Why estradiol patches are in short supply and what to do

Estradiol patches on backorder, progesterone capsules hard to find, and a lot of anxious scrolling in between. Speaking of Women's Health Podcast host Dr. Holly Thacker recorded this because the hormone therapy supply chain is colliding with a surge in demand, and too many women are getting stuck without a plan. She walks through what’s actually driving the patch shortage, how WHI-era fear still shows up in exam rooms, and why “everyone needs a patch” is just as misleading as “no one should take hormones.”

If you can’t get your usual prescription, you’ll hear concrete alternatives: switching patch schedules, considering gels or sprays, using combined estrogen-progestin products, and when nonhormonal therapies for hot flashes and sleep may fit. She ends with a simple preparedness point: don’t wait until the last refill day to protect your health. Subscribe, share this with a friend who’s struggling to get her meds, and leave a review so more women can find evidence-based menopause care.

Transcript

Why Hormone Prescriptions Are Hard

Dr. \ 0:14

Welcome to the Speaking of Women's Health Podcast. I'm your host, Dr. Holly Thacker, and I am back in the Sunflower House for a new podcast. And I wanted to get this out quickly because I know a lot of women are having trouble getting hormone prescriptions in terms of the supply chain and the pat shortage. So I wanted to go into a little bit about why this is happening and what you can do about it. So I've been in this field a really long time, several decades. And it was really exciting to be in the menopause field early on. I uh attended one of the first meetings of the North American Menopause Society, now termed the Menopause Society. And um it was an exciting time. There was a lot of interest in both the treatment and the prevention of hormone therapy. There were some strong indications that there was a lot of preventive benefits. The largest preventive trial, the Women's Health Initiative, was beginning enrollment. And then things kind of crashed right around the time that I was opening the Center for Specialized Women's Health at the Cleveland Clinic, when all those headlines came out. And it's really a travesty in American medicine, and it certainly reverberated around the world, that women and their healthcare clinicians, and I like to say clinicians, physicians, nurse practitioners, healthcare team, not providers. In fact, I was so happy recently, the American College of Physicians came out with a position paper strongly discouraging that word, which is really an insurance term and has some bad historical connotations. So women and their health care clinicians have certainly been misled by the Women's Health Initiative dogma, and a lot of it was kind of promoted by the media. There's a lot of clicks and attention when news is negative. So it's so far past time to understand menopausal hormone therapy. And this, of course, is not medical advice, and um it's information to empower you to be strong, be healthy, and be in charge, which is our motto. And we do have a lot of health care clinicians, doctors and nurses,

