Many women complain that physicians are reluctant to treat menopause with the full range of available therapies, often dismissing symptoms as 'natural' and something to be endured. A review article in CMAJ finds that physician fears around menopausal hormone therapy and lack of knowledge regarding treatment options often impede patients from receiving treatment.
On this episode, Drs. Mojola Omole and Blair Bigham speak with Dr. Iliana Lega, the lead author of the review entitled "A pragmatic approach to the management of menopause." Dr. Lega is a Clinician Scientist and Endocrinologist at Women’s College Hospital in Toronto. She encourages physicians to update their therapeutic understanding of menopause and to initiate conversations with women about the symptoms of perimenopause as they enter their forties.
Drs. Omole and Bigham also hear from Janet Ko, the co-founder and president of the Menopause Foundation of Canada. She shares her personal experience of receiving a delayed diagnosis of perimenopause and the impact of hormone replacement therapy on her well-being. Ms. Ko also shares the results of the foundation's study on women's experience receiving care for menopause, and reports that 72 percent of women found medical advice to be unhelpful or only somewhat helpful.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
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Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
Many women complain that physicians are reluctant to treat menopause with the full range of available therapies, often dismissing symptoms as 'natural' and something to be endured. A review article in CMAJ finds that physician fears around menopausal hormone therapy and lack of knowledge regarding treatment options often impede patients from receiving treatment.
On this episode, Drs. Mojola Omole and Blair Bigham speak with Dr. Iliana Lega, the lead author of the review entitled "A pragmatic approach to the management of menopause." Dr. Lega is a Clinician Scientist and Endocrinologist at Women’s College Hospital in Toronto. She encourages physicians to update their therapeutic understanding of menopause and to initiate conversations with women about the symptoms of perimenopause as they enter their forties.
Drs. Omole and Bigham also hear from Janet Ko, the co-founder and president of the Menopause Foundation of Canada. She shares her personal experience of receiving a delayed diagnosis of perimenopause and the impact of hormone replacement therapy on her well-being. Ms. Ko also shares the results of the foundation's study on women's experience receiving care for menopause, and reports that 72 percent of women found medical advice to be unhelpful or only somewhat helpful.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
Dr. Mojola Omole:
Hi, I'm Mojola Omole.
Dr. Blair Bigham:
I'm Blair Bigham. This is the CMAJ podcast. Jola, today we're talking about menopause.
Dr. Mojola Omole:
It's so exciting. As someone who has a toddler and ovaries which are failing, it is a relevant topic. And this article, which is titled, “A pragmatic approach to the management of menopause” has been getting quite a lot of traction in the news because it has been groundbreaking from the previous data that we have on hormonal replacement therapy for the management of menopause.
Dr. Blair Bigham:
Why do you think it's gotten so much media attention, Jola?
Dr. Mojola Omole:
Well, I would say that from my exposure to it, as a breast surgical oncologist, the previous Women's Health Initiative study really scared a lot of people into stopping the use of HRT because of the risk of breast cancer that was quoted in that study. So what I'm really interested in when we're talking to the author, and also with our patient advocate, is just really and truly, do we have any data that talks about what happens if you go beyond five years, and what happens if you can't get off your hormonal therapy because life is just pretty miserable? And so, I really want to talk about what are the risks that are associated with that, because those were the same risks that scared people in the first place when the WHI study came out.
Dr. Blair Bigham:
Right, so the stakes are high. It's either be miserable with your symptoms or get breast cancer if you're on treatment. That's what we've got to tease out here.
Dr. Mojola Omole:
Because that's what was presented previously.
Dr. Blair Bigham:
Well, let's get into it.
Dr. Mojola Omole:
The review paper in the CMAJ points out, although many treatments exist for menopausal symptoms, there's quite a bit of fears around the risk of menopausal hormonal therapy, and there's a lack of knowledge regarding treatment options, which gets in the way of patients actually receiving treatment and having a better quality of life. We will look at what fuels these fears and the available treatment options when we speak to the review's lead author in a moment. But first, we really want to talk to someone about what the impact of this is actually having on women. Janet Ko is the co-founder and the president of the Menopause Foundation of Canada. Janet, thank you so much for joining us.
