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4. Perimenopause: Is Hormone Replacement Therapy (HRT) (MHT) for you? with Dr. Jewel M. Kling
59 Plays16 days ago
In this episode, we welcome Dr. Jewel Kling, an expert in women's health and menopause. Dr. Kling is a professor of medicine, chair of the Division of Women's Health at the Mayo Clinic in Scottsdale, Arizona. She is also the director of the Women's Health Center and dean of the Mayo Clinic Arizona Campus. With a background in public health and internal medicine, Dr. Kling has become a recognized leader in the fields of menopause, sexual health, and LGBT care education. She speaks nationally on menopause and hormone therapy and has published extensively on the subject.
Dr. Kling joins us to dive into the topic of perimenopause, shedding light on common misconceptions and discussing the best approaches to treatment. In particular, she offers her insights on the pros and cons of starting hormone therapy during perimenopause and how to address contraception during this transitional period.
Key discussion points:
- Perimenopause and Hormone Therapy
- Managing Symptoms
- Contraception Considerations
- Individualized Care
Throughout the episode, Dr. Kling provides evidence-based insights and reassures women that effective treatments are available, especially for those suffering from persistent symptoms beyond the typical transition period.
As an advocate for women's health, Dr. Kling is also involved in advanced hormone therapy training through the International Society for the Study of Women's Sexual Health (ISWHISH), where she and Dr. Sarah Cigna offer a comprehensive course for healthcare professionals. See below!
Resources Mentioned:
- Advanced Hormone Therapy Course - A year-long virtual course for healthcare professionals, covering a range of topics, including hormone therapy and its effects on sexual functioning throughout different life stages, including pregnancy, lactation, and menopause.
- The Menopause Society - A resource for menopausal health and guidance on finding certified menopause practitioners.
If you're experiencing perimenopausal symptoms or seeking guidance on hormone therapy, this episode offers invaluable knowledge and practical advice for navigating this stage of life with confidence.
For more information on the Advanced Hormone Therapy Course and other resources, visit ISWHISH.
Recommended
Transcript
Introduction of Dr. Jewel Kling and her expertise
00:00:00
Speaker
I'm so excited to have Dr. Kling here with us. Dr. Jewel Kling is a professor of medicine, chair of the division of women's health internal medicine, assistant director of the women's health center and Dean of the Mayo Clinic Alex School of Medicine, Arizona campus at the Mayo Clinic in Scottsdale, Arizona.
00:00:16
Speaker
She completed medical school and a master's in public health at the university of Arizona, Tucson and internal medicine residency at Mayo Clinic, Arizona, followed by chief internal medicine fellowship year. Her clinical and research interests are in menopause, sexual health, LGBT care, education, as well as efforts to expand the discipline of sex and gender-specific medicine.
00:00:36
Speaker
Dr. Kling is recognized as an institutional and national expert and leader in menopause. She speaks at national meetings on topics related to menopause and hormone therapy and has published extensively in the field. She is a North American Menopause Society certified menopause practitioner, a fellow and board member of the International Society for the Study of Women's Sexual Health, ISHWISH,
00:00:56
Speaker
and a board member of the American Medical Women's Association Sex and Gender Health Collaborative. She's also part of the Transgender and Intersex Specialty Clinic Committee at Mayo Clinic Arizona and has been a past co-chair of the LGBTI Mayo Employee Resource Group.
Common misconceptions about hormone therapy
00:01:10
Speaker
She is a wonderful person, and I'm so excited to have her to speak to you all today. She's a go-to person for complex cases, and today we're talking about perimenopause. so welcome, Dr. Kling. Thank you so much for being here with us.
00:01:26
Speaker
Yeah. Thank you so much, Dr. Pope, for having me. And please call me Jewel for the rest of our interaction. Happy to be here. Thank you so much. So I wanted to get your thoughts about treatment during perimenopause because i see patients all the time who come to me seeking hormones because I'm pretty pro-hormone. And they've been told by other providers that you know they have to wait until they're menopausal so 12 months of no periods before starting treatment.
00:01:53
Speaker
And for me, i I really think it's based on the individual, but I'd love to hear what your thoughts are, pros and cons of starting hormone therapy during perimenopause and what we should be considering for women.
