CME | Hot takes and flashbacks of menopause

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Hit play, and let's embark on this journey to. I'm Taman Osborne Roberts, a family medicine, lifestyle medicine and obesity medicine physician for the underserved from Denver, Colorado. I'm also an occasional medical executive and policymaker and early career scholar of happiness studies and a professional medical communicator.

I'm joined today, as always by my cohost. Hello. Good afternoon. Good to see you all. My name is Dr. Jason Marker. I am an associate director at the Memorial Hospital Family Medicine Residency Program in South Bend, Indiana. My name is Lauren Brown Bechtold, and I am the program director for VCME Family Medicine in Modesto, California.

It is fantastic to be on the go with the two of you yet again today, and today we have a, a redux, if you will, of a prior topic that we discussed, that being menopause. We're gonna delve in a little further today, but let's start with a quick case. So this case is a 51-year-old woman who's coming to your practice.

She believes she's in menopause. Her last menstrual period was about seven months ago in recent labs from an outside physician showed a negative urine pregnancy test and an FSH and an LH in the menopausal range with uh, a DEXA as well with T scores ranging from negative 1.5 to negative 2.3. She knows she's had about 14 months of fatigue, hot flashes, brain fog and hair loss, and is wondering how she might best treat such.

What do y'all got for her? Well, lemme tell you. I think I would say that she is in the perimenopause. It's not been a year since her last menstrual period. She does have a lot of symptoms, which typically goes along with the perimenopause, but she does not meet the criteria for. Formal menopause. Now our listeners might pause and say like, well, what about those lab tests?

She's got an FSH and an LH in the menopausal range. And I guess that's part of what we negotiate as family doctors with our patients in this perimenopausal time of their life. So a couple quick points on my mind. You know, the FSH starts to rise. Up to two years before menopause, and it actually doesn't stabilize at a consistently high level, which is over 40 generally for up two to four years after menopause.

And so the FSH test doesn't help me as much as I maybe would've want it to. In this particular scenario, LH and estradiol, like they, they don't even have some of the same data that the FSH does anyway. Folks who are doing a little bit of reading, patients who are reading on their own about this are gonna maybe ask about.

anti-Mullerian hormone, and that's becoming a more common test. It is approved by the FDA, but it's not recommended by ACOG at this point. It becomes undetectable about five years prior to menopause, and so that's something to know about that test. If it's not one that you're familiar with, some people are coming in with that test result already done and wondering what that means for them.

Also, what I would do with this case is I would say there's a lot of symptoms there. Yes, they can be symptoms of the perimenopause, but they could also be symptoms of something else. We have to think about thyroid disease, neoplasms. Some of these are just symptoms of the normal aging process, so I try to bring some curiosity, open-mindedness, have a good bit of conversation and shared decision making regardless.

Once you think that a patient is in menopause, which I'm not sure this patient is, you gotta start treatment. And Lauren, I think, I think you're gonna lead us on into the specifics about how to do that part right. Yeah, I certainly am, but not right now. And so don't you worry, it is coming. And Jason, I don't even have any other responses to kind of the case review that you gave us.

'cause you did such a beautiful job. Yeah, thank you. Thank you. No, I, I'd agree Jason. That was actually a really, really fantastic lead in and really gives us a good place to, to jump off from. Let's start with the level set. So first of all, let's be clear, one of the things we'll be discussing specifically today, really the focus.

Is hormone replacement therapy, also known as HRT. As we all know, there are other pharmacological treatments, SEAL for menopause. Many of them can actually be used as cot treatments or adjunctive treatments along with hormone replacement therapy. But today we're gonna focus in on HRT. Additionally, we've also discussed in a prior episode, the recent reassessment of the evidence.

Making HRT again, a viable option for treatment. We won't rehash that a lot here, although there are a, a few particular things we should mention about that. One of them is really to level set on, on just the point of it coming back into broke. We won't go through the reapplication of the evidence, but two things come up.

One is that recently the FDA removed the black box warning for HRT, so that is now gone and HRT, yeah, that are the treatment that we have without a black box warning. In addition, we all understand that there are people out there, you know, family physicians out there who still may be a bit uncomfortable with the concept of prescribing HRT because it's not a risk-free treatment, but it's important to understand that all the treatments that.