The WHI Headlines And Lasting Myths

Dr. \ 3:16

therapists, and people interested in health promotion and wellness who follow along. And it is important for those that have prescriptive authority, which I think most importantly fall or should fall in the hands of physicians. And of course, in many states, advanced practice clinicians like APPs, nurse practitioners, physician assistants can prescribe. And I think after a course of therapy has been set out and everything's stable, that's the best position. There is this trend for pharmacists to begin to prescribe, which I'm not a fan of because they do not go to medical school. Um, but unfortunately, it's hard for many patients who need prescriptions to get prescriptions. So, on the other hand, I understand trying to widen that net. So, for several years there was this unfounded fear that menopausal hormone therapy would increase a woman's risk of dying from breast cancer. And it is simply not supported by the clinical trial. And so, this kind of critical misunderstanding that's kind of snowballed into this terrible urban myth has really robbed so many women of profound health benefits. And we're not just talking about the short-term relief of menopausal symptoms like the hot flashes and night sweats and skin crawling and vaginal dryness and irritable bladder and bone aches and bone loss leading to osteoporosis and fracture. But the long-term benefits in selected women are truly staggering and still largely unappreciated. As an aside, um, I was working with a colleague or a few colleagues on writing a review article for OBGYN physicians, trying to empower them and give them some practical information about prescribing hormone therapy because the demand is so high. And it's because the demand is so high, um, in part why we're having patch shortages and hormone uh therapy uh supply chain problems, actually, which we're gonna go into detail and give our listeners some tips and things that they might consider. And so, when working on this article, we thought this is really a good thing to do, and we want to make it simple and straightforward and practical. We want to empower more people because certainly the number of people like me in the United States and uh some of the physicians that I've trained over the last three decades to be women's health specialists only number a thousand or so. So it's not enough to take care of the women in this 40 to 70 plus age range that need evaluation and treatment. And going back and forth with the manuscript, uh, a lot of the things that I had written were like taken out, or it was like the old wording about increasing breast cancer risk, and it's amazing what the misinformation has done to the psyche of, you know, even academic, you know, physicians who are used to reading the literature. So no wonder the average person or the non-medical woman out there uh has been confused. It's really a shame. And with this pendulum swinging, it's not that the evidence has changed. And like I was telling my colleague in 1975, I think it was when the United States Surgeon General came out with smoking, is associated with an increased risk of death, cardiovascular disease, and lung cancer. It wasn't that there was new research, okay? There had been research showing this for a long time, but the medical profession, by and large, ignored it as a whole. And that's the same thing with hormone therapy, okay? I've been pretty much saying the same thing. You can go back and read the books and articles that I published. Um, you know, I had colleagues um shun me. You know, I I had kind of inappropriate interactions in medical meetings, um, and I really was working hard to try to get that information out. And certainly we do get new research, we do get new options, new therapies, hormonal, as well as non-hormonal, as well as other important diagnostic and therapeutic options for conditions that affect women at midlife and beyond. But a lot of the basics have truly stayed the same. Um, and so I always encourage people if they want to get an updated version of my book, The Cleveland Clinic Guide to Metapause, that they go back to season one in 2023 and listen to the updated podcast version. But if you go to the library or, you know, uh go online and get a copy of it from 2009, by and large, a lot of it is still the same. So it's not that the pendulum or we have new evidence, and that's why all of a sudden people need to jump on the bandwagon. In fact, my plea for women is to not be affected by oh, what your friends are doing. Oh, my friends are all in the patch and they love it, or oh, my friends say I shouldn't do this, or my sister had breast cancer, and so I'm not taking anything that's hormonal. You want to approach it looking at the totality of the information, knowing what your personal values are, knowing your health information, working with your physician uh for shared decision making. And so because there are profound and unappreciated health benefits like metapausal hormone therapy, cutting the risk of myocardial infarction, heart attack by a third, the same with type 2 diabetes, and we're in a diabetes epidemic, slashing the risk risk of osteoporosis and debilitating bone fractures, and likely reducing the risk of cognitive decline, especially if you start hormone therapy within 10 years of menopause, continuing it for at least a decade. So, this point is so key. Metapausal hormone therapy is one of the

