You are not too old for menopause treatment

A single birthday should not erase your options for menopause care, yet many women hear a flat “no” the moment they turn 65. We challenge that reflex with evidence, clinical nuance, and practical guidance on how hormone therapy after age 65 can still fit into real life, especially when symptoms, bone health, and genitourinary syndrome of menopause are still in the picture. 

We walk through a blockbuster Medicare claims analysis of 10.9 million U.S. women over 65 tracked from 2007 to 2020, looking at outcomes tied to different hormone therapy types, doses, and routes: vaginal estrogen, transdermal estrogen patches, and oral estrogen. 

Then we get practical. We talk estrogen patch shortages, progesterone supply problems, and how pharmacy pricing and formularies can block care. We also cover why “hormonal age” of menopause matters, when labs like FSH and estradiol help, and how common supplements like biotin can interfere with testing. 

If you’ve been told it’s “too late,” listen and bring your questions. Subscribe, share this with a friend, and leave a review so more women can find evidence-based menopause care.

Transcript

Why Revisit Hormones After 65

Dr. \ 0:16

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 old edition. There's a few podcasts of our 220 plus podcasts that I've done that I remember by the exact date. And the one we want to reprise is one that I did on October 14th, 2024. And the reason why I remember some of the dates of some of these podcasts is because I have recommended to patients oh, you should listen to this one if you didn't listen to it or maybe re-listen to it. And that's because it has such important information. And the topic of the podcast was hormone therapy after age 65. Discover the truth and the benefits. And the reason I want to reprise this one is because every day we all get older, people are getting closer and closer to 65. And a lot of our listeners and patients are already over 65. They may or may not be on Medicare. And the podcast that I did was based on CMS data for American women on Medicare, followed for well over a decade over 11 million women with every single diagnosis possible. And it was very, very striking for a number of reasons. And the reason why it's important to go over this again and listen to the podcast again is because since then, in November of 2025, after decades of people like me and my colleagues pressing, um, imploring, uh, testifying, um, putting commentary on the websites of the government to take the box warnings, one off of vaginal estrogen, as well as the scary box warnings that were just applied across the board to menopausal hormone therapy post-infamous women's health initiative. And it's not that there's just quote new research that debunks the old research, okay? The prior expensive, long, prospective, randomized control, scientific kind of gold standard women's health initiative was in large part, uh, in part by the media and others, um, misinterpreted or not put into proper context. And so finally, that has been done. But a whole generation of women have been negatively affected. And it's because of the box warnings being lifted, I think a lot of doctors and nurse practitioners and healthcare teams are seeing women flood into their offices asking about hormone therapy, maybe suffering in silence or not in silence for years, thinking they couldn't take hormone therapy. Uh, women who had maybe taken other non-hormonal options, uh, wanting to talk about vaginal estrogen for their local genitourinary symptoms, their recurrent bladder infections, their overactive bladder, uh, their sexual pain uh conditions, uh, friable, irritated, itchy, raw vulvar tissue. Uh, there's also women who uh want to know if it's an option for their bone health because osteoporosis affects one in two women over age 55. And it's great that we have so many treatment options, so many more than we had when I started my practice. Uh, for some women, uh, they would prefer to consider estrogen therapy. So there's a whole lot to unpack.

Box Warnings Lifted And Demand Surges

Dr. \ 4:34

And because there has been a surge in interest, a surge in demand, that's part of the reason we've had shortages of the estrogen patch. Uh, Wall Street Journals covered it, a lot of major newspapers, it's all over social media. I did a podcast uh uh earlier this year about what to do in the case of patch shortages. And it's not just the patch. Uh, we have had uh sometimes supply issues with the 100 milligram or 200 milligram dose of prometrium, which is natural progesterone mixed in peanut oil. There have been some uh supply issues with oral hormone therapy, including the oral bioidential estrogen progesterone bijuva, which is mixed in MCT medium-chain triglyceride coconut oil. Um, in fact, I had a patient the other day was so surprised that she got her uh prescription mailed to her door within a day of ordering it, which was uh very impressive. I'm like, be happy about that. Um I've had to have patients order uh their hormone uh regimens on a variety of Canada drug websites uh because of supply chain problems. Sometimes cost has been an issue, uh, and that generally has been an issue for a long time based on the pharmacy benefit managers, kind of controlling people's formulary. And I always encourage women, just because something's not on your formulary, or just because you have prescription insurance that you're paying for, doesn't mean you have to follow the insurer's instructions or what big pharmacy like ExpressCare or CVS CareMark or Optim RX or any of these big pharmacy benefit manager plans. It doesn't mean that's your only option or only choice. And some patients find that paying cash, they can actually get the brand name of a hormone as opposed to the generic paying the same or more money going through their insurance. And so it's a complicated issue. I've covered um it on speaking of women's health.com. There's a lot of workarounds, whether it's the trumprx.gov site going maybe directly to the manufacturer and bypassing the pharmacy benefit managers. Uh, goodrx.com uh allows for people to get kind of the crumbs or the kickbacks from the pharmacy benefit managers in the form of coupons. And it's amazing if you just open up goodrx.com, put the prescription that you're looking for, have Wi-Fi on so that it looks at your geographic area and it will pull in all the surrounding pharmacies for that medication for either one month or three month supply, and it will show you such a wide variety