Contraception and hormone therapy during perimenopause
00:02:05
Speaker
Yeah. i' I'm so glad that you're focusing on this topic because I also hear that same thing. i don't know where that started. yeah We obviously can do a better job in our education of health professionals and of women, but there's no reason to wait 12 months past the last menstrual cycle to start treatment, whether that's with hormones or non-hormone treatment for women that can't use hormone therapy. But for women that are starting to experience symptoms like hot flashes and night sweats or mood or sleep issues, certainly once you start experiencing those symptoms, you can consider starting treatment.
00:02:40
Speaker
I think we'll probably get more into this. There are some caveats when you're starting treatment during the perimenopause that look a little bit different than menopause, including making sure that we have some form of contraception if women don't want to get pregnant. That's certainly one of the things. And then the other thing that can get a little tricky, now I should probably say this caveat at the beginning is I'm not a gynecologist. I'm an internist. I partner closely with my gyne colleagues, but is the the bleeding patterns. And probably any of the listeners are like, oh yeah, I mean, that was my first sign that I knew I was going into perimenopause was my bleeding started changing either heavier or you know more frequent. But whenever we start adding hormones into the mix, it can make that a little bit more complicated. And some of the hormone therapy formulations we have don't
00:03:28
Speaker
help with that, in fact, can make it a little bit trickier. So I do think that it's a really good point. And maybe for people who are listening, like, let's just jump into the contraception. So for a woman who's 45 years old, but having...
00:03:41
Speaker
you know, sleepless nights, hot flashes, vaginal dryness, like what does she need to be thinking about if she wants to get on treatment and then what she wants to do for contraception?
00:03:52
Speaker
First, let's start there, right? That women can get pregnant up until 12 months past their last menstrual cycle. Yeah. And I'll always start there. I know. Well, and I think a lot of us think You know, you skip a couple of periods, you're in your late forties. You're like, I'm not going to get pregnant. And I bet you have examples. I certainly have examples. I even saw a consult, a woman who waited months to see me because she was like having a regular periods. And then she went months and got a period and did labs and checked a pregnancy test and she was pregnant. And I think she was like 49 or 50 and to call her and say, you're pregnant. Like
00:04:30
Speaker
she just did she didn't want to be pregnant and she just assumed that she couldn't. And so that's the first thing to say, hey, you can still get pregnant. And so if you don't want to be, let's figure out what that option is.
Tailoring hormone therapy to individual needs
00:04:40
Speaker
And sometimes that's perfect, right? Because like a low dose birth control pill can both treat the menopause symptoms like hot flashes and night sweats, it can provide that contraception, and it kind of regulates the bleeding too. So that might be the perfect option. It's not the only option, right? Like that's the other thing.
00:04:57
Speaker
Because i I sometimes will have patients who say, i don't do well on the birth control pill. I really don't like it. And you know for lots of different reasons, I'm sure you have the same experience. I appreciate you saying that. You're right. Some will say that I don't like it, or maybe they can't. They have migraines with aura, or they've had a blood clot in the past, or some other reason that they can't. And so if that's the case, reviewing other options, like the long-acting reversible contraceptives, the LARCs, the intrauterine devices, especially the progestogen-containing ones, like the brand name Mirena is a
00:05:31
Speaker
fabulous one. i think a lot of us love those for patients, both for the bleeding profile, like it can treat that abnormal uterine bleeding. It can be used off-label for endometrial protection for hormone therapy. And it's a wonderful contraceptive one that I'll use with patients in this scenario. And then you can just add an estrogen, like an estrogen patch or ah gel or another menopausal hormone therapy formulation to treat the hot flashes and night sweats that typically help with the sleep issues and sometimes the mood issues and other things that women are also presenting. I love that, especially for the women who are having bleeding problems. So I'll have patients who sometimes have a polyp that's come up during perimenopause and they need to go to the OR to have that removed. And I really try to offer them while you're under anesthesia, let's talk about an IUD because if you want to be on hormones, this would be such a nice opportunity. And then we don't have to worry about the bleeding so much when you have a progesterone IUD. iut
00:06:27
Speaker
Yeah, and it lasts eight years. So if you're seeing somebody at 45, average age of menopause is around 51, 52. That's going to get her through that transition. And then when it's time to take the IUD out, she likely may not have any more periods. And then you can transition her to, say, the patch and oral progesterone or whatever other kind of menopausal hormone therapy
Misconceptions about hormone therapy doses
00:06:48
Speaker
formulation. And she won't need that contraceptive any longer. i just wanted to say one other thing here, Rachel. I wonder if you've heard this too.
00:06:54
Speaker
i think many people... think that hormone therapy formulations are stronger or higher dose than contraceptives. That's somehow a misconception that a lot of people come into, and that's not the case. I mean, kind of taken together, hormone therapy is about four times lower than even the low-dose birth control pills, and hormone therapy does not provide contraception. And so in case I hadn't said that or we hadn't talked about that, think those are important things for women to hear.
00:07:25
Speaker
Yeah, and that's also very reassuring. I like telling people that too, so that if they didn't do well on birth control pills, they might actually be fine with menopausal hormone therapy because it is a lower dose.
00:07:36
Speaker
And why it works better for their symptoms when it's a lower dose, I can't necessarily medically explain. I don't know if you have a better explanation, but I huge like i like having things separate, like the estrogen and the progesterone separate because you need the estrogen for the symptoms, but the progesterone for the uterine protection. So I like- yeah being able to have those separate so you can adjust the doses. But yeah, it's such an important point that it's a lower dose and doesn't provide contraception. of For somebody who doesn't need contraception, maybe their partner had a vasectomy or they're not sexually active or with someone who could impregnate them.
00:08:09
Speaker
What do you tell them about menopausal hormone therapy or perimenopausal treatment in general? Yeah. So I typically will go through all the different options. So would offer them if they were interested, even if they didn't need the contraceptive, a low-dose birth control pill because they could no longer have a period in that scenario, like a menstrual cycle, an option with something like an IUD plus a patch. Or they could consider a menopausal hormone therapy formulation, such as a transdermal patch, the gel, vaginal ring, Even the pill of estradiol plus micronized progesterone, the pill of progesterone to protect the lining of the uterus, which they could do cyclically. So doing it like the higher dose, the 200 milligrams, the beginning of the month, like the first 12 days of the month, which would help.
00:08:57
Speaker
somewhat with the bleeding pattern. And i certainly have plenty of ah women that decide to do that, go in that route. And some do really well with that option. And so gives them some choices and then just follow them closely to see how they're doing.
Importance of hormone therapy in early menopause
00:09:12
Speaker
ah would love to hear what you do. like how you Same thing. I offer a lot of people a patch with the micronized progesterone cyclically. So just two weeks out of the month. And if we have an issue with bleeding, I might have to tweak it or sometimes I'll try a different progestin, but that's usually my standard. I like the patch in general because you know not processed by the liver. And so that ends up to be you know a good thing for a lot of people. But I know i have some colleagues who use the you know estrogen tablets routinely and also works really well.
00:09:41
Speaker
I probably use the estrogen tablets more, not as an initial, but in follow-up for women that go through menopause either early or prematurely. So those women like less than 45 years of age or prematurely less than age 40, after we've looked into if there's any other secondary causes, why they may have gone through menopause in those earlier premature ways. But And those situations, I may be checking their estrogen level to try and get them to a ah higher range. And that may be a whole other podcast for an interview for us. But it actually brings up a great point because I saw a patient who went through surgical menopause at a very young age and then had not been offered hormones or estrogen specifically after her ovaries were removed. It was not done for cancer. It was not done for endometriosis.
00:10:33
Speaker
It was done for a benign reason. And she was not offered hormones. And she was told that they would cause breast cancer. She was in her mid-30s. And oh yeah, that was a shocker for me. um She's on estrogen now. but But yeah, that is definitely where I use tablets to be able to have some even You can even use higher doses when needed. But you would agree those patients need estrogen for their bones, for their heart, for their brain, that's sort of long term.
00:10:58
Speaker
When we're talking about early and especially premature menopause, really it's not just menopausal hormone therapy treatment to treat the symptoms of menopause. There's plenty of data that shows that women in those scenarios need hormone and replacement therapy, at least until the average age of menopause.
00:11:16
Speaker
to treat or prevent the long-term health consequences of premature menopause, the risk of osteoporosis, the risk of dementia and Parkinsonism, all the long-term health consequences, cardiovascular disease risk. We see these in these large cohort studies. There's been three. One of them that came out of Olmstead County near Mayo. My colleagues published off of this.
00:11:38
Speaker
But the good news is, yeah, is that if you do give hormone therapy until the average age of menopause, most of those risks are mitigated.
Analyzing misconceptions about estrogen treatment in perimenopause
00:11:46
Speaker
And based on expert recommendations, including most recent premature ovarian insufficiency guideline that came out of, I believe, the International Menopause Society, we should really try and get that level close to where we would expect her level to be in a a physiologic level anyway, like her estrogen level. So... Yeah, that makes sense, right? That makes a lot of sense. And I know a lot of people are worried about about breast cancer for a good reason, but it's really different for women who are in premenopause or early menopause.
00:12:16
Speaker
So I want to bring up but something from social media because a million of people have sent this clip to me. So this is of the Holderness family. They crack me up. I've been following them before they started talking about perimenopause because they're just hilarious and creative. But this particular clip that was sent to me was of the mom of the family, the main female character. She's going through perimenopause and she was describing her issues to dr Sharon Malone, who you know, of course. And she said that she has high estrogen levels and that wherever she's getting her care, she had had her estrogen levels tested multiple times throughout the month. This is not you know early menopause, not to confuse any listeners. This is like perimenopause. She's in her mid to late 40s. And she said that she has PCOS. And so therefore, she's not on an estrogen for her perimenopausal symptoms. She's only on a progesterone. And I think maybe she said an antidepressant or maybe she didn't specify that. But I wanted to talk to you about what you thought because i definitely had a reaction to that. And I wanted to see what you thought. Like, what do you think about someone having high estrogen levels through perimenopause and then not being offered estrogen and only being put on progesterone?
00:13:26
Speaker
And she's having symptoms of perimenopause, like hot flashes and night sweats. yeah Yeah. She's miss so miserable that it's become like a major percentage of her social media content. Oh, geez.
00:13:39
Speaker
Gosh, well, that certainly is not what our guidelines would say. i mean, ah first of all, the levels don't necessarily correlate with symptoms and we don't use those levels to guide whether or not we're using treatment or not. And if she is miserable, she deserves a conversation about starting treatment.
00:13:57
Speaker
We don't recommend progesterone as a first line treatment for hot flashes and night sweats. So I suspect that that's where you're going with my reaction with this. Yeah. Yeah, i'm not to let you out, but I was just like, this not evidence-based.
00:14:10
Speaker
Why does she have progesterone? She might need progesterone to protect her uterus from estrogen, but then she's saying she has too much estrogen, which I was like, for someone who's not in the medical world or in the menopause hormone world, like having too much estrogen it isn't a thing I'm aware of.
00:14:25
Speaker
So I wanted check with you. I mean, the only thing I can think of is sometimes in that kind of late perimenopause transition, you'll have a couple of those like super ovulatory cycles. Yeah.
00:14:35
Speaker
And that's probably why we see some women get pregnant. It's the same thing with POI. Even in women that go through premature menopause, you have to have some type of backup contraception because you can still have like an ovulatory cycle, but with probably a high estrogen, but it would be very odd.
00:14:54
Speaker
And yeah, to your point, like who's quantifying that? What lab are they doing mass spec? Like but How are they looking at this? There's so many variables there, but bottom line is we're going to listen to a woman's symptoms and treat them based on her ah her symptoms and without contraindications, which thankfully that list of contraindications is really small.
00:15:15
Speaker
Most women can consider using hormone therapy to treat their perimenopause and menopause symptoms and don't need to check a level to start on treatment. Yeah, I think that was the first red flag to me was that she mentioned she had had her estrogen levels checked multiple times throughout the month to verify. And like, that's not evidence based, right? Like perimenopause, we don't check the levels frequently because they are going to be all over the map. And it's not going to be helpful. We still will offer you treatment if you are medically eligible to be on estrogen. Treatment being estrogen. Sorry, I keep saying treatment, but it's really about the estrogen, right?