What Hormone Therapy Can Prevent

Dr. \ 10:05

most impactful therapeutic as well as preventive medications in modern medical history for improving women's longevity and their long-term health outcomes on both an individual level and a population level. Boom. Now that doesn't mean it's risk-free. That doesn't mean everybody needs to jump on the bandwagon. But this swing of people saying, no, even though I'm suffering, I can't listen to this, I can't take this therapy, when it's so much safer, relatively speaking, in terms of relative and absolute risk, than so many therapies we prescribe every day. To this other pendulum that we're at, where women who aren't even hormonally deficient are rushing into doctors' offices demanding that they get their patch for symptoms that might be from another medical problem or might be from lifestyle or stressors or vitamin deficiencies or poor lifestyle and lack of sleep. So appropriately prescribing menopausal hormone therapy is really a pivotal issue that demands attention from the women's health and medical field. And I think that every individual woman approaching midlife and all the health care clinicians that see women need to understand the data, be balanced, be involved in shared decision making, uh try to immunize yourself against uh pop culture and what you hear in the media or what you see in Instagram. Um I have women come in and tell me, well, Dr. So-and-so on Instagram, someone who's probably not seeing patients, who's pushing products and supplements, which may or may not be indicated, says that I should do this. Well, if you haven't individually evaluated that patient, um, then that's not appropriate. And what's good for your best friend or your pickleball partner or even your sister uh who you share potentially a fair bit of genetic material with, doesn't mean that's the right choice for you. Um and when I'm in the teaching situation and I'm uh training physicians, uh which I do with fellows who've already completed residency, and sometimes we do have residents, and I have academic appointments and have lecture to medical students. I like to make the point that there's very few absolute contraindications for a pre-menopausal woman to be robbed of her ovarian function and sex hormones. Now there are a few, but there's very few. And there's very, very few contraindications to allowing a woman uh who's pre-menopausal, and we're even pushing that envelope with reproductive endocrinology and infertility and in vitro fertilization, um, that women cannot be in a super high hormone environment, such as pregnancy. And in some states, um, you can get birth control pills over the counter without even anyone with prescriptive authority to prescribe it. And it always struck me as very ageist and sexist that for women under 50, even 55, pretty much anything goes. In terms of you want to be pregnant, you don't, you want high hormone levels, you don't. Um, and there's no like absolute things that you can't do this. And then you get to be a woman who's had her hormones, maybe had pregnancies, maybe taken synthetic um pharmacologic levels of hormonal contraceptives by pill or patch or vaginal rings, maybe you've had a C-section because that was the best option for delivery for you and the baby or babies. And all of those things have much higher risk of blood clot, which can be life-threatening, than menopausal hormone therapy, even oral menopausal hormone therapy. And there's not this super high anxiety, but somehow there's this unfounded anxiety of giving women back a little bit of estrogen so that they have a level of estrogen what a man who's older than them has. I mean, honestly, the vast majority of men who continue to make testosterone, who assuming that they haven't been treated for prostate cancer or lost testicular production of testosterone, testosterone gets aromatized to estrogen. And that's why your father may have a higher estrogen level than you do at age 55 and he's 85. So I think that society, clinicians, patients, uh family members, neighbors, we all have to be aware of not being ageist and sexist. And I can make a general statement. Again, this isn't medical advice or treatment for you individually, but most women within a decade or so of menopause, especially if they have symptoms or concerns about diseases that we know are impacted by lack of estrogen, should be counseled, given appropriate information about menopausal hormone therapy. And not just for moderate to severe symptoms. That was always a big pet peeve of mine. Like by the time somebody gets to see me and they've had to wait and make an appointment, maybe take off from work, you know, deal with cancellations, deal with traffic, pay for parking, like there's a lot of hoops to go through. Uh, and unfortunately, sadly, it seems like there's even more and more hoops to go through in terms of getting care. I think that's one of the reasons why online care has proliferated. And I really do think in-person care uh has a lot of additional benefits. And I discussed that recently in a podcast that I did with Dr. Leipold, a primary care physician, where we were talking about um, you know, when you should see a primary care physician as your principal primary uh physician who's kind of overseeing things, kind of the quarterback, um, but not necessarily the specialist versus do you need to see a specialist? And she made a point that you should really have a good relationship, of course, with your caregiver, and that you should use that person as a source of truth. And when I was re-listening to the podcast, I was thinking, I wish I would have pushed back on that live time. That's true if your clinician is up to date and not scaring you and going off of um

Ageism, Sexism, And Better Counseling

Dr. \ 17:35

urban myths and telling you, no, you can't be on hormones. Oh, that's gonna cause cancer. I mean, it's actually going to likely make you feel better, function better, be able to stay in the workforce. We have some very interesting pharmacoeconomic research in that vein, but potentially live longer. So I kind of jokingly, but not exactly jokingly, tell a lot of my patients, hmm, I hope you're saving for retirement because a lot of my patients live a long time. And you've been listening to the Speaking of Women's Health podcast. I'm your host, Dr. Holly Thacker. I'm the executive producer or uh the executive director of uh Speaking of Women's Health. Our executive producer is Lee Clecker. You've heard her on uh as a guest podcaster in the past. I'm also the director of our Center for Specialized Women's Health, and for 29 years I've directed the Specialty Women's Health Fellowship at Cleveland Clinic, and I am a professor in both medicine and OBGYN and reproductive biology at the Cleveland Clinic Learner College of Medicine at Case Western Reserve. So I teach, I write, I'm involved in research, and I'm deeply involved in patient care. Um and I'm a salary physician, and this is a nonprofit, so we're not selling you anything, and it's really to the incredible generosity of donors and philanthropists, many of whom are patients and dear friends, that have allowed me to guide and direct uh this nonprofit, speaking of women's health, for the last 18 years. And it's all been driven by a passion to get the right information out. So it might not be as entertaining as a fiction book, and and that's what I would tell women when they would come and bring me, you know, a famous actress's book who's now deceased, I won't mention, but she wrote a book about um hormone therapy, and I'd have patients give it to me. And I'm thinking, okay, I specialize in this area, and that's not that there's not things for me to know and learn, and I understand why women feel like they needed to have their own advocate or do their own research, but I think that something I used to say, well, there's a lot of things that her book says that's true, women deserve to look good and feel good and enjoy sex, uh, but it's the way she's telling you to do this is not scientific and grounded in science. Uh, so that I think it's better if you want to read a book or get information off of social media to actually get it from folks that have some proven expertise. And that doesn't mean that the expert credential class or the so-called experts in a lot of things medically have been right. In fact, you can go through history and um find a lot of mishaps for sure. And so I do think that's important to be um aware and to educate yourself as best you can with good resources. That being said, sometimes when I have women tell me that they've done their own research, I'm thinking, okay, it depends on what you're actually critically reading and what in where you're getting your information and what's the maybe motivation behind that. Um, and I just have seen a lot of women damaged by uh getting care uh from cash pay practices that are pushing pellets and injections, people that don't have the expertise that are trying to increase their income. And um conversely, I've seen women who've seen salaried employed physicians who just tell them, No, I'm not gonna prescribe this because I don't feel comfortable. Well, it's not. Whether the doctor's comfortable, it's about the patient's health and comfort. So that's a whole lot. And engaging people in shared decision making and letting them know about options, including non-hormonal options, especially in the area of hot flashes and skeletal health, as well as the genitourinary syndrome of menopause. And in all of these three domains, we do have a lot of options. You know, I like to advise physicians that it's important to understand the difference between chronologic age, age of menopause, and the actual time of getting to be hormonally deficient, because they can all be different ages. And as I tell my trainees, if you stop your patient's hormone therapy or you don't prescribe it, then you certainly are responsible for checking and following the urinary status, checking their bone density, since half of women rapidly lose bone. Checking about their cognitive status in terms of sleep and vasomotor symptoms and mood. And some women say they feel fine, but they happen to be on a medication like an SSRI or NSRI or a candy neuron NK inhibitor, so that's why they don't have symptoms. And in women who've had endocrinopathies or any history of mental illness or sleep disorders, you really have to be careful about stopping hormone therapy. The other point I make is that women that have premature menopause or early menopause before age 45, certainly those with primary ovarian insufficiency under age 40, those with surgical menopause where the ovaries have been removed, women with gene mutations who are cancer previvors or survivors, may actually need HRT, hormone replacement therapy, and not just hormone therapy. And women that are over 65 do not need to be treated like the bathwater, and you're throwing the baby out with the bathwater. Yes, they may mean need dosage reductions, but there's no specific time limit to hormone therapy. In general, younger women, women with surgical menopause or more intense symptoms, may need higher levels to protect their bones than someone who's naturally menopausal. Now, moving on to talking about the supply chain shortage and what maybe you need to be aware of.