Patch Shortages And How To Save

Dr. \ 7:46

of cost. So it really does pay to be a consumer, and it also pays to be up on not just the latest research, but it being correctly interpreted by people practicing in the field with a lot of experience. And nothing is completely risk-free, nothing is completely safe and 100% effective for everyone. But what I impart to my trainees, fellows, residents, colleagues, patients is that if you look at the standard to which menopausal hormone therapy has been held up to and compare it to any other medication, an antibiotic, a blood pressure medicine, cholesterol-lowering medicines, um, things that are prescribed regularly, common old medications that have been around for a long time, as well as some of the newer kids on the block. And ironically, and not so ironically, but importantly, of all the medications that we prescribe in the field of medicine, there is nothing that has had the massive impact on both disease burden reduction and expansion of not just lifespan, but health span as menopausal hormone therapy. And like a lot of patients who come to see me, many who have to wait a long time, which physician referrals help get you in sooner. We also have our concierge custom fit program that can accelerate appointment times. And we have information about that on our speakingofwomen's health.com site. And I hope to have our administrative assistant, Brenda, who's a woman of multi-talents, uh, who takes incoming calls and helps uh get this coordinated and scheduled on a future podcast to talk a little bit more about that program. Uh but that being said, I know that my colleagues, partners, my team, as well as uh physicians across the country are seeing women flood into their office, many of them over 65, wondering, is it too late? Can I take hormone therapy because of X, Y, or Z? Do I need it? Um, I want it. Is it too late? And unfortunately, many women are just being turned away and told, well, you're over 65, it's too late. And that's not appropriate. Certainly, we like to start a hormone therapy menopausal MHT within 10 years of menopause and or under age 65. Now, I have some patients who don't go into menopause till 59. So maybe when they're 68, they're still within that 10-year time period. Conversely, some women have early menopause much before age 45. So at age 65, they've already had 20 years potentially of no hormones. And that's why it's critically important to date the hormonal age of menopause, not just when your period stopped, but actually getting blood work, which the American College of OBGYN uh group doesn't really emphasize a lot about checking hormone levels, and certainly they can fluctuate a lot. Another problem with getting hormone levels is biotin B7 can interfere with many lab assays. And I did a whole podcast on biotin because so many women are on it, so many women care about hair, and over age 40, uh, it's harder to grow hair. 40% of women have 40% less hair. And if there's excessive scalp aging, which can accelerate during menopause, that can be very difficult on the hair follicles. So it's a hot topic, but I can tell you that only about one in 10,000 women are biotin deficient, B7 deficient, who need biotin for hair growth. And because these megadoses many times don't make a difference and they interfere with lab, you've got to be very careful about it and certainly stop those hair vitamins a good 72 hours before blood work. That being said, checking an FSH follicle stimulating hormone and an esterdiol level, particularly if you've had a hysterectomy but still have ovaries, if you have a morena or Liletta levo energile intrauterine device, that causes lack of periods. It's good to check hormones. If you're taking most hormonal contraceptives that have synthetic estrogen, you cannot check the estrogen and the FSH. And you actually have to be off it for far longer than a week or two to even get even slightly reliable levels. Now, if you're on a progestin-only pill with an estrogen patch, many times we can get an FSH and estradiol. If you're on Natasia, which is natural estradiol, in a hormonal contraceptive that's formulated to treat abnormal uterine bleeding, we can check an FSH and estradiol. With Nextellus that has three milligrams of drosperinone, good for skin and hair, and a natural E4 estetrol. Um