We engage in, have risks, and at this point, looking at the evidence and understanding really what, what it's looked like. Certainly there are risks, we'll talk about those specifically as we move along, but the risks are now acceptable and within the range of the majority of our other treatments we get.

So this is not a, a particular treatment that we should shy away from. It's in our box of tools to use to help patients and, and should be looked at that way. So a few additional basics of hormone risk replacement therapy, and one, we're talking about hormone replacement therapy. We really are talking about treatment with estrogen, with or without a progesterone.

As far as the specific type of estrogen to be used, the recurrent recommendation is to use 17 beta estradiol. Which is the bioidentical version of the human hormone. This is referred over other types. You may have patients coming in asking about conjugated, equine, estrogen, or other sorts of estrogens.

Typically, various brands of 17 beta estradiol are the ones that we recommend to use. Additionally, anyone who has an intact uterus should also be on a progestin. With oral, natural micronized progesterone at about a hundred milligrams a day as the recommended simplest regimen. There are cyclical regimens you can potentially use, but the daily regimen is the most commonly used one, and that's to prevent increased risk of endometrial cancer.

Systemic hormone replacement therapy with estrogen is a very, very useful treatment, and as much as it treats multiple symptoms of. Menopause, you know, hot flashes that we tend to think about a lot in menopause, but there are many, many other symptoms that go along with menopause, from fatigue to hair loss, to vaginal atrophy, urinary leakage, a whole range of things, and systemic hormone replacement treatment therapy, treats all of those.

We've discussed the overall risk and benefits of hormone replacement therapy in previous episodes. I just, you know, touch briefly on the wrist. We think largely about thromboembolic events, you know, dvt, CVAs, things like that. There are also risks of breast cancer with extended HR team. We'll discuss those a little bit later.

But at the end of the day, effective treatment and other risk to be managed. So Jason, do you wanna lead us into talking about route of adminis? Sure. Absolutely. You know, there's so many different ways that this can be delivered, and that's great because in shared decision making with our patients, we can have that conversation and and find a place that we're both comfortable with.

I will say that the current evidence would suggest that the transdermal patch is the current preferred route of administration, unless there's some contraindication to that. It seems to have a lower risk of cardiovascular accident and thromboembolism as compared to placebo is also. Probably safer live for people at risk for liver disease as they tend to bypass the liver that way.

Other systemic non-oral formulations like high dose transvaginal preparations, creams, ointments, have really not been very well studied, so it's probably likely best to assume that they have the same effect as oral preparations for now. And so you're generally gonna err on the side of pushing towards a transdermal patch and seeing how that conversation goes with the patient.

It is true that the oral preparations can improve LDL and HDL cholesterol, but may increase triglyceride, so there's trade off there. The transdermal may have the LDL effect at higher doses even so you may not be able to escape that for women at particularly higher risk who are already perhaps on STA, nor have elevated levels of their lipid metrics.

Oral preparations may decrease free testosterone. They could decrease the bioavailability of T four and increase serum cortisol and for selected patients. Those are things I need to be concerned about and may need to move from an oral preparation to a transdermal preparation because of that concern as well.

So. My neck of the woods here in Northern Indiana. The oral route is, is the commonest. I, I have some conversations to do to get a transition over to a transdermal approach, but again, some of that will be local to your region and you'll just have to work your way through that with your patients as you have those conversations.

Jason, that's a really great point. Those conversations are really important and can sometimes feel uncomfortable, right? We, in medicine, we practice the art of medicine. We can get used. To one way of doing things and later get data that there might be a different better way of doing things. And, and there's also community norms and and group norms that might lead us, like you said, to have the majority of patients on HRT in your neck of the woods on an oral route.

And is that because they failed the transdermal route or was that just not recognized as the preferred option? And are you potentially going to have to have some. Potentially uncomfortable conversations with people who really don't wanna give up that pill and go through that shared decision making process.

