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5. Hormone Therapy in Perimenopause & Menopause with Dr. Rachel Pope
114 Plays24 days ago
"Hormones—what is the deal with them?"
In this special solo episode, Dr. Rachel Pope pulls back the curtain on the world of hormone therapy (HT). While we know that hormones are vital for cardiovascular health, bone density, and quality of life, there is still so much the medical community is uncovering about the "perfect" dose and duration for the average woman.
Dr. Pope gets personal in this episode, sharing her own recent experience with perimenopausal symptoms—from heart palpitations to her first-ever migraine—and how tracking her cycle led her to a life-changing realization about estrogen fluctuations.
In this episode, we break down:
- The "Extreme" Ends of Menopause: Why early menopause (POI) and late menopause both carry significant health risks and what they teach us about the power of estrogen.
- Hormone Breakdown: What do Estradiol, Progesterone, and Testosterone actually do for your sleep, mood, anxiety, and libido?
- Systemic vs. Topical: Why a patch might help your hot flashes, but you might still need a cream or ring for vaginal and bladder health.
- The Perimenopause "Storm": How the week before your period reveals the first signs of hormonal decline (and why you might not need a million different medications to fix it).
- The Safety Debate: A candid look at the Women’s Health Initiative data, breast cancer risks, and why Dr. Pope isn't "batting an eye" at low-dose transdermal estrogen for healthy women.
- The DEXA Scan Dilemma: Why waiting until age 65 for a bone density scan might be too late, and why Dr. Pope advocates for earlier screening.
Key Takeaways:
- You are an individual: There is no "one size fits all" for how long you should stay on hormones. It requires a yearly conversation with your doctor to weigh your unique risks vs. benefits.
- Prevention is key: Hormone therapy isn't just about stopping hot flashes; it's about protecting your heart, brain, and bones for the long haul.
- It’s not the "Fountain of Youth": While hormones are underutilized, they aren't a cure-all. Balanced medical care still means addressing mental health and lifestyle alongside HRT.
Are you curious if your symptoms are "just aging" or actually perimenopause? Subscribe and listen to Our Womanity as we dive deeper into these topics with world-class experts throughout this series!
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Transcript
Understanding Hormones and Health Risks
00:00:00
Speaker
Hormones. What is the deal with them? Okay, so we know a lot about hormones, but I believe that there's more that we don't know compared to what we do know. And why do I say that? Because, all right, we know that if a woman goes through early menopause, like say in their 30s or... you know, they have premature ovarian insufficiency. So their ovaries basically stop functioning and they go into early menopause or they have a surgical menopause or something from chemotherapy, from cancer treatment, they go into sort of chemical menopause. Any of those things, we know that without hormone therapy to replace what they would have otherwise been getting from estrogen and progesterone, or at least estrogen, and that they have higher risk of cardiovascular disease and really all cause mortality.
00:00:48
Speaker
That's pretty scary and pretty significant and shows us how important hormones are, right? When we see women who go through late menopause, so they continue to have periods throughout their 60s, we see that those women are at higher risk for endometrial cancer, breast cancer, right? So like we see these two sets of extremes. But for all the average women, the women in the middle, we still don't 100% understand which hormones are best to continue after your body stops making them and for how long.
00:01:19
Speaker
We do know that hormone therapy helps to relieve symptoms. And we do have a very good reason to believe that a lot of these hormones are going to prevent long-term health problems. But again, the details in terms of for how much and how long we still don't all totally
Personal and Professional Interest in Hormone Research
00:01:36
Speaker
understand.
00:01:36
Speaker
So this is an area that I am extremely interested in not only because it helps my patients, but I also want to be able to answer questions to my sisters, to my friends, and even for myself. So, you know, which hormones do what? I get this asked a lot and I'll try to break it down for
Role of Hormones in Menopause Symptoms
00:01:52
Speaker
you. So we know that estradiol in terms of hormone therapy, if you are going to be prescribed a patch, a gel, or a tablet, that is extremely helpful for sleep, for mood changes, for hot flashes, night sweats, all of those sort of classic symptoms of perimenopause and menopause. Now, what about progesterone?
00:02:13
Speaker
Progesterone is an interesting one because we give it to women to protect their uterus from the estrogen. And yet we see some very beneficial side effects from it. What do we see? We see it helps with sleep.
