Busting Common Hormone Therapy Myths – Podcast Transcript

November 27, 2023.

‘Busting The Most Common Hormone Therapy Myths’ is the focus in this episode of Perimenopause WTF! Dr. Heidi Snyder Flagg & Dr. Robin Noble discuss’ the biggest  misconceptions out there surrounding Hormone therapy. Myths such as, ‘Hormone therapy is only used for hot flashes’, or ‘natural products are safer than synthetic hormone therapy’. Stay tuned for a ton of myth-busting answers in today’s conversation!

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Full Podcast Episode

Introduction to Speakers

Dr. Robin Noble – gynecologist based in Portland, Maine with 20 years of experience at InterMed. MD of the OR, physician leader, Masters in Healthcare Delivery Science. Launched the NGO Let’s Talk Menopause – Chief Medical Advisor.

Dr. Heidi Snyder Flagg – obstetrician, gynecologist, and menopause specialist, founder and managing partner of SpringOBGYN (NYC, founded in 2002), working in this field for more than 10 years.

Podcast Transcript

Myth 1 – Hormone Therapy is a treatment that replaces hormones within the body.

HRT = hormone replacement therapy.

But it’s a misnomer. Not actually replacing hormones, only in a couple of clinical scenarios with premature ovarian insufficiency and surgical menopause in young patients.

So there is a new term coined for it = MHT = menopause hormone therapy – which is not inclusive of women who are in the perimenopause stage since symptoms of menopause can occur 5 to 10 years before its onset.

So the best term in use is HT = hormone therapy. Inclusive of perimenopausal, menopausal, and trans male patients.

Dr. Streicher from the Midwest, menopause specialist and sex therapist, jokingly calls HRT “husband replacement therapy” for women whose husbands can’t find the clitoris during sex.

Myth 2 – It’s only used to treat bothersome hot flashes.

Common misconception about HT is that it is only for when women experience hot flashes. But HT has FDA approval for the treatment of osteoporosis.

Supplements and compound medications (made by pharmacies) and marketed as “natural products” are not FDA approved. In the US, these medications aren’t regulated well. There’s far better regulation in Europe.

Chondroitin sulfate – a supplement in the US for joint pain – they tested tens of thousands of the supplements and found that none of them contained what they said they contained, except for the ones from Costco.

Myth 3 – HT is very expensive.

It doesn’t need to be expensive. People are struggling to get access to it, but that’s due to a system problem in the US. Ideally, patients should be able to get it from local drugstores and most of them are covered by insurance.

You can get either the Rolls Royce version of the drugs or the more common and local options. Single options like transdermal estrogen with oral prometrium at night are less expensive than combi patches. But there are more expensive options too, like the vaginal ring which people can use once every three months. Ask your insurance company which drugs are covered under their plan.

Myth 4 – You need to be seen frequently and get your blood levels checked to measure hormones.

Clinical intervention based on symptomatology, not on specific levels.  Estrogen has a 12 hour half life and so it can titrate out of the system very quickly. Apart from your annual exams, book a separate appointment with a menopause specialist so that you can exclusively discuss the various symptoms, and then book a follow-up three months after that.

Let’s Talk Menopause to release a detailed guideline on how to approach your physician and what to do prior to getting ready for that visit.

Myth 5 – You should not start HT at a young age.

There are age guidelines surrounding hormone therapy.

Timing hypothesis – the earlier around that transition, the better it is in terms of not only symptom management but also implications for heart health and brain. You do not need to wait to start HT until you are officially menopausal. You can get help even during the perimenopausal stage

Not a great idea to start HT after 10 years into menopause. Some cardiovascular diseases and coronary plaques can occur in those ensuing years, and starting HT post that could increase the risk of heart attack and stroke.

Starting HT around the start of the perimenopausal stage is ideal for symptomatic control. However, this is very individualistic and anyone can get treatment after a good discussion with their menopause specialist and a cardiology work-up to ensure nothing goes wrong.  Local vaginal estrogens and non-hormonal therapies for hot flashes could also be a good option in such cases. There are selective estrogen receptor modulators that hit the bone and the vagina like Asphena (Aspemafine) that could be safer options too.

Myth 6 – HT is only for women transitioning through menopause.

How long can you do HT for?  5, 10, 20, even 30 years. Patients in their 70s and 80s can also be on it, especially if they have had a hysterectomy.  Data suggests to continue estrogen therapy, and that transdermal is safer.

No set rule on when to stop, there are times when it is worth revisiting.

Estrogen progesterone therapy seems to increase breast cancer after 5-7 years of use. So in such cases, patients slowly try to wean off it. Women’s Health Initiative, 20 year analysis – they looked at the estrogen progesterone and after 5 years of use with the average age of 60, risk is increased only for 1 in a 1000 or 2 in a 1000.

There are risks of breast cancer, osteoporosis and bone health, and cardiovascular disease. So HT needs to be a systems wide approach because even if someone decides to not do HT, the above risks abruptly change at menopause. Also, if someone starts HT before contracting any heart disease, estrogen is protective and can prevent dire consequences of cardiovascular disease.

Myth 7 – HT causes uterine or ovarian cancer.

The reason that progesterone is used with patients that have a uterus is to protect the endometrial lining. In the 1950s, the use of estrogen vastly increased the risk of uterine cancer. But with progesterone, the risk is mitigated. 

As for ovarian cancer, there isn’t an increased risk when using prolonged HT. 

Myth 8 – If I had breast cancer, I shouldn’t use vaginal estrogens.

Because of the lack of absorption into the system through the vagina, we can use low doses of topical estrogen on the vagina to help alleviate symptoms of GSM that people suffer from, particularly breast cancer patients. Patients are cautioned off cream, though, because it is more easily absorbed. It is also patient-use dependent, and patients shouldn’t use too much of it and too deep into the vagina. A little bit of cream on the vulva is ideal. 

Can patients use vaginal creams in addition to the HT? Yes. For localized symptoms, it is very effective. 

Can start the vaginal estrogens at any time, and continue till the end of time. Perfectly safe.

Myth 9 – HT causes cardiovascular disease.

Getting started on HT before the disease sets in is important. Estrogen is an anti-inflammatory and a vasodilator. It is a preventative measure for heart disease. 

When should someone stop HT?

If they have had a myocardial infarction, stroke, pulmonary embolism, or a deep venous thrombosis that’s been unprovoked.

More concerned with people that have an increased risk of clot or stroke, or an estrogen receptive positive cancer. For such cases, transdermal or transvaginal therapy works better as it doesn’t increase the risk of clot or stroke. To put it in perspective, there is more risk in taking cars for transportation than using HT.

Myth 10 – HT causes weight gain.

This is a concern for people and they have difficulty in not just gaining weight but also losing weight. They can’t continue to eat or drink the way they have before. People also report that around the perimenopausal and menopausal period, they start to notice it’s going to different places, somewhere in the middle. This is because of the change in ratio of estrogens and androgens, resulting in a more male pattern deposition of the tissue. This is the metabolically active fat that increases the risk of diabetes, metabolic syndrome, and cardiovascular disease. So, HT doesn’t cause weight gain. It mitigates those changes. But it’s not a weight loss regimen either. This is the point in someone’s life where they need to increase their workout intensity (gentle cardio), improve their muscle mass, increase their protein intake etc. 

Myth 11 – HT is the only thing that works for hot flashes.

SERMs – brand new candy receptor blockers

There are lots of options for hot flashes, not just HT. CBTs, SNRIs, SSRIs (selective estrogen receptor modulators or “fancy estrogens”) work as estrogen in certain tissues of the body and they bypass the breast and uterus. But it is expensive, oral, and a lot of doses. Currently, it is bezodophene paired with premarin, which is from pregnant horse urine. It is good for hot flashes, bone health, brain, and vagina, and it doesn’t increase the stimulation of the breast tissue or the endometrial lining. 

Myth 12 – HT is a cure-all.

It is not. It is a combination of lifestyle factors like sleep and stress mitigation that work together effectively.

Summary

  • Shared decisions with a trusted provider.
  • One size does not fit all.
  • There is no magic bullet.
  • Need a combo of HT and lifestyle factors – exercise, nutrition, stress management, sleep.
  • HT is safe with correct timing, mode of delivery, health screening, and personalized care.

Questions

  • Is there a particular ratio among estrogen, progesterone, and testosterone?
    • There are FDA-approved doses that doctors start with. Then they have a follow-up in 3 months.
  • Oral contraceptives around perimenopause vs HRT.
    • The birth control pill is a higher dose. It is essentially the same formulation as HT. When you are perimenopausal and still menstruating, you do need birth control. It controls the period bleeding. Oftentimes, perimenopausal women suffer from heavy bleeding and cramping. Birth control pills suppress the ovarian function. 
  • Oral progesterone is typically given at night.

Resources

Menopause.org

letstalkmenopause.org

Resources on heyperry.com

Emas-online.org

Imsociety.org

Disclaimer: This is not medical advice, does not take the place of medical advice from your physician, and is not intended to treat or cure any disease. Patients should see a qualified medical provider for assessment and treatment.

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