Janet Ko:
It's a pleasure to be with you.
Dr. Mojola Omole:
So let's just start off with what was your experience with menopause? How old were you and when did you first have symptoms?
Janet Ko:
So in my very early forties, I started to experience symptoms that I did not know were connected to hormonal fluctuation. So things that I experienced were night sweats, chronic sleep deprivation, fatigue, joint pain, brain fog, a lot of forgetfulness, and then I had heart palpitations, and it was these heart palpitations that truly frightened me, because I thought I was having a heart attack. I went to multiple doctors, and then eventually went to emerg one night, because I thought I was having a heart attack, and every doctor who was very kind and supportive said that I was healthy, that my heart was healthy and that I did not need to worry. But the heart palpitations persisted, and it would have been quite illuminating and it would have been extremely helpful if somebody had said, "You're in your early forties and this is a symptom of hormonal fluctuation,” and that, “you are in perimenopause."
Dr. Mojola Omole:
So when did it become clear to you that this was perimenopause?
Janet Ko:
For me, it wasn't until I was much later into my forties that I thought and understood that this was menopause, when I started to have hot flashes and period changes. And those were the two things that I actually understood were truly the signs of menopause. By that point, I was quite exhausted from suffering through symptoms, sleepless nights for several years. Realized that this was menopause, and then just thought, well, I will push through it, believing in the myth that when you reach menopause, everything will be over.
Like many women, I was offered to go on an antidepressant, and I remember thinking, I am not depressed. I may be going through some mood changes and have sleep deprivation, but I am not depressed. And this is something that happens with many women, because women themselves and healthcare providers aren't understanding and connecting the dots on what hormonal fluctuation means.
When you lose your estrogen, that can impact your joints, your brain, create those heart palpitations, lead to changes in your mood. Doctors start to treat things on an individual basis. Oh, you have crying spells. You feel down, you're blue, here's an antidepressant. Well, you may have low mood associated with perimenopause, menopause, but that doesn't mean you're clinically depressed, and a healthcare practitioner we believe is probably more confident prescribing antidepressants than they are prescribing menopause hormone therapy. And an antidepressant certainly may help you, but it shouldn't be the first thing offered. Or you might not be sleeping. So then you're prescribed a sleeping pill.
So you can see how women are getting support for various symptoms, but they're not dealing with the root cause and getting to the heart of the matter, which is your hormones are fluctuating, you're losing your estrogen, and this impacts your entire body. And if women understood that and if their healthcare practitioners could explain that to them and then look at, well, what are the things we can do to help you, the preventative things you can do, and then up to and considering menopause hormone therapy or other treatments as needed.
For me, once I realized what was happening to me, did more research, I got a referral to an ob gyn who was a menopause specialist, and it was in that conversation with her, which was a very high quality conversation, where we looked at me as a candidate for menopause hormone therapy, and for the first time discussed not just the risks, but the incredible benefits.
So I know for me, within a week of starting menopause hormone therapy, I felt like myself again. It was a true game changer. And we hear that from a lot of women. And I am not a proponent of menopause hormone therapy. I'm not advocating that every woman use it. I'm advocating for agency. For women having the agency to make a choice, an evidence-based choice about their own health. And right now, that's not happening.
Dr. Mojola Omole:
So through your research with the foundation, in terms of the scope of the problem, what did people say to you? How often did physicians proactively speak to people about menopause, versus waiting for them to bring up, "Oh, by the way, I'm having these symptoms, or I haven't had my period, and I'm feeling a certain way."
Janet Ko:
Only one quarter of healthcare practitioners proactively raised the topic of menopause with their patients, and when women themselves took it upon themselves to have that conversation with their healthcare practitioner, the majority, over 70%, found the conversation to be not helpful or only somewhat helpful. And sadly, four in 10 women felt that their symptoms were undertreated or not treated at all.