Timing Menopause With Better Testing

Dr. \ 13:24

we can attempt to get an FSH and estradiol and see where you're at, as opposed to where it's just completely worthless with the synthetic estradiol. Some women are on four milligrams of SLIND, which is enough to suppress ovulation. And usually the FSH does go down, but sometimes it's still hovering around 20. And if you persistently get that over time with age and symptoms, we may be able to make that diagnosis of menopause and then switch to a menopausal range hormone regimen, not an ovarian control regimen. So that being said, what about women who clearly are 10 years past their hormonal age of menopause and are clearly well past age 65? It's not that you can't take hormone therapy, it's just that the incredible benefits on life prolongation, reductions of potential memory loss and Alzheimer's, and reduction in cardiovascular disease are likely not going to be there, like we can say in younger women. So it still can help hot flashes, and we have non-hormonal options for hot flashes, although some of the newer uh NK1 and NK13 inhibitors that have been a godsend for treating hot flashes in women who can't take hormone therapy, active clotting, active estrogen-positive cancer, many times are not covered in the Medicare population coverage. The other group of women where the hormones do uh still work is in bone health. Now, it's only approved for management and prevention, not necessarily active treatment of severe osteoporosis. So women with established osteoporosis who fractured many times need osteoanabolics, bone building agents, and then antiresorptives to lock in those gains. And we've had several podcasts on bone health. But for someone with osteopenia and a few hot flashes, and maybe still has some vaginal dryness or sexual function changes that local estrogen or local vaginal DHEA is not enough for, it's reasonable to consider shared decision making and informed consent, uh, menopausal hormone therapy. Now, ideally, all medical conditions are controlled, the blood pressure is controlled. And if I had a penny for every time someone told me, oh, my blood pressure is always normal. Um now it's not, well, guess what? Everybody's blood pressure is always normal until it's not. So if you're over 50, you should have a blood pressure cuff, you should be taking it in the morning, um, maybe once a week or once a month, you should bring in your blood pressure cuff to your physician's office because multiple elevated readings do impart an increase cardiovascular risk, stroke, heart failure, kidney failure. So you want blood pressure controlled. You want any active cardiovascular problems stabilized. And certainly in women over age 60 to 65, based on data out of Finland from uh Dr. Tommy McCola, women with established cardiovascular disease who are on a statin and hormones generally seem to have less heart attack and stroke than those women just on a statin or just on hormone therapy. Now, the flip side is women under age 60 without any heart disease. There is no primary prevention with statins, and statins increase diabetes, type 2 risk. And type 2 diabetes in women is a greater cardiovascular risk than type 2 diabetes in men, which is still a risk. So if you start with clean arteries and decent brain tissue, generally menopausal hormone therapy seems to help in the anti-aging realm of those tissues. But if you already have disease and it's past the time for prevention, if there's still indications for treatment of your symptoms or an adjunct to your bone regimen, or an adjunct to the local vaginal estrogen treatment. Now, if you're one of these women who has no menopausal symptoms and your bones are either normal or they already are being taken care of, and you're over 65, I strongly recommend you consider at least a gram of natural estrogen cream on your vulva and just the opening entroitus of your vagina at least once a week. Because in this large study, which you're going to hear about again in just a few minutes, the women on vaginal estrogen actually had the lowest death rates compared to women not on hormone therapy, like