Have you had to do that so far? I have people who've been on their oral HRT for a long time. It's been working really well for them and maybe they had quite a lot of symptoms before they got on that, and now here I am recommending taking them off of that and putting them on a patch there. There is some understandable skepticism and making that transition, but that, that's for me to sort of put on my scientist doctor hat and talk about risks and benefits and that this is.

Should do just the same thing as their oral pills. And the other thing is, this is not a final decision. If we switch over to a transdermal patch and it doesn't work for some reason, like I still have options. And so that often will be the shared decision making point where they're willing to make the transition and see how it goes.

Yeah. Yeah. Interesting. What this actually makes me think of this whole conversation is how attached to all humans can get to certain medications, either physiologically or emotionally. And I have taken care of a lot of women who are like, I like the idea of going off of HRT is terrifying, and that then taking HRT becomes so rote to them that, that then I just get like routine.

Med refills from the pharmacy as requests to fill things that are potentially inappropriate. Sometimes, like I've caught a routine refill for relatively high dose oral estrogen for HRT, who was a woman with a uterus who wasn't taking progesterone. Wow. And so, and so it's interesting because my resident actually filled.

That routine refill request and luckily we, we ended up catching it, but it can be really interesting to have these conversations to question our biases and other patient biases about like, well, this is just what I take, when in reality we have to be thinking a little bit more or a little bit more frequently about whether you're gonna take this.

So with that said, I'm actually gonna take us into dosing because it's an, it's an interesting conversation and really the biggest reason that we wanted to do this episode as to man called it a redux because our listeners said like, Hey, your menopause episode. What's good and what the heck we, we wanna know how to prescribe.

So with all of that said, let's actually talk about dosing, because again, in our menopause episode that we had previously done, the big takeaway from some of our listener feedback was, we want specifics. We, we don't really wanna have this philosophical conversation about the Women's health Initiative, like give us specifics about the dosing that we're gonna be doing in our.

Exam rooms in our N of one with the patient in front of us. And so the big sort of takeaway is that it used to be this idea that with HRT one size fit all, there was standard dosing that you did for all people and really. Now it's recognized that there's a nuance as with everything, right, that we can think about the appropriately chosen patient clinical monitoring of symptoms for dosing and titration, and shared decision making for discontinuation as well.

And so that statement. Might scare a lot of people right now of like, gosh, don't make this so complicated that I still can't follow what you're about to tell me. Please don't be deterred, just, just stick with us for a second. Okay. So first question, you are in the appropriately chosen patient. Okay. Toman talked about some of our risks.

About some of the reasons to think about not using systemic hormone therapy, particularly with regards to things like thromboembolic risk and cardiovascular disease in the appropriately chosen patient. At what age should we initiate HRT? If the patient is wanting that, right, and and the answer is when they present to you, when they present to you, you have diagnosed them with menopause, which is a clinical definition of 12 months of amenorrhea that you can start right away if that's desired.

What's interesting is that starting earlier, soon after menopause is diagnosed, it actually. Reduces your overall risk of stroke in the long term. Now, you could also imagine that maybe someone has never been evaluated outside of menopause, right? That maybe they didn't have insurance, maybe they moved from another country, and you are seeing a 65-year-old person who has debilitating vasomotor symptoms, who hasn't had the opportunity to talk to a doctor in the last.

15 years, and you might have the question of, man, can I give this person HRT if she's really suffering from side effects of menopause? And the answer is, maybe. The answer is that's a conversation to be having with your patient. And again, presuming that there are no absolute contraindications, the overall kind of consensus is that after the age of 60, it just requires increased counseling.

If you are 10 years outside or 10 years after the onset of menopause. It requires some increased counseling and, and that's because the risk benefit ratio is a little bit less favorable with those greater risks, coronary heart disease, stroke, venous thro, embolism, dementia, et cetera, to man. Jason, I'm gonna pause here.

Any thoughts about this age or timing of initiation that you've seen in your clinical practice? No, this is very much in line with what I've seen. Most women will come in during the perimenopause. Ready to have some conversations and actually they're pretty open to a dialogue about when they should start treatment, and it gives me the chance to take the good history, do whatever examination or laboratory studies may be indicated.

But I don't find that there's a lot of controversy here in my practice. They women are aware that something's changing with their body. They maybe have asked a few other people first, but they come in looking for a conversation, and I've found this to be a pretty straightforward thing. Great. I would agree with all of that.

Short and sweet. I like it. Okay, so what are we gonna start? As you talked about, Jason transdermal, formulations of the estrogen are generally preferred because they have lower risk profiles. And so if you're starting with transdermal, the recommendation is to start at a low dose 0.025 milligrams per day and.

Titrate up from there when you're starting and you're like, wait, wait, but what do I prescribe? We talked about this being 17 B sdi, but some of the things that you might type into your EMR are brand names like Vive dot ra, Dottie, Lilana Mini, VE aor. Those are the things you're going to be typing into your EMR, and that's all versions of of estrogen, okay?

With that prescription, if your patient has a uterus. Then you are also going to be reaching, like you talked about, to man for some sort of progesterone. And so if you're reaching for a micronized progesterone, you're going to be prescribing and typing into your EMR Prometrium or progestin. And if you're looking for a hydroxy progesterone, you're gonna be typing in Provera probably as you talked about.

And I'll just highlight again here, this can be a cyclic prescription. Where you're taking something like 200 milligrams for 14 days outta the month, or it could be continuous where you're taking a hundred milligrams every day. There are some reasons that women might choose one or the other. There are some side effects from from estrogen, even at lower doses.

And so if women are wanting less of the medication over the course of the entire month, they might request a cyclic prescription. But some of the issues with that is one, you have to remember. I need to take this about two weeks outta the month. And two, you might have some withdrawal bleeding when you come off of, of that cycling of progesterone, and so that might be distressing for patients as well.

Questions here, my team, as we talk about like practical, the prescription of HRT for our listeners. I think a lot of times this is gonna be something you're prescribing based on a brand that you became familiar with in residency, or is particularly common amongst the other physicians in your community.

So I think it's just reasonable to, sometimes I will ask a patient like, are there other women in your world who have suggested to you a certain patch that you should be on and can sort of get that in the air before I start to make a recommendation. Hmm. Yeah, great point. Once again, I have nothing to add.

You're on a roll. Go for it. So if you do have a patient who, for whatever reason, declines or is unable to use a transdermal patch, you might be reaching for oral systemic HRT, and those doses are going to be starting generally at 0.5 m per day. And your brand names that you might recognize here are things like Estrace, fem Trace, and Premarin.

Premarin being. Probably by far the most popular of or recognized of the names that that we have. And again, you'll then be prescribing your progesterones. And so as you are starting again at transdermal at 0.025 mgs per day, or oral 0.5 mgs per day, the question is, well, well that's not the ceiling of my dosing.

And so what we know is that HRT is very effective at taking care, eliminating or decreasing. Vasomotor symptoms in Menopausal Women's, about 75% will have remission of those symptoms while on HRT, but it takes time. It's not a magic bullet. And so the recommendation is to be checking in with your patients.

Some people say every six to eight weeks, you might consider titrating up based on symptomatology. Some people say, and let's wait a little bit longer and go for like a three month reevaluation regardless. Checking in with your patient to say, what are symptoms doing right now? Do we feel better? Or do we need to be going up on this medication?

And so for our transdermal patches, we can go up to as high as 0.2 milligrams per day for oral. Dosing. We can go as high as eight milligrams per day, and it's a little bit questionable of what is the dosing that we're going to increase by at those six to eight week check-ins, but it's probably reasonable if you're using transdermal estrogen, if you were at 0.025 going up by that same dosing.

So your next stepwise regimen would be 0.05, et cetera. The progesterones. Don't need to be titrated up or down. That's where we're at. The next question, once you reach the ideal dose where your patient is not suffering from those potentially severe vasomotor symptoms, the question is length of treatment and the evidence really comes around at around three to five years.

It limits the risk of breast cancer, which increases after that five. You're going to need to be chatting with your patients that, hey, we're at some point going to be taking down these medications. Although I will pause and say. That there are many practitioners who will stand by the statement that in the appropriately chosen patient who has not developed extreme contraindications to continuing HRT, that they might keep patients on this.

For their entire lives. That is not a recommendation that has been officially endorsed, and so that's not what we're endorsing here, but I might have some listeners who are like, whoa, wait. And so I'm just mentioning it very quickly. When you're doing this shared decision making with your patients of coming down off of HRT, the recommendation is to taper and the recommendation is to say like, are we able to come down without debilitating symptoms?

There are patients who might say, I cannot come off of this. After five years, I cannot come off of this after age 65 or 70, and this is going to require a lot of conversation, right? Extensive conversation about risks of continued treatment and reasons that they might want to continue. I have met women who have said like, I, I cannot be alive if I cannot have this medication because that is how miserable I am.

And man, you document the heck out of that and and have to decide what your comfort level is then going to be. Jason, you had some thoughts about this when we were prepping for this episode? I did. I did. We talked about it a week or so ago, and like I've inherited a lot of women in their seventies and eighties who have been on HRT for a long time, and.

I don't want off of it. And I came outta residency thinking, oh my gosh, I don't what, I dunno what's gonna go wrong with her, but something is going to go wrong. And this is where a lot of shared decision making comes in handy. And the ability to have a conversation with your patients based on a mutual trust and things like that.

So. Over age 70 HRT does show increasing risk of cardiovascular disease, so you have to really do some smart risk stratification. Shared decision making. As I say, you wanna make sure you lean into the lowest dose you possibly can. Sometimes I've been successful in at least lowering a woman's dose. I have switched some women from oral to transdermal who were on oral all those years and I can at least switch 'em over to transdermal.

And then sometimes we look at the things that are really the symptoms, they are fear that they will experience without it, determine whether those actually are gonna exist, if they stop it and treat those symptoms with non-hormonal modalities. So the bottom line is we have a lot of tricks in our bag as family doctors when it comes to the.

Older woman and HRT and we shouldn't be afraid to be open-minded and curious about that and see what we can do to help them out. I will say I've had a couple of women in their seventies or eighties who come in with new menopausal symptoms who haven't had any symptoms since in their early fifties, and that always just makes, it stops me in my tracks and I think, okay, I don't, I can't really blame this on her ovaries as much as she may be trying to, and I gotta put my thinking cap on and do really the big, robust workup I need to for why she's having those symptoms.

Mm-hmm. Jason, I know what you mean by what you just said, and I know you know what you mean by what you just said, but some of our listeners might have some questions about the idea of, I can't blame this on her ovaries, no matter how much the patient in front of me might want me to. And there is pushback in both the medical community and also just like society at large that says, man, like if a fraction of the amount of dollars that have been spent on men's health and exploration was spent on understanding the health of women and in particular menopause.

Which is generally something that is not wanting to be discussed by society, that like we might know whether we can attribute this, not, not blame anything, but attribute this to the life stage of menopause. Right? And so I think it's a really interesting. Point to say that we've had HRT for 20 plus years and we're just now in a state where we're actually helping women out with this and, and that we need a lot more dollars in research to be understanding all of the spectrum of what happens with this life change.

You are so, so. Right, and I agree with that, and I think it's that paucity of information that not only do we have as physicians, but as even out there in the common collective of how a body works. That gets us into sort of this place in a woman's age where she has a few symptoms perhaps, and it just becomes like, oh, maybe, maybe this is a menopause thing.

I know it's been a while since my last period, but maybe that's what it is. And my job as a family doctor is to sit down and say, okay. We are now going to have a very robust conversation about what's happening with your body, what other things are out there, what this could be, what it probably isn't, how we sort this out together, like this is one of the most important conversations of shared decision making that I will have with a patient across the course of her lifetime.

Yeah. And speaking of another piece of shared decision making, in addition to having an understanding of how our bodies work, as well as attempting these for patients in menopause, let's talk a little bit about lifestyle medicine and it's, it's well inside of all of this. So it should be pointed out that like with many things is actually very good evidence that really all of the pillars of lifestyle medicine are remarkably important for reducing menopause symptoms.

They actually do seem to work things like adequate sleep. Things like stress reduction. Mediterranean diet has some evidence in regards to assisting with menopause symptoms. A regular exercise, at least 150 minutes of moderate preferably aerobic exercise over the course of a week can be helpful. Now, all of these things are very helpful.

They don't necessarily completely eliminate menopause symptoms, and in addition to that. They shouldn't necessarily be considered as a first GoTo or substitute. They're another thing in the bag of tricks. I think one of the things that we've continuously gotten into and affirm today is that there has been a, a, a lot of misunderstanding over time that has probably led to a patient morbidity in regards to menopause deal from treatment.

They're saying, we are gonna do these things. We aren't gonna do these things. What it really comes down to now is that we have a lot of things to look at. We have, as we mentioned at the top of the hour, some non-hormonal treatments. We have hormonal treatments, which for a lot of people are mainstay 'cause they really work so, so well.

And then lifestyle can be an adjunctive treatment as well. It's another thing in what we have. If you have a patient who is just incredibly anxious, doesn't wanna touch hormones, is still concerned about what they've heard previously about them, well this is one way to help them optimize. Even for patients who want HRT.

If they're interested in lifestyle medicine treatment, it's a way to potentially have them on a lower dose of total hormone and avoid further side effects or to provide additional relief. But these are all things that we've used to help patients through this particularly difficult time that a lot of people have, uh, going through.

Whoa. Jason, Lauren, I think that takes us pretty far through a lot of what we wanted to talk about today. Do either of you have any last, you know, kind of parting thoughts or clinical pearls for our listeners? I'm excited to see how we're able to get HRT into the hands of women who need it, particularly now that the black box warning has been removed by the FDA.

Fantastic. I think my final word is gonna be that a female menopause is a, a natural process that does not need to be over pathologized, but it does cause a lot of symptoms. Symptoms that have a treatment HRT, and we need to do that well and we need to do that in communication with our patients to lower.

The very small risks that could come along with some versions of that, some doses of that, some formulations of that, but being wise about what's available, which risks available with which products, and how to minimize other risks for the patient in their long-term healthcare are things that are well within our scope of practice to do, and we need to be prepared to do that.

Fantastic. I think my only take home thought on all of this is much as it is with, it seems like every episode we do, but we're family doc, so I guess I shouldn't be surprised. Treat the patient in front of you, not the condition in front of you. Mm-hmm. Mm-hmm. A lot of options are individualizing care and treatment for people going through, uh, this particular physiological change.

And we should be flexible and open-minded to treat patients in the best way that they deem possible. That minimizes any attend interest. And I will just throw out that we have a bunch of a FP things coming up that are really extensive on menopause. Y'all. There is going to be a live stream in April.

We'll have the show notes available and there is some really great other articles that are coming out through the a f AAFP as well as many of our other journals and, and colleagues. Recently we had menopause management. When hormone therapy is appropriate. That was published in January of 2026 in a FP.

And so you've got some great options if you're wanting to dive in deeper, if you're still feeling a little bit uncertain, and thank you for that board. Fantastic. You plug through some of the upcoming educational. Yep. You've reached our moment of gratitude. Who would like to go first? I will be happy to go first.

I have great gratitude for all of the female patients I've taken care of who've helped me understand a lot more about the management of menopause and how to use these medications. I feel like I left residency without a really strong foundation there and learned a lot and was given a lot of grace and opportunities to learn more as I got into my practice.

Lovely. Laura. I'm super grateful that the conversations around menopause are happening a lot more. I've recently gotten into Peloton and their instructors who are talking about their living in their cron era or their back nine era taking, taking some terms from other cultures and like the fact that this area of life is being really celebrated and and that's amazing.

And for my part, I'm grateful overall for the continued scientific process in medicine. I think that there's been a lot of attacks, if you will, against medicine and public health from very, very high levels lately. And I will just say that I think in particular with H HR T and what we've seen. Not simply, uh, a one-time look, uh, at the evidence, but a reconsideration or uh, a re-analysis of the evidence and then moving that out into the medical world and practice is just such a great example of why evidence-based, scientifically oriented medicine is one intent.

Yeah. And it works really, really hard to try and find the best answers for people who need it. That's a great point. And with that, we've come to the end of our episode, and that's all the time that we have today. Thank you for joining us for another episode, and we appreciate you joining us on this journey to elevate family medicine to continue this journey.

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