We hear from women all the time, and their stories go like this: It takes women years of trying to figure out what's happening to their bodies, and then eventually finding their way to a healthcare practitioner, and then more often than not, they feel like their symptoms are dismissed. I talked to a woman last week who waited two years before going to her doctor, and then she makes it into her doctor's office, talks about everything she's going through, has done her own research and feels like she's a good candidate for hormone therapy and wants to try, and her doctor says, "No, I'm not comfortable with that. That has a lot of side effects. Why don't we start you with a vaginal estrogen?"
That's great, because vaginal estrogen is very safe, effective. It's not systemic. It's available over the counter in the UK. It can certainly support women with their sexual health and with the genitourinary syndrome of menopause. But it's that disappointing conversation with a healthcare practitioner who is not up to speed with the latest clinical practice guidelines and the latest evidence.
So that woman leaves the office feeling a little bit diminished, and she starts looking elsewhere for support. So she may go to a hormone clinic where she has to pay for non-Health Canada-approved hormonal treatments, because the healthcare community does not have the expertise and the confidence or the information to prescribe.
Another conversation I had within the past week as well shows the difference where a woman I spoke with had a very high quality conversation with her family physician, who was up to speed and very knowledgeable about menopause and about the clinical practice guidelines. And in that conversation, they determined that she was at very high risk for breast cancer. She did not feel, nor did her healthcare practitioner feel like menopause hormone therapy was an option for her, so she did not go that route, but she was put on a vaginal estrogen, which she thought was great for her sexual health and for the prevention of UTIs and other things.
That's a great example of having an excellent, high quality conversation with a practitioner who is up to speed. And she leaves the office feeling very empowered, like she's made a good choice and she's had a good conversation with somebody who's assessed the risks and the benefits for her of not just menopause hormone therapy, but all other options relative to her personal situation.
Dr. Mojola Omole:
So your 2022 report is called, “TheSilence and the Stigma”. So to what extent do you think physicians are responsible for perpetuating both the silence and the stigma when it comes to menopause?
Janet Ko:
Oh, this isn't about casting aspersions on anyone. I think this is a societal issue that we face. It's fascinating to me that as women, we get support going through puberty. There's education in schools, there's coming of age stories. It's not perfect, but it's certainly is there and is supportive. Then we get support to not get pregnant, to get pregnant, to have children, to go through the labor, the delivery, to deal with things like postpartum depression and other things, to get reintegrated back into the workforce.
But when it comes to perimenopause, menopause, post-menopause, there is this deafening silence. And we believe that that silence is wrapped up in ageism that exists as women get older, and that needs to change. We need to start to value women as they age. And I think it's that acceptance and tolerance of women's suffering that has allowed and perpetuated the minimization of women's symptoms and their experiences through menopause, the dismissal that many women feel when they have conversations with their healthcare providers about what they're going through.
So I think this is a large issue. When you think about, you turn 50 and in the province of Ontario where I live, I got lots of information from the provincial government about mammograms, about other things that I should know. Not one word about menopause. So those are things where I think everybody has a role to play, the workplace, society at large, government and certainly our healthcare practitioners.
Dr. Mojola Omole:
Janet, thank you so much for joining us. This has been a really great conversation, and hopefully the media attention that's been going on, we continue the momentum. Janet Ko is the co-founder and president of the Menopause Foundation of Canada.
Dr. Iliana Lega, clinical scientist and endocrinologist at Women's College Hospital in Toronto. She's the co-author of the review article in the CMAJ, entitled, “A pragmatic approach to the management of menopause”. Dr. Lega, thank you so much for joining us today.
Dr. Iliana Lega:
Thank you for having me.
Dr. Mojola Omole:
So the paper is titled, A pragmatic approach to the management of menopause. If the approach you're suggesting pragmatic, how would you describe the approach taken up until recently?
Dr. Iliana Lega:
I like that question to start. What we meant when we titled it A pragmatic approach to menopause is we wanted to make it as straightforward as possible, as clear as possible. We find there certainly are, as we all know, guidelines that do recommend treatments for menopause, but guidelines are often so long, hundreds of pages, and we wanted really just to distill it down to the most practical take home messages, really. So that's why we called it, “a pragmatic guide”.
What your question, I think, is referring to more is what's the current state of menopause treatment and why, maybe, we wanted to write this. And certainly it's terrible. We're really under-treating menopausal symptoms in many different ways. As clinicians, unfortunately, given the whole fallout from the WHI study, we don't have a lot of knowledge or comfort, and I think there's still a lot of concern and fear about using hormones in particular. And so because of that, largely menopausal treatment symptoms remain untreated, I think, for the most part.
Dr. Blair Bigham:
I guess I'm curious, sort of in your practice, Iliana, as an endocrinologist, what were you seeing that made you think, oh, we really need to write this paper?
Dr. Iliana Lega:
The main reason I thought this paper would be salient and helpful is because in my endocrine practice, where I'm referred patients for endocrine issues, not necessarily menopause, because I do a lot of general endo, because I do menopause and I'm super interested in it, I started asking women who are in their forties, certainly in their fifties, "Are you still having a period? Do you have any symptoms of menopause?" And what really struck me is that really, almost none of them had any sort of discussion with their primary care physician about it. And they told me, "No one's ever asked me. No one's ever asked me if I'm having hot flashes." And then obviously, I'm familiar with the research in this area, so I know that a lot of physicians really don't start the discussion and conversation, which leads to a lot of women not even knowing there are safe options.
Dr. Mojola Omole:
So you mentioned the WHI study, which was that large Women's Health Initiative study, and I remembered it came out, was it...
Dr. Iliana Lega:
2002.
Dr. Mojola Omole:
What do you think the impact that study had in training of physicians about the use of hormone therapy for menopause?
Dr. Iliana Lega:
It's actually really interesting, and as I've started giving more talks and talking to my colleagues about menopause, I've really dug a bit deeper into the history of hormone therapy, and I think it's really interesting to think of that given where we are now. So essentially in the 1980s and '90s, it was very common to treat menopause with hormone therapy, and at one point it was one of the top medications prescribed to women, actually, hormone therapy.
And then the WHI study came, and the WHI was really supposed to be the definitive study showing, hopefully, the benefit, but really proving that hormone therapy, or at least showing that hormone therapy is beneficial. And in fact, the results were quite the opposite. It showed that there was an increased risk of stroke, heart disease and breast cancer with hormone therapy, and because of that, millions of women basically immediately came off of hormone therapy. Doctors stopped prescribing, became scared to prescribe, and to a certain extent, we are where we are now because of the tremendously negative impact that study had.
What's really interesting to look at, though, is that the same researcher, really soon after the initial studies came out, the results came out in 2002, the researchers immediately went back to the data and they realized they had included a lot of older women. So the mean age in that study was actually 63, with women as old as in their late seventies. And actually, the majority of women were over age 50 and into their sixties and seventies. And when the researchers looked specifically at the subgroup of women who are age 50 to 60, so what we call young menopausal women, in that age group, the risks were really quite different, and there was no increased risk of heart disease, and the risk of stroke and breast cancer were actually very low.
Since then, there's been other studies, not as large and many of them observational, that have shown the same, that have shown that overall hormone therapy, really the risks are really quite low, and certainly the benefits are really high, but it's been so hard to walk back that initial fear and anxiety.
Dr. Mojola Omole:
So what are the benefits of hormone replacement for managing perimenopausal symptoms?
Dr. Iliana Lega:
The main benefit is reduction in vasomotor symptoms, so hot flashes. Hormone therapy reduces it by 90%. And that's why really, primarily menopause guidelines recommend treating women with hormone therapy who have vasomotor symptoms. That's a primary indication. But there are other benefits as well, and certainly the benefits of treating vasomotor symptoms goes far beyond just the vasomotor symptom itself, because vasomotor symptoms can deeply affect sleep, can affect mood, energy, which all then trickles down into the work environment, the relationships, et cetera.