00:15:51
Speaker
Yeah. What's interesting too, we talk about this and well, maybe I won't get too much into this because this gets a little bit nerdy when we start talking about the levels, but we talk about migraine. That's okay. You can get nerdy with me. love all the nerdy now. It's all good.
00:16:08
Speaker
Oftentimes we think about migraine with aura being a contraindication to say birth control pills, we see a lot of women with menstrual-related migraines where they just get their migraines around their periods. And it turns out that using birth control in that scenario is not a contraindication because if you do like a low dose of a birth control pill, it actually, and do it continuously,
00:16:32
Speaker
And you look at the level of estrogen in your body actually brings the level of the estrogen in your body down. So sometimes giving estrogen in a continuous format can bring that level down. so they just feedback, right? Like and yeah yeah get on social media, I mean, we have to play it out for people, but like there is such a thing as negative feedback, right? You give someone estrogen and same thing with the birth control pill. That's how we turn off ovulation. interrupts that conversation between the brain and the ovaries. And so it kind of yeah keep keeps everything stable. I know. It was so bad for her. I was like, okay, she's miserable. She's wondering, her question is like, how long is this going to continue? yeah And of course that's her question because she's not getting treatment or are the treatment's not helping her.
Timing and options for hormone therapy
00:17:16
Speaker
And so I'm sure that she's not alone and there's lots of women out there. And I'm hopeful that some of them will be listening today and look for a menopause certified practitioner to practice evidence-based menopause care.
00:17:26
Speaker
Yeah, so that they can get treatment. To her question, how long will it continue? i mean, the most recent data shows that it'll continue for a long period of time. And there's but up to a quarter of women that it can continue well into their 60s and beyond, which no woman needs to suffer that long. Like we have safe, effective treatment. So please.
00:17:46
Speaker
you know, see somebody that can can treat you. Yeah. And that's the other pedestal that I'll get on is like, okay, if the safest time to start hormones is within the first 10 years of menopause, then if you're not getting treatment during that time, but you happen to fall into that unfortunate percentage who continues to have symptoms beyond, you know, beyond a decade of menopause, then we're only then limiting your options if we're not treating you the appropriate time.
00:18:12
Speaker
Right. That's true. That is absolutely true. That a window, the timing hypothesis, that window is is certainly something we we want to be mindful of. You can always have an individualized discussion with your clinician and do some risk benefit evaluation, do some studies to look at your cardiovascular disease risk and see if maybe you could consider outside of that window. But we do have some wonderful non-hormone options to treat things like hot flashes and night sweats and some of those other symptoms too. And more even coming out, hopefully in the next six to 12 months, there are treatments.
Resources for healthcare professionals in women's health
00:18:46
Speaker
You don't have to suffer, which is great. Yeah, absolutely. Well, thank you so much for your time. I wanted to point people towards more resources because you and Dr. Sarah Cigna, who's also been on the show, have an amazing course going on. So for anybody who is a healthcare professional and wants to get more experience, could you mind telling everyone about the Advanced Hormones? course? Yeah, we have a first ever advanced hormones course through IshWish. It's all virtual. We've already done two sessions, but we'll have many more. It's a year-long course run every month. And if you sign up, you'll still get to see the first two sessions, but then you can join the future courses live to ask questions and then get them on demand as well. It's a basically like hormone highway. So the different
00:19:32
Speaker
parts of our life as a cisgender woman, but we also talk about it transgender, non-binary folks and how those issues affect sexual functioning. The next one is pregnancy and lactation and how that impacts sexual functioning. It's on a Friday afternoon, once a month that we'll have that course.
00:19:50
Speaker
That's awesome. And then of course, through the Menopause Society, there's always great information, great resources. And of course, the conference, which I think is already sold out, unfortunately. The room block sold out.
00:20:02
Speaker
I don't think the actual course is sold out. So it's still time to register for the course. Well, thank you. Thank you. Thank you so much for your time. I really appreciate it And such a pleasure to talk to you today.
00:20:12
Speaker
It was my pleasure. Thanks for doing this.