00:02:24
Speaker
It helps them to feel calm. It helps to reduce anxiety. So then you could ask, all right, well, then maybe we need to be getting progesterone long-term too, even if you don't have the uterus. Is there some sort of benefit?
00:02:37
Speaker
We don't really know. Because we don't really know that, I'm open to prescribing it for women, even if they don't need it. But at the same time, should we be doing that? And for how long should we be doing it? These are questions that I'd like to have answers for. Okay, what about testosterone?
00:02:52
Speaker
Testosterone we know is indicated for hypoactive sexual desire disorder. That's HSDD. So when women have decreased desire and it's causing a strain for them or distress for them, testosterone systemically is very useful.
00:03:06
Speaker
But for my patients that are using testosterone for that reason, they also tell me they have increased energy, better mood, right? All of these things that we see are benefits too. We also see benefits with topical hormone use, and that's when they're used in the genitals.
00:03:21
Speaker
So vaginal estrogen can be used as a cream, a tablet, or a ring placed inside the vagina, and we see it help with blood flow, moisture, decreasing pain, decreasing UTIs. All wonderful
Topical Hormones and Vaginal Health
00:03:34
Speaker
things. Why we're not getting that same benefit when we use systemic estrogen, probably it's not high enough of a level or high enough of a dose of estrogen to actually reach the vaginal tissue. So we do need to use something that gets right to the vagina and the bladder.
00:03:49
Speaker
That's that topical estrogen. Topical testosterone. I prescribe a lot of times to patients who have pain at the vestibule, right? The entrance of the vagina, because there's a ton of receptors for the testosterone there. I give it to patients who have issues around the urethra because they have tons of testosterone receptors there.
00:04:05
Speaker
I also give it to patients who have issues with orgasm. And that's an area of research that I'm really interested in and looking into right now to see is topical estrogen and testosterone to the clitoris helpful for orgasm. Again, it's a whole area, right? Sexual function where we don't know, we don't know much, or we don't know enough. I'll give you my own example with hormones and kind of why I want women to have more access to treatment and to understand sort of yourself where you can be preventing additional medications.
Hormonal Fluctuations Post-Pregnancy
00:04:38
Speaker
So I am in my early forty s You know, most people wouldn't even be thinking about perimenopause, but I think about it every day because this is what I do at work, right? So in the last year or so,
00:04:49
Speaker
Basically, I have a two-year-old, so i gave birth to her two years ago. So about a year after i was done being sort of postpartum, I feel like my periods came back to normal. All of my hormones were back to normal. And I started to notice I was getting heart palpitations randomly.
00:05:05
Speaker
Mostly in the evening were they more obvious to me, but they would happen throughout the day. And I started to notice after a few months that they were always the week before my period. Now I tell my patients as they're going through
Symptoms from PMS to Perimenopause
00:05:17
Speaker
perimenopause that symptoms start to be revealed during that week before your period, because that's when all of your hormones, estrogen and progesterone start to decline.
00:05:27
Speaker
And it is a bigger drop than what you might've been accustomed to five years ago when you were not perimenopausal. So I start to see this kind of blending from PMS symptoms to perimenopausal symptoms. Whereas we see symptoms of irritability, maybe cramping, maybe even vaginal pain. I hear patients talk about during their PMS days. And as they get into perimenopause, it ends up being more than days. It's like weeks and then takes up more than weeks, like almost the entire month. Right. And that's usually when they're coming into seek care. But for my patients who are really in tune with their bodies and really watching their cycle, they start to notice these things all worsening the week before their period And I started to notice this for myself too, but it was heart palpitations. It was a little bit off putting, but you know, not something that I was going to start medication for. It was something I wanted to get evaluated. So I saw a primary care physician, i had my thyroid tested which is important. You want to make sure that there's not something else medically going on. It was normal. She checked out my heart. There's some very basic monitoring that can be done, but you know, i wasn't having palpitations at that time. So it's not like anything was really caught, but there's options. If you want to continue exploring down that road, if you think it's something cardiovascular, you could do a Holter monitor where they're monitoring your heart for 24 hours. You could do an echo, you know, the whole thing is available, but we just started with some very, very basic monitoring and the thyroid testing, which was all negative. And then it was the first day of my period and I was at work and I had the first migraine of my life. You know, I treat women with migraines. I am very familiar with them in terms of other people experiencing them. But when i had this migraine, how it knocked me off my feet. I actually had to go home early and cancel the rest of my clinic because I was sick. It made me vomit. i basically put my head down and closed my eyes and turned the lights off. Like it was, it was insane. I was very lucky to be at work. People who were giving me, you know, offering whatever medication they could give me that they had in their bags because they suffer from migraines. I had some, you know, Advil in my purse, fortunately. And eventually it passed.