And so, hormone therapy is extremely effective for vasomotor symptoms, so I sometimes tell them, and I believe when they come back, it's true, it's like a miracle. They feel a hundred percent better, most of the time, from that point of view, and they feel, they can't believe they feel back to how they felt before. So it's really, the impact is huge. I can't understate that.
And that's why it's so important that we're talking about this, because there's no reason women need to feel like that, especially when we have a good, safe treatment, right? And again, in young women, because guidelines recommend treating with hormone therapy in ages 50 to 60 for vasomotor symptoms, there's certainly a benefit on bone health, and quite striking benefit in terms of fracture reduction, which not a lot of studies often find. They may show that bone density gets better, but really fracture reduction similar to what we see with bisphosphonates, to be honest. So really quite profound findings.
And then also it improves genitourinary syndrome of menopause. So vaginal dryness, urinary symptoms, UTI, all that is also improved with hormone therapy. And lastly, in, again, the young age group, there may actually be a benefit for cardiovascular risk in women who take hormone therapy. So a lot of benefits even beyond the vasomotor symptoms.
Dr. Mojola Omole:
So before I ask you questions just regarding the risk, I just wanted to clarify in terms of the duration. So I'm a breast cancer, I'm a breast surgical oncologist, and so this is something that comes up to for me often. So what is the guidelines, in terms of the duration of treatment for the hormone replacement?
Dr. Iliana Lega:
There's not clear guidance, I have to say. So currently, most practitioners, and the guidelines to a certain extent recommend treating for five years, but that's only because the WHI was for five years, and so that's the best data and evidence we have for treatment. However, even in the guidelines, there's certainly, this is the North American Menopause Society guidelines, which are, for North America, the best guidelines. Certainly, you can treat beyond that into age 60, even beyond 65, certainly acknowledging that the risk of breast cancer goes up with longer duration of use.
Dr. Mojola Omole:
Is that, I guess... Yeah, that's what I wanted to ask you, is in terms of, you kind of alluded to some of the risk, and so I just wanted to talk a little bit about that, and also just talk about your thoughts regarding the fact that those risks, as you just said, do increase with duration of use.
Dr. Iliana Lega:
Right, so because of that, really, most people would start treatment thinking that this is going to be a five-year course and then reevaluate at that point. After that, it becomes a very individualized decision, and really, it's based mostly on patient preference. The thing is, vasomotor symptoms can last far beyond that five-year mark. In fact, they can last for 10-plus years. So some women, when they go off of hormone therapy, they're still having vasomotor symptoms, and then it's really a discussion and balance of, well, how bothersome are those symptoms to you, and do you want to accept this slightly higher risk?
At that point too, we try, if we're going to continue past five years, we certainly try to see if we can use a lower dose, for example, so some risk mitigation strategies for reducing breast cancer risk would be trying a lower dose, and then also using a formulation that may be safer in terms of breast cancer risk, which we're not clear on. There's not good data on that. Some people say transdermal estrogens instead of orals, and certainly a Prometrium instead of a Provera is certainly a safer option, likely, for the breast.
Dr. Mojola Omole:
So what are some HRT regimens that have the best evidence that support the use for them for people under 60?
Dr. Iliana Lega:
So WHI used Premarin, which is conjugated equine estrogen, which we don't use that much anymore, and Provera. And that's another really important caveat from the findings of WHI, is that we don't use the hormones we used in that study. We use what we like to call body identical hormones more now, which is the actual same hormone your body would otherwise be making, but obviously it's synthetically made. So currently, my go-to and what I think is probably the most physiologic and best formulation, is giving the estrogen through the skin, so transdermally, which is a patch for most, for people who can afford it, because it is the most expensive, unfortunately, Estradot patch, or there's also an EstroGel formulation, it's just a bit more clunky to apply, and then Prometrium as the progesterone, which is, again, body identical. So to me, that's the best formulation, and it's most physiologic in terms of replicating the body's own hormones for now.
Dr. Mojola Omole:
How do we manage those patients who are on it for longer duration of time because of their symptoms and the quality of life? And if we should do anything different in terms of screening for them in terms of breast cancer?
Dr. Iliana Lega:
As far as we know, there isn't any difference in screening that is recommended. Again, at those low doses, the absolute risk is still quite low for breast cancer, and so because of that additional screening beyond what is recommended, first of all, it hasn't really been studied, but even expert opinion doesn't recommend additional screening beyond what is currently recommended.
Dr. Mojola Omole:
Is it complicated to prescribe these?
Dr. Iliana Lega:
It's nuanced. It's not like the OCP or the oral contraception, where it's one pill has both the estrogen and progestin and you take it. There are some formulations that have both in it, but the progestin in those formulations is much more synthetic, so it's less, as I was mentioning before, sort of body identical. For example, the Estradot patch, you would need to use the patch and switch it twice a week and then take Prometrium as a pill, and that would be every day.
So it's a little bit clunky, I would say, and a lot of the formulations, you need to take two separate types of medications. Again, assuming a woman has a uterus, because if not, then you don't need to give the progestin. And I think the other thing that confuses people is that there are multiple formulations now that are coming on the market, and so it's a little bit overwhelming in terms of choices, in an area that people don't talk about or know a lot about to begin with.
Dr. Blair Bigham:
So this has come a long way in the last 20 years, from when that WHI study sort of came out and almost vilified HRT. Is this a new prime time, or...? I'm an emergency doctor, so I have no idea how to treat menopause. But how much here is brand new versus how much of this is just trying to correct the impact of that big study from 20 years ago and just get people up to date?
Dr. Iliana Lega:
I think it's a combination of both. I think people's knee-jerk reaction when they hear any type of estrogen is cancer. That's the first go-to. And so, no matter, even then, if you start try to have the nuanced part of the discussion where, well, there're these newer estrogens, and they're body identical, and we're using lower doses, and we're using it not for as long, and we're using young, it's still, once you say the C-word, it's hard to get past that. So I think a lot of it is still undoing that.
There are certainly some newer medications like Tibolone and all these sort of fancy new medications that have come, estrogen hormone therapies that are new. But the transdermal estrogen story is not brand new, for example. That's been around for at least 10-plus years, if not longer now.
Dr. Blair Bigham:
So we have this treatment, patients report and makes them feel great, yet still it's so underutilized. How much of this is maybe a bias within medicine? How much of this can we just blame on a previous study that maybe scared people away from it? Can you dissect that a little bit more for me?
Dr. Iliana Lega:
Sure. I mean, we know that women's health and women's issues are, unfortunately, sometimes trivialized. Women's health has not been studied as extensively, or women have been left out of a lot of studies. And certainly there's a lot of taboo, unfortunately, when talking about menopause. I wouldn't say it's... Certainly, women are embarrassed to talk about the symptoms, because oftentimes they involve sexual symptoms or vaginal symptoms. But certainly there's not comfort or thinking that, oh, if I go to my doctor with these symptoms, I'm going to be validated and I'm going to be offered treatment. Oftentimes women are, I think, really their symptoms are minimized.
I think in general, unfortunately, there's still this sense that menopause is quote unquote "natural," and that's just how you're supposed to feel when you're at this age, and you just have to suck it up. Which is, again, pervasive, I think, unfortunately, in society.
And then, from a medical point of view, I think there's also something else interesting that has happened because of the fallout of the WHI. Medical education in the area of menopause has really suffered. So I don't know about you guys. I never learned much at all about menopause, either in medical school or in residency. Everyone says, "Oh, but you're a hormone doctor, didn't you?" No. Endocrinologists don't learn about this. And certainly it's the same for family practice and gynecology.