Patch And Progesterone Supply Shortages

Dr. \ 24:48

We are seeing a national shortage of patches, including the twice-a-week estradiol patch and the once-a-week estradiol patch. Also, we've had some shortages. CVS reported a shortage of 100 milligrams of progesterone capsules in the brand name Prometrium, both 100 and 200 milligrams. There's also generic progesterone mixed in peanut oil. And part of this is because since in 2025, finally, after several of us lobbying for several years, the box warnings were lifted off of menopausal hormone therapy and also on vaginal estrogen. And a lot of women who were suffering or who were told that they couldn't take hormones, as well as some younger women who were having monthly periods and don't need menopausal hormones, but maybe had other issues that they weren't sure if they were perimenopausal, all rushed in and you know were wanting prescriptions. So that's part of the supply issue. But it's kind of highlighted, and I've had several discussions with my team, that there was this kind of pop culture trend post-WHI that, oh, the problem's not hormones, it's that oral hormone regimen they use in the WHI. And that's not true. There are reasons to use patches, there are reasons to use oral agents. And separate estrogen and separate progesterone are not necessarily better by any means. In fact, it was the PEPI trial that looked at giving estrogen and cycled progesterone for 12 to 14 days out of the month. And cyclical hormones are usually associated with bleeding. And when you separate the estrogen and the progesterone, you don't always get the uterine protection. And natural progesterone is not always well absorbed. It has to be taken at night because it can be a sedative hypnotic. It needs to be taken with food because the stomach acid destroys the progesterone easily. And what amazes me is how women will tell me, oh yeah, I took the pill for 15 years. Oh, I took the birth control pill for 30 years. Oh, I had three children and two C-sections and one V back. Like, you know, been through an awful lot. And yet then they're petrified of a low dose of oral hormone therapy, which contains so much less estrogen than even the lowest dose hormonal contraceptives. And so, in general, most women who've tolerated hormonal contraceptives in the past, who don't have histories of blood clot or high triglycerides, or gallstones, or gut absorption issues, generally can safely tolerate oral hormone therapy. And in the Danish osteoporosis trial, which was an oral hormone regimen, there was reductions in several diseases and death rates, and no increase in clot. Now, for those women that have known hypercoagulopathies prior, deep vein thrombosis or blood clots, pulmonary embolism to the lungs, those women who maybe are what I call hormone virgins and that they were never pregnant or took hormonal contraceptives, maybe they're adopted, don't have a big family history. Those people you might be a little bit more concerned about that. But one fact that's not well recognized is that reductions in death rates in large randomized controlled trials have actually been done with oral hormone therapy because that's more widely available and cheaper. For instance, oral conjugated estrogen in women without a uterus and oral conjugated estrogen with madroxy progesterone acetate, also brand name titled PremPro, was associated with reductions in death rates in women who started hormones within 10 years of menopause. And this evidence is one of the reasons why finally the box warnings were lifted last fall, and this is what's driven demand in hormone prescriptions. But a lot of women have heard some uh influencer say, oh, just get separate estrogen and separate progesterone. And as I mentioned, the oral estrodiolin orethesterone acetate in the 10-year DOPS trial was in women ages 50 to 60 and did show an increased risk of DVT. Now, if you gave it to older women, more women, women with a prior history, I'm sure you would see increased risk compared to placebo. So I'm not minimizing that that is a potential possibility. And I tell women we make calculated uh decisions about risk every single day. Um like the other day I was driving into work and there's a shorter way to go, but there was increased traffic. Uh you know, my app was telling me maybe go the longer way, and I thought, no, I I want to get to the office on time. And uh it was lots of traffic, and we were at a stop, and boom, this big truck rear-ended me. I rolled the window down. I'm like, why did you hit me? I don't know, but I wasn't texting. I'm like, okay, that probably means you were.

When Oral Therapy Makes Sense

Dr. \ 30:20

And so I, of course, I got into the office a little bit late, and I've been dealing with that. So there are risk in everything we do. Risk in patients. I used to say people who were so upset about the results of the Women's Health Initiative rushing into my office to see me. Um, some of those people might have been involved in getting speeding tickets or car accidents. Even things that we do every day, like eat food. You know, you can get food poisoning. Generally speaking, that's the older I get, the more I like to make my own food at home. Um could choke. I've choked on an apricot pit one time because I was trying to do too many things at once, like drive my kids to their baseball game on time and eat for the first time in one day. So we make decisions and trade-offs every day. But when you're looking at prescription medicines, whether that's antibiotics, blood pressure medicines, diabetic medicines, cholesterol medicines, the field of medicine has held up menopausal hormone therapy to a completely different standard than all these other medications that we prescribe. And everybody's individual, that's why you have to listen to the patient. Um, so I prescribe drugs every day that 90 plus percent, 99% plus percent of people tolerate very well. And every once in a while there's someone who has a very unusual side effect, stops it, or has an allergic reaction. So we can't always predict what's going to happen. But in general, if you uh have previously tolerated hormonal contraceptives, uh if you're generally healthy and active, oral hormone therapy is also generally more available and cheaper than the patches. Uh, like I said, if you've had pregnancies and deliveries, which are much higher risk for clot. Um now, women who've had uh preeclampsia, uh help syndrome, pulmonary embolism, even those women usually uh uh if their blood pressure is controlled, can tolerate oral hormone therapy. But if they've had active blood clotting or genetic risk for clotting, then uh we do prefer transdermal. So estrogen can increase thrombotic risk in women with cerebral vascular disease over the age of 65. We say one extra case per thousand women on oral hormone therapy. But I do have women over 65 who have good blood pressures, they don't have atrial fibrillation, and they prefer oral hormone therapy. So just because they automatically have a birthday in turn 65 doesn't mean they have to be switched to a patch. And we actually have a lot of data from CMS in 11 million women's study for 13 years on various prescription hormone regimens. And any hormone, high dose, low dose, and certainly vaginal estrogen were all associated with lower death rates. Now, oral estrogen does go through the stomach and liver, and there's some hepatic conditions that might worsen. There is one bioidentical oral estrogen progesterone in two doses, mixed in micronized, medium-chain triglycerides or coconut oil. And the way it's it's absorbed, it doesn't seem to have the same effects on coagulation proteins or blood pressure that oral estrogen, uh estradiol in a tablet does. Um generally speaking, we don't like to give oral therapy with uncontrolled hypertension. Um, if the triglycerides are very high over 400, oral estrogen can raise triglycerides. Conversely, oral hormones lower LP level A by 20%, and this is frequently overlooked. And oral estradiol, conjugated estradiol, seems to do a better job in trials at reducing epicardial fat. And in women that have androgenic hair thinning, uh skin issues, oral is generally preferred by the dermatologist compared to transdermal. And while smokers should not use oral contraceptives over the age of 35, that doesn't mean that smokers can't use menopausal hormone therapy. And some physicians have tried to tell women with migraines that they have to only be on transdermal. Actually, it's the consistency of the dose that matters. Um, years ago, I did a randomized controlled crossover trial using a weekly estrogen progestin patch versus oral conjugated estrogen with MPA in migronerves with the hypothesis that the transdermal would be better. But actually, in the trial I found that there was less migraines on the oral, and and that's because, as my mentor, uh Phil Sorel told me he was sitting right next to me, is how our long-term friendship started. His poster was next to mine. He's like, Yeah, pick the wrong patch. Meaning, I should have picked the twice-a-week, every 84-hour patch, because the weekly patches, the levels can drop off on day seven, and anytime you have a drop-off in hormones naturally or by dosing for menopausal purposes, that can trigger a migraine. Um so a lot of women, if they can't get a patch, they can safely transition to oral, but you have to get your uh clinician's input. There are some gels like divigel that comes in a little foil

Practical Substitutes And Patch Workarounds

Dr. \ 36:05

packet, Eva Mist, which comes in a spray that can be dosed up to three sprays to the skin. There's a lesterin and estrogel. Um, in general, my experience when checking blood levels is those transdermals don't seem to get quite as good at estrogen levels as the patches, but they can be used in women who don't like something stuck to their skin and adhesives like that. Um, there's plenty of combined oral estrogen uh progestin combinations like MIMVI and Abigail or generics of Activella, Bijuva's bioeddenical, Angelique. Um, many of my patients have to order this on Canada drug because it's so expensive in America. And last time I checked it wasn't on TrumpRX.gov, but duavy, which is conjugated estrogens without progestin with basadoxifine, um, which is a good option for women with breast tenderness or any insensitivity to progesterone or women who've had breast cancer in the past or have DCIS, it might not be quite as good a protection of the endometrium as standard estrogen progestin, as suggests by a recent recent case control trial. But um now my patients are seeming to have easier access and getting it. Now, perimenopausal women, um, whether they require contraception or not, uh, a lot of times menopausal hormone therapy is just not strong enough to control bleeding. Uh, nextelus is a natural E4 estetrol with drosperidone, and then there's one hormonal contraceptive with natural estradiol that's also approved to control abnormal bleeding, netasia. We've had some supply chain problems with nostasia. What's nice about netasia nextelus is it can help with both bleeding, cycle control, vasomotor symptoms, contraceptive, contraception simultaneously, and is much more estrogen than just rubbing something on your skin or putting on a patch. Um I think the women who should be prioritized to make sure they have their patches are those who've had blood clots or high clotting risk or significant cardiovascular risk or very recent MI or active liver disease or malabsorption, their gut just doesn't absorb it, or immobilization. Uh, but for the vast majority of women, they don't have to. Now, um, you can ask your prescriber for a higher strength of the patch and cut it in half. Some of my patients who can't get the weekly patch have to go to the twice-weekly patch, and vice versa. Um, natural progesterone, just because it's natural, is not necessarily better. I think norethotron acetate, uh, drosperinone, madroxy progesterone acetate, which are all very well absorbed, um have consistent endometrial protection. Also, natural progesterone can worsen heartburn. It relaxes the lower esophageal sphincter. Some women don't like the dizzy or relaxed uh feeling on natural progesterone, they feel drugged. Other women who are anxious and don't sleep well love the natural progesterone. So again, it's individual. But if you don't take the progesterone or progesterone and you have an endometrium of uterus, you can definitely increase the risk of endometrial hyperplasia and cancer. Now we have non-hormonal options like linquet. I talked to our graduating senior fellow, Dr. Sung, who unfortunately is leaving us. She's going to the Mayo Clinic in Jacksonville, if anybody's listening in Florida. Um, and she talked a lot about Linquet and NK13 non-hormonal option, which is good for sleep and hot flashes. For the last three plus years, we've had VIOSA. In fact, I had CME podcast in 2003 on

Nonhormonal Options And Closing Advice

Dr. \ 40:10

phessolinitant, the first non-hormonal treatment for hot flashes. We have off-label drugs. There's one SSRI at low dose peroxetine, 7.5. That's the only SSRI approved for hot flash treatment. But if you're on tamoxifen for breast cancer prevention or breast cancer treatment, it affects tamoxifen's metabolism, so you can't take that. So, my advice to prescribers are that use oral options when clinically appropriate. Try to reserve the patches for those that really require it. Some of patients can obtain estrogen patches through Canadian pharmacies, but shipping can take several weeks. Definitely demand is not going to be lessened anytime soon. Remember that if you're separating the estrogen and the progesterone, even though some people will take both continuously, it's technically only FDA approved to cycle the progesterone or progesterone for 12 days. If you've got a uterus and want a patch, my favorite is to use COMBI patch or Evoral Conte, which is natural estradiol, 0.05 with a progestin. And a lot of women over 65 get by on half a patch, so three months lasts six months. Certainly women over age 65 who want oral therapy for whatever their reasons are, based on the CMS data, they still have lower death rates than women not using any hormones. And for any woman over 65 who maybe her bones are fine or she's on another osteoporosis treatment, maybe she's never had hop flashes, feels great, and just didn't want to take hormones to stimulate the breast or uterus potentially. At that point, if you're over 65 and not on systemic hormones, you should be on some vaginal estrogen cream once or twice a week. And really, I think any physician in any field should feel comfortable being able to renew an estradiol estrogen prescription. Now, if you're having vaginal bleeding or have undiagnosed bleeding, you need to see a gynecologist. Now, for those perimenopausal women who have a levonergesteral IUS intrauterine system device like Mirena or Lileta, even though you're told it's good for eight years for contraception, it's only good for five years for uterine protection if you're using an estrogen patch or oral estrogen or estrogen spray or gel. And so you need to know the date that that was put in. And I really appreciate you tuning in to this edition about the benefits of hormones, some of the history of medicine, some tips on alternatives if you're faced with some pat shortages. I think any critical medicine you should have an extra supply of and not wait till the last minute and get stuck. You know, there's natural disasters, there's emergencies, there's travel. So I think it's always better to be prepared. So thank you so much for joining us. If you like this podcast, give us a five-star rating, share it with friends. And if you don't already subscribe, collect, or follow our podcast wherever you listen to podcasts on Apple Podcasts, Spotify, Podbeam, Amazon Music, wherever, be sure to follow us. And remember, be strong, be healthy, and be in charge.