00:07:33
Speaker
I realized this was a menstrual migraine. you know, I started looking into it. I found this webinar about menstrual migraines and I saw that they are triggered by a decrease of estrogen, progesterone, and a release of prostaglandins when the period starts and your uterus starts to cramp. And it's like the storm of hormones that then causes these migraines. And i thought
00:07:56
Speaker
this every month. am not going have a migraine every month. So I called my best friend who's also an OBGYN and I asked her to order me an estrogen patch and to get me in her schedule for an IUD, right? So if you don't want to take the progesterone to protect your uterus from an estrogen patch estrogen that you're using for hormone therapy, you can use an IUD, like a progestin IUD, like a levonogestral IUD, the Mirena is what I chose. And that will also protect your uterus.
00:08:21
Speaker
So I got the IUD placed. I started an estrogen patch, a very low dose because I'm still having my own cycles. I'm still making my own estrogen. And guess what? My heart palpitations didn't come back and I have not got a migraine since. And it's been at least six months. So I knew because I was tracking these things and because I'm aware of these symptoms, that i could prevent them by starting hormone therapy and that this was indeed the beginning of
Evaluating Hormone Therapy and Personalized Treatment
00:08:48
Speaker
perimenopause.
00:08:48
Speaker
I got lots of messages from friends who were like, oh, you need to start this medication for migraines. Oh, do this, right? Like you can go down that road too. I could have started something for heart palpitations, started something for migraines if they happen, but because I knew what was going on, I was able to just supplement my daily life with bit of estrogen and prevent those fluctuations. And so this is where I am so interested in understanding for women going through perimenopause, when those symptoms are coming on, what they are, are they bladder related? Are they sleep related? And helping women get that treatment that they need without having to add on a million other medications or go down a million other pathways.
00:09:31
Speaker
Now, I'm not here to say that you don't need migraine medication or you don't need an antidepressant. Absolutely. All of those things are helpful and beneficial. It's only that I want to understand why these things are happening and if we can prevent them from happening by supplementing with hormones. Then the question comes up, well, how long should you be on them? And I don't have the answer for that. I tell my patients every year, we kind of look through risks, benefits. Has anything in your medical history changed? Are you still getting benefits from all these hormones, right? Is there anything new that's come out in research to change our idea of your risk versus benefit? I do think that a low dose estrogen patch or transdermal estrogen is very safe. I would not bat an eye on starting a birth control pill for somebody in their 40s and an estradiol patch, even at its highest dose, is less than what amount of estrogen is in a birth control pill. So I'm not worried about those risks as long as you are otherwise healthy and don't have contraindications to estrogen.
00:10:32
Speaker
So the other thing people ask me all the time is how long should I be on hormone? And again, we really don't have the right answer. And probably the answer is it's different for everyone. Everybody starts their period at a different age. Everyone goes through menopause at a different age. And everyone also has a different set of risk factors. You know, our data comes from the Women's Health Initiative, which was with a different formulation of estrogen that we don't usually prescribe anymore if we, you know, otherwise can avoid it. And so that data showed that there's a small increase, one per 1,000 after five years. So everything was looked at these five-year increments, sorry, increase in breast cancer, that is. And so when we think about when should we make a decision, i usually tell people, well, we could kind of reconsider at five years since that is a number that we have seen other forms of estrogen evaluated at. It doesn't mean you have to stop then, but on a yearly basis, at minimum, you
00:11:27
Speaker
can look at your health risks, look at the benefits and kind of do a way out of the two. If the benefits are still outweighing your risks, then continue. We don't know all of the risks, right? But I also think that probably a lot of the risks are inflated and we can use birth control pills as a proxy for a lot of situations. I'm hoping that more and more research will continue to come out to give us more information, but that is kind of where we are stuck right now I do have patients in their 70s and beyond who want to continue their hormone therapy and are otherwise healthy and doing great. i have patients who are in their 50s and I wouldn't recommend hormone therapy because of cardiovascular risks, right? So everyone is different and you can't really substitute. sort of the good medical care that will look at you as an individual, look at your health risks and get more information if you need more information,
Reassessing Bone Density and Hormone Therapy Timing
00:12:21
Speaker
whether that's through looking at a risk score, looking at your vital signs, just a simple blood pressure, or whether that's doing a calcium score with a CT. So there are a lot of different ways we can look at your health. I do think it's a shame that our screening for bone density is at an age at which it starts to become seemingly more risky to start hormone therapy. So we recommend screening for bone density at age 65. And lot of societies recommend not giving hormone therapy or starting hormone therapy
00:12:55
Speaker
beyond the age 60 or 10 years past menopause. So for me, the 60s are a gray area. It just completely depends on the person. But it is a shame that if at 65, it's the first time you're being diagnosed with osteopenia or osteoporosis and you would benefit from estrogen, that then it would give us pause to start you on estrogen. Should those screenings be adjusted? Maybe.
00:13:16
Speaker
you know, I think we look at the long-term outcome of osteoporosis, and we're probably missing the chance to intervene with osteopenia at an earlier age. So if you are someone who has mother who's had a hip fracture, you are a smoker, or you are on steroids for a long-term, or if you just have a small stature, you're at higher risk and we can justify to your insurance to cover a DEXA scan, I think probably for lots of other people, you should just get a DEXA scan earlier and pay for it out of pocket until these changes are instituted to have things covered by insurance. I'm not an authority on the topic, but you know, that's just kind of my observation that it's a shame that we might find real indication for hormone therapy at a stage where it may not be the safest time to start it.
00:14:01
Speaker
And so wouldn't it be better if we started earlier? i think so. So I guess that is where things are at this stage. The other thing I wanted to sort of cover today is talking about should you be on hormone therapy if you don't have symptoms. So what are symptoms? So I see a lot of women who have difficulty sleeping, hot flashes, night sweats, mood changes, especially anxiety, especially waves of depression that are not otherwise consistent with your mental health history. I see ADHD start to peak up for women. I see all these other things that are not just hot flashes. Then of course, vaginal changes, vaginal pain or vaginal dryness, that can also be dealt with just with local hormone therapy, vaginal estrogen or prasterone, which turns into estrogen and testosterone.
00:14:47
Speaker
But if you have no symptoms whatsoever and menopause and perimenopause has been smooth sailing, should you start hormone therapy? I don't have the data to say absolutely yes, you should.
00:14:58
Speaker
But I think if you want to see if it would help with anything, specifically your bone health, you can try it as long as there's no medical harm. If you don't have a history of blood clots, of heart attack, of stroke, or breast cancer in your own health history, if you don't have liver disease, you could try it and you don't have to be married to it. You don't have to be
Making Informed Decisions About Hormone Use
00:15:20
Speaker
on it forever. i just wish that I could tell somebody you should be on it for X amount of time and we know that's going to protect your heart, your brain, your bones. I don't have that concrete explanation. Maybe in 10, 20 years, we will. Asserting it for women who are at otherwise high risk. So I have patients who are in their 70s who ask. I have patients who've had heart attacks who ask, patients who've had strokes who ask.
00:15:43
Speaker
Those are much more tricky conversations. And I try to pull in additional experts, right? So I want to talk to your cardiologist. I want to talk to your hematologist if you have a you know, blood clotting disorder and really try to figure out what is the safest type of therapy that you could be on to help you with your quality of life. But should you be on it if you don't have symptoms, maybe it would be too risky for you. That is where, you know, you have to make that decision along with your healthcare care professional. So I hope this has been helpful. Where are all of these hormones? You know, what can they do for you? i think they could do a lot. I think we shouldn't be as scared as we have been, but at the same time, should everybody be taking all hormones? Probably not, right? It is not the fountain of youth. It's not a cure-all. It's not a fix-all. We still have people who need medication for depression, who need medication for sleep. It just doesn't fix everything, but I think they are overall underutilized. So hopefully this has been informative and stay tuned as we dive into each one of these things with experts throughout the rest of the series.