So I think because doctors stopped prescribing hormone therapy around that time, they also stopped thinking about it. They took it off the curriculum, or at least it's a very small part of the curriculum, and now we have all these residents who have no experience prescribing or seeing people prescribe hormone therapy, and because they don't have comfort or expertise in it, they prefer not to talk about it with their patients because they don't really know what to say when woman comes with these symptoms, because they're not well-versed in this area. So I think it's complex, the problem.
Dr. Mojola Omole:
So when should physicians start asking patients about perimenopausal symptoms?
Dr. Iliana Lega:
Well, perimenopause symptoms can start as early as 10 years prior to the last period, and then menopause statistically is at age 51. That's when statistically most women will have their last period. So menopause symptoms then start in the forties, during what we call the perimenopause, which is a time prior to menopause. Obviously in an ideal world, where family doctors had all the time in the world, they would start asking as soon as a woman entered her forties. And again, it doesn't have to be a complicated discussion. Certainly if the answers are positive and a woman is having symptoms, it creates a more lengthy discussion. But it's as simple as, "Are you still having periods? Are you having night sweats? Are you having any changes in your mood, vaginal dryness?" And if not, then... And then again, it opens discussion, where then they say, "Well, when you do, or if you do, just know that there are things we can discuss in terms of possible treatments." And all I want more than anything is for women to know there are treatments and to seek out conversations with their healthcare providers, and for their healthcare providers to be better able to give them the information they need. So, this is great.
Dr. Mojola Omole:
Awesome. Thank you. Dr. Iliana Lega is a clinical scientist and endocrinologist at Women's College Hospital in Toronto.
Dr. Blair Bigham:
So Jola, how do we balance this risk? It sounds like it's a lot less than what we thought it was with these newer pharmacological agents, the newer data around actual breast cancer risk. What's your takeaway?
Dr. Mojola Omole:
I've always been a proponent on having people make their own informed decision, and it is a hard conversation to have. I land on, there is no issues if you're someone who is young and you're taking this for five to 10 years. I actually extend it to about 10 years. Vaginal estrogen, I actually never care how long you're on that for. And I do think that in general, my advocacy is around early screening for breast cancer, so starting screening at 40 and going every year, versus what we're currently doing now in Canada. I would say that if everybody was on that screening protocol, I would have less of an issue with someone being on this longer than the five years that we know is pretty safe for them to be on it for.
Dr. Blair Bigham:
So why do you think we don't have sort of a unique set of guidelines for that group of people who are on hormone therapy?
Dr. Mojola Omole:
Because no one cares about women's health. Women's health is underfunded constantly, and if you practice anything in women's health like I do, we're underpaid.
Dr. Blair Bigham:
True.
Dr. Mojola Omole:
So at the end of the day, when Dr. Lega is talking about, well, we actually don't have the studies, I'm like, oh, shocker, we don't have studies that look about what happens to people, women who are on these medications for long term. I'm sure if this was hormone replacement therapy for men, there'd be lots of robust data on the long-term effects of it.
Dr. Blair Bigham:
So it's been ignored, even though it's so ubiquitous, and now we're in this state where we kind of have to make it up. But what would you do if you were a family doc and you have a woman who says, "I want to stay on hormone therapy." What screening would you advise?
Dr. Mojola Omole:
I would just say to do... Although we say that there's no role for self breast exam in terms of preventing breast cancer, I still believe in encouraging people to know their body, so I would say continue with your self breast exams on a monthly basis, and do mammograms every year.
Dr. Blair Bigham:
Annual mammograms.
Dr. Mojola Omole:
Annual mammograms, and if there's anything that is worrisome to you, seek to talk to your family doctor, and as a family doctor, investigate it. And even in that patient, if you do an outside imaging and it says, oh, everything is fine, but there's still an index of suspicion because the person feels a mass or something, send them to a diagnostic breast center to get imaging using 3D mammography.
Dr. Blair Bigham:
Right.
That's it for today's episode of the CMAJ podcast. Please remember to or share our podcast and help us get the message out. I'm Blair Bigham.
Dr. Mojola Omole:
I'm Mojola Omole. Until next time, be well.