a 30% reduction. And I think that's indicative of less bladder infections, which can lead to urosepsis and death. And it also might imply certain characteristics. I mean, women on vaginal estrogen probably are going to the physician more frequently, may have other resources. Now, vaginal estrogen, estradiol, it's generic, it's dirt cheap. I have patients go on the Amazon Pharmacy uh Mark Cuban site, go on goodrx.comgov, um, or goodrx.com, I mean, and get uh generic estrogen cream. There are tablets, I don't see them dissolve very well. There are uh coconut inserts and Vexi, uh, which a lot of my patients will go on Medcare and get for $50 a month, especially if they don't like creams, which are a little messier. Welcome to the Speaking of Women's Health Podcast. I'm your host, Dr. Molly Thagger, and I'm back in the Sunflower House for a brand new edition of the Speaking of Women's Health Podcast. And the topic we're gonna go over today is actually a very important uh publication in the Journal of Medicine. It is a blockbuster, it's a study of over 10 million, actually over 10 million United States American women over age 65 and their use of various types of hormone therapy and the medical claims that uh made to Medicare, our government. They have all the data. I'm actually a little bit surprised that this was published because um Medicare really discourages the use of hormone therapy in women over 65. And I've talked about this in other podcasts. In fact, um you get nasty letters as a prescribing uh physician if you have more than 7% of your females age 65 and older on uh hormone therapy. And uh I've always kind of joked is this just because they don't want their beneficiaries to live longer? Because we certainly have known for quite a long time that women who take hormone therapy systemically under the age of 65 within 10 years of menopause live longer and die from all causes in general less often, even though that's not the uh general urban gestalt. So the thoughts were basically well, if you're already past this critical time period of 10 years from losing your estrogen, that maybe some of the preventive benefits on the brain and the cardiovascular system uh wouldn't be as great. Now, we've known for a long time that if you give local estrogen at any age, that is going to help the vaginal atrophy, the so-called genito-urinary syndrome of menopause, which is a much better term because it encompasses overactive bladder, bladder irritation, recurrent bladder infections. All these things are made worse when a woman loses the sex hormones and that tissue, which is very sensitive to the sex hormones, dramatically drops. Um and even standard or low dose systemic metapausal hormones. Therapy may not be quite enough for the urogenital tissue. So this study looked at beneficiaries that were in the medical database for 13 years from 2007 to 2020. And as you'll recall, the Women's Health Initiative, the largest expensive preventive health trial, randomized controlled trial in older women, primarily average age 63, 64, was uh published the first series um July of 2002, which was just a few months after I opened up the Center for Specialized Women's Health. And all the headlines, you know, caused panic, caused millions of women to throw away their prescriptions, and really had a terrible, terrible fallout. When they finally released the age stratified data, we found out that women who had taken hormones uh had lower death rates, particularly if they started within 10 years of menopause. So this particular study and the authors uh were um a PhD C-O B A I K, um, and a physician by the name of Clement McDonald and a master's in science um Fitzumbay. And so they published this in April of 2024, and we have this study actually summarized and bookmarked on our Speaking of Women's Health website. So if you don't have that bookmarked, speaking of women's health.com, under the drop down under news, you'll you'll see us uh post this study. And uh the implications of this is very important because we do have a lot of women over age 65 who want advice and counseling. And unfortunately,

When Hormones Still Help After 65

Dr. \ 24:09

most physicians, nurse practitioners, prescribers, uh, physician assistants will frequently say, Oh, over 65 you should just stop. Um, I mean, they discourage a lot of times inappropriately women under age 65 from not taking hormone therapy. So this is really uh very disappointing. In fact, I I just saw a lady today in the office, and I followed her for years for perimetopause, got her situated with uh menopausal treatment, doing well on low dose hormone therapy, her bone density was improved, her symptoms were controlled, she had no side effects. Um, and she still required a little bit of local estrogen because the the systemic dose was pretty low. We tend to lower the dose after age 65. And she just said, Well, I wonder if I'm supposed to come off of it now. And I'm like, this is someone that I've seen and re-evaluated and given her, you know, access to the latest information, which has constantly reinforced that you do want to treat estrogen deficiency. And I said, Well, you're not gonna spontaneously make estrogen again, and you can certainly go off treatment, but then we will definitely have to use something to treat the osteoporosis, which actually had improved osteopenia, and you may have to actually use more local treatment for your vagina and bladder. And I said, What's different? What's making you think? Are you having side effects or problems or is it an expense issue? And she just remarked, Well, my primary care doctor said I should get off of it. I'm like, Yeah, because your primary care doctor probably doesn't want to get, you know, letters saying, you know, don't prescribe this. This is considered high risk based on really old criteria, the old beer criteria. So I hope this study is used um to uh change recommendations. But if it's like anything else, like the black the box warnings on vaginal estrogen, um, which shouldn't be there, you know, still are there. So, and people have been working on that for a long time. So, whatever large governmental alphabet agencies say isn't really always um the latest and greatest. And so that's why, in order to keep you strong and healthy and in charge, we want to bring you the latest information in health, wellness, uh, and certainly working to dispel these myths and misunderstandings. So after July of 2022, uh all the pharmacy database records saw huge plummeting of hormone therapy. And it's disappointing because women still were entering menopause and they still were estrogen deficient. Many of them had hot flashes, many of them lost bone, many of them had other menopausal symptoms, you know, that can range from all sorts of things from hair thinning to poor sleep to brain fog. And we've covered a lot of these topics in depth in uh prior podcasts. Um, we have well over a hundred podcasts now. And uh, so people that are new to this, you might want to take some time to scroll back over prior topics. You can also go on the website speakingandwomen's health.com and just put in a topic you're interested in, space podcast, and then search, and it should bring up podcast uh on that topic. So um the WHI was really devastating for a generation of women, and that's because overall health outcomes are better in women who are not hormonally deficient, and risk for mortality, certain cancers, and cardiovascular outcomes in this study of women. It was not a randomized controlled trial, it looked at all women in the database, and obviously it looked at just what prescription they were on and what the list of diagnoses were. And um, but it's powerful because there's so much data. And the information on diagnosis and claims and prescriptions, you know, it's not 100% accurate, but it's about as accurate as you can get looking at medical records. And they broke things down based on the hormone therapy types like plain estrogen, oral, patch, vaginal, progesterone, natural oral, synthetic progestin, and uh also just women who only use local vaginal uh treatments. And they looked at several different outcomes. And it's important to note that age doesn't necessarily make hot flashes go away, and you can be five years, ten years, even 20 or 30 years past your final last menstrual period, which is generally the time that you enter into menopause, which is a retrospective diagnosis. Uh, symptoms don't go away. And the bone loss, which occurs to half of women, continues. And the genitourinary symptoms can continue over time. Um, I think I should I'll post on uh my website with a link in the show notes from the book that I wrote, The Cleveland Clinic Guide to Menopause. I have a slide that looks at estrogen levels and then onset of disease and when it when it comes on. And looking at that, because I I wrote this several years ago, the book, and then I updated it when I podcasted my book at the beginning of last season in 2023, the Cleveland Clinic Guide to Menopause. I noted that we just talked about the classic areas of what happens after menopause. Half a woman have hot flashes, half a woman lose bone, and about 80% can have some genital urinary symptoms. I didn't include other things like general longevity or cardiovascular outcomes or cancer outcomes, um, dementia, which of course is a big concern for the 65 plus crowd because one in two women have dementia by age 85. Um, but the ones that really aren't disputed and that are clearly linked and that generally um stabilize or get better in the vast majority of women, um kind of stuck to that. So there were 10.9 million um women that were looked at. They looked at the prescription drugs, the medical records, and they got the data from the centers of Medicare and Medicaid Services, CMS, and the health outcomes they looked at, um, and they looked at, as I mentioned, estrogen, progesterone, progestin, as well as the doses and strengths and what the route of administration. And they looked at all-cause mortality because that is the most um inarguable bad outcome, basically, that you can have, which would be death. And that's not really disputed. You're either alive or you're dead. Um, and if you're dead, you're not making any more claims for Medicare. They also looked at cancers that women are very concerned about, such as breast cancer, ovarian cancer, and dimetrial uterine cancer,

Inside The 10.9 Million Medicare Study

Dr. \ 31:49

as well as lung cancer and colorectal cancer, and colorectal cancer is really rising in younger people. Heart disease, the number one cause of death in women, was looked at with breakdowns of congestive heart failure, myocardial infarction, which is a heart attack or MI, and of course, um AFib, which is more common in women over 65, and then the dreaded dementia, uh senile dementia of the Alzheimer's type. So only 14% of women over age 65 during this time period from 2007 to 2020 used any type of hormone therapy. And furthermore, the percent of women age 65 and older using any hormone therapy declined from 11.4% at the beginning of the study to only 5.5% in 2020. And in the late 2010s, we already had the mortality data with the Women's Health Initiative. Um, so I think that's really extremely unfortunate that the numbers of use has kept decreasing. And um death incidence in this study was much lower among women who used any type of hormone therapy compared to those who used none, which of course was the majority of women. And we're talking about 6.3 deaths per thousand women, even though you can't have a third of a person die, but you know, it's the the statistics, compared to the baseline in non-hormone users of 12.6. So that's a significant difference. Now, of course, socioeconomic status and health status, comorbid diseases, uh, were not randomized. But observational data is very important, and randomized control trials are not the end-all be-all. And we certainly found that in the Women's Health Initiative, because even when you randomize women to get placebo or hormone therapy, if the person has hot flashes, they're going to know if they're on the placebo because they're not going to really have improvement in their symptoms or only the placebo effect versus those women on hormone therapy. Now, um, what they did do to try to get a gauge on socioeconomic um status was looking at Medicaid eligibility from a special supplement as a proxy for income. Because for years it's been argued that women with better socioeconomic status, higher education levels, take better care of themselves, know more about health, can visit the physician or healthcare facility more often. And is this just a proxy marker? But given that this, we've got this huge, huge database, and there's several interesting tables in the study, and it looked at, you know, the age comparisons on hormone therapy versus not hormone therapy, percentage of whites, blacks, Hispanics, Asian. Um, and it looked at uh so many different whether they lived in an urban area or rural area based on their zip code, whether they had ever had a pulmonary embolus, blood clot in the lungs, or atrial fibrillation, or heart failure, or stroke, cataracts. So, of course, like for instance, a lot of people over 65 have cataracts. If you haven't heard the uh podcast on cataracts I did uh earlier, that would be a good one to listen to. So almost 68% of the women who took hormones had cataracts. And that compared to like 52% of women uh that hadn't taken uh any hormones. So again, there's like high burdens of diseases in kind of both groups, and most of it's really pretty pretty equivalent, heart failure, depression, uh the baseline or diagnoses of any dementia, um, osteoporosis, rheumatoid arthritis, colorectal cancer, ovarian cancer, anemia, asthma, high cholesterol, high blood pressure, alcohol use disorder, bipolar, drug use, personality disorder, um, schizophrenia, and other psychotic conditions. So it was like 1.8% in both groups, just as an example. Um, epilepsy. Uh, you know, estrogen can stimulate the brain. I I would have thought maybe less women with epilepsy would be on hormone therapy in this group older than 65. And it was, again, 2% equal in both groups. Um, hepatitis, liver disease, uh, mobility impairments from arthritis, obesity, tobacco use. So you can see, and I haven't even named all the conditions, uh, but those were all the codes that they uh looked at. And the bottom line, and before I get to the bottom line, just to remind you, you're listening to the Speaking of Women's Health Podcast, and I'm your host, Dr. Holly Thacker. We're in the second season, 2024, talking about this blockbuster study of over 10 million United States women over 65. And the bottom line of this study, which looked at 13 years of data of U.S. older women, that

Mortality Findings By Route And Dose

Dr. \ 37:20

vaginal estrogen, transdermal hormone therapy, and oral estrogen therapy were all associated with reductions in mortality risk. 30% if they were on vaginal, 20% if they were on transdermal, and 11% on the oral estrogen. Now, that doesn't mean that only oral is that only uh vaginal is better. Um, and certainly we know from the randomized controlled trial of the Women's Health Initiative that estrogen alone in women with a hysterectomy um reduces breast cancer well into the to the 70s. We also know that women that are likely just to be on estrogen systemically are most likely not women that have a uterus because you have to protect the uterus and give a woman progesterone or progestin. And also, from what I see, is that um during this time period because of pharmacy benefit managers and uh you know drug pricing, and I I go into that quite a bit on my podcast on how to save money on medicine. And you can also read the article that has lots of great links. Um, vaginal estrogen, even though it's been around for decades, sometimes insurances and and Medicare are trying to charge women like um $500 for a little tube. So to be on vaginal estrogen, I wondered if it's a little bit more of a proxy uh for being extremely motivated, maybe in an intimate relationship, maybe a little more socioeconomic uh status. Seeing that uh there was more mortality reduction with lower doses in transdermal kind of goes along with our concerns about oral estrogen and a higher dose after 65 is known to increase the risk of stroke, one extra case per thousand women. Uh but because the women in all the groups in general did better and had much less burden of disease, this has changed my practice in that I'm a little bit more flexible and not so rigid about you need to reduce the dose, we need to do transdermal. Uh, because there are some women uh based on their personal circumstances, their finances, their lifestyle, uh, who really prefer one type of treatment over another. And so it's really not one size fits all. I mean, menopausal medicine is easy in that you don't want hormonal deficiency, but it's very nuanced in terms of what's the best, most individualized, appropriate regimen for a woman. And when these authors looked at women who had used estrogen and compared it to those who had never used estrogen or who had stopped it and looked at reductions in death rates and reductions in several cancers and heart problems, it's very impressive. Now, generally speaking, the lower doses along with transdermal and vaginal preparations had somewhat better risk profiles. So that does kind of generally reinforce guidelines. Um, we saw a 19% mortality adjusted hazard rate, which was 0.81, 16% reduction for breast cancer, 13% reduction of lