some progestins in there. It's a big concoction of stuff.
But it turns out synthetic and it's very panthetic. Yeah,
and it's synthetic as in, you know, it's from pregnant
mayor's urine, but it's put together in natural into a tap.
Speaker 6 (40:58):
Yeah.
Speaker 3 (40:58):
So that was study in the Women's Health Initiative twenty
years ago, and when they looked at women who were
taking the estrogen on its own, so without any progestine
synthetic progestine, those women actually have a decreased incidence of
breast cancer. It seemed to be really protective of breast tissue.
And what it seems to do is cause something called
apoptosis of abnormal cells. So if a cell is growing
(41:23):
and it's going through quality control and they pick up
on it, the combined aquanic estrogen can help kill that cell.
And then so actually we know that that is good
for women who haven't increased risk of breast cancer, right, yeah,
it can actually.
Speaker 6 (41:43):
Even and I think the data was even more so
than the than the estradyl I remember correctly, right.
Speaker 3 (41:50):
Oh, yeah, maybe that was Yeah, it was even more
so than definitely. Yeah, I don't even know if we
can say that estradil.
Speaker 7 (41:58):
Definitely increasing risk.
Speaker 4 (42:02):
Yeah yeah, right, so then the way strapolate that all
the time, but yes, you're in correct.
Speaker 7 (42:07):
Yeah.
Speaker 3 (42:09):
And then the basidoxaviene is not licensed for use on
its own over here. They only use it in that
mixture pill, the dewav And that's almost like tomoxifen, right,
the same family, yeahsta, yeah, And so really good for
your bones, really good for the lining of the uterus,
and really good for the breast. So you've got this
(42:31):
double it's like a booster book, which should be really
protect me or the breast. Yeah. And there's a study
going on at the moment called the Promise Study, and
it's in women who have dcis of the breast, which
is not breast cancer, it's like pre cancer. And they're
(42:53):
giving women do a VY for five or six weeks
before their surgery, and they're looking at you know, the
biopsy results from before the medicine, and then they look
at the tissue again after the surgery. And so I
think there might be some really exciting results from that study.
I can't wait to hear.
Speaker 5 (43:11):
Yeah, I am too.
Speaker 3 (43:13):
Yeah, how hopeful for women maybe who've had breast cancer.
And instead of saying to them, okay, we want you
to be on tomoxivan for five years or an aromatase inhibitor,
we say, here's your duave. It's got estrogen innits, you
don't get all the side effects, it's press breast protective,
and it's got a sister of tomoxivin in it, which
is Yeah, doing that.
Speaker 7 (43:32):
Work, that'll be really nice.
Speaker 6 (43:34):
I know.
Speaker 3 (43:34):
I can't wait for that day.
Speaker 5 (43:36):
Oh, that would be fantastic.
Speaker 4 (43:38):
I know, and then we don't prescribe very often the
oral estradial or like the synthetic you know, premarin, you know,
but you know it's I think we've villainized the orals,
but you know, not we did need to.
Speaker 7 (43:57):
You know, there are women that we will put oral
estra dial.
Speaker 4 (44:01):
I think one of the things that's just important to
know is that baseline risk for women between the ages
of fifty to fifty nine, there are five cases of
having a blood clot for every thousand women. And then
when we add you know, oral estrogen only over five years,
(44:23):
it's one and a half more cases. When we combine
oral estrogen with a synthetic progestin, then it's five five
more cases, so a total you know of ten ten,
ten women out of one thousand and so, you know,
I think, you know, we try to avoid risk when
(44:45):
we can, but the risk of oral of being on
oral estrogen for blood clots increases for the first six
to twelve months and then goes back down to baseline.
I like it for women who have high cholesterol, you know,
trying to get their LDLs down. I find it to
be helpful to get their LDLs down. But I do
(45:10):
know that their sex hormone binding globulin tends to go up.
And if it's more than one seventy and we're trying
to put you on testosterone, then you won't get the
same benefits because all the hormones are just going to
bind bind up, and you're not going to have any
free and available to use. But and you know, there's
some women who just want to take oral, and there
(45:31):
are some combination you know, there is a combination pill
that is, you know, estra dial with progesterone and women
like that as well. And so again, I think it
depends on what works for your life.
Speaker 7 (45:43):
And if you're.
Speaker 4 (45:44):
Someone who's healthy and doesn't have high cholesterol and you're
not worried about a blood clot, you've been on birth
control pills, you've been pregnant without any problems, and you
want to be on oral, then do your thing.
Speaker 6 (45:55):
Yeah, yep, I think as long as you know those contraindications,
you know, high blood pressure, things like that thyroid, you know,
because those can interfere and sometimes oral estrogen synthetic and
non I have found will increase can increase the bloo
pressure in some women, even those that haven't had hypertension,
(46:16):
and then obviously those that do have hypertension, So we're
careful with that thybroid just because it combined the thybroid
modulin and can interfere with that.
Speaker 7 (46:24):
So those more thyroid hormone you need to adjust.
Speaker 5 (46:29):
Yeah, yep.
Speaker 3 (46:31):
Sometimes with oral estrogen, some of it gets a lot
of it gets converted to esterone, which is more inflammatory.
Estradiol is quite anti inflammatory.
Speaker 7 (46:42):
So that's another good point.
Speaker 3 (46:44):
Yeah, and also can increase kind of gall bladder disease
like gallstone. Right, So I would say negatives for the
old oral estrogen would be you get your increased esterrone.
It competes with your thyroid medication if you're taking the
can cause gallstones, can increase your risk, and it increases
(47:06):
your sex harmal binding globulin which can decrease your testosterone
in your libido. But like you said, if you're a
healthy woman and you don't have any issues going on,
you're probably going to be very safe taken oral estrogen.
Speaker 6 (47:20):
Yep.
Speaker 5 (47:21):
Yeah, I agree.
Speaker 6 (47:21):
I think you have some of those patients or at
least I do, where you know they're just like I
don't want any risk, I want to decrease any risk
and then that's where we're just like, listen, we have
a plethora of transformal options.
Speaker 5 (47:34):
Yeah, that's fine too.
Speaker 4 (47:36):
So personally, one transformal option we didn't talk about was
the the spray in your forearm, one to three sprays
daily some women.
Speaker 7 (47:51):
I've had a.
Speaker 4 (47:52):
Couple of patients on it, and I don't know, they
just decided they didn't like it. I don't know why
they didn't like the spray on their arm, and we
just we just wound up switching them.
Speaker 3 (48:04):
Yeah, insurance, that's a nice one for timed insurance can
be a bit tricky as well with THEMS.
Speaker 6 (48:09):
Yeah, and sometimes the gel too, Yes, but those are
both the gel and the spray I find are so
nice for timed dosing in those patients, like you're saying, Christine,
they have, you know, more flashes at night or during
the day, or they're doing great on their patch, they
can't go up to their next dose because it's too much,
but they're still having flashes at night.
Speaker 5 (48:30):
Then a gel er spray is nice to add. Let's
add a little spray at night and pretty good to go. Yeah.
Speaker 4 (48:37):
And I think the other thing that sometimes I will
see is this speaking more to the clinicians confusion about
that patch, and so just remember that the dose on
the patch times two is what it's equal to an
oral estrogen. And so if you're over one milligram of
(48:58):
oral estrogen, which is zero point zero seven five patch
would be your uterus needs more progesterone.
Speaker 7 (49:07):
You need the two hundred milligrams.
Speaker 4 (49:09):
You definitely need the five milligrams of a northendron acetate
just to make sure you're protecting protecting that lining and
keeping the woman from bleeding. So, and you know, gel
and oral are equal to each other, but that patch,
you know, and women get confused too when we switch
(49:31):
them from gel to patches as they think we're dropping
their dose, but we're actually not.
Speaker 5 (49:38):
Yeah, and you can absorb it a little differently too.
Speaker 6 (49:40):
You might not be absorbing the patch the same as
you do the gel or the spray, So sometimes we
may have to still adjust even though we think it's
the same.
Speaker 3 (49:48):
So, yeah, we may have to skip testosterone and give
that gel.
Speaker 6 (49:54):
I think it needs it's an own episode, It deserves
its own.
Speaker 5 (49:58):
It's so beautiful you want to run.
Speaker 7 (50:00):
You're going to do our wrap ups since if.
Speaker 3 (50:04):
Yeah, yeah, you have secretary stary Okay, so let's pull
this all together with some takeaway tips. So, first of all,
menopausal hormone therapy is so so safe, please don't be
scared of it. And hopefully by listening to our podcast
(50:25):
you are becoming more comfortable thinking about it and talking
about it. And we also want to get rid of
the myth that it's only for severe symptoms. You know,
we need it for our bones, our brain, are all
our organs, and to stay in good health. And there
was another one I thought of there if you want
(50:48):
to go on a certain type of hormone therapy and
you're finding that your insurance is not covering it, we
know some tips for that, so make sure you check
good or X website to see if there's a coupon
for that. Mark Cuban's cost plus website is very helpful,
(51:08):
especially for vaginal estrogen cream. It's so much cheaper there
than a lot of insurances. And then there's the hort Club,
which I think is part of Transitions Pharmacy, So you
can join that for ninety nine dollars a year, I think,
and then you can order your hormones through there, and
for a lot of women because they're on maybe the
(51:30):
gel or something that's not covered by their insurance that
works out much deeper than the big copas from their
pharmacy an Amazon.
Speaker 4 (51:38):
Oh, Amazon right now is the lowest vaginal estrogen cream?
Is it?
Speaker 6 (51:44):
Oh?
Speaker 4 (51:44):
That's good.
Speaker 6 (51:45):
I don't know.
Speaker 3 (51:47):
All right, I've tried. Remember you're not alone in this journey.
Be informed, be empowered, and keep thriving through midlife. Until
next time, stay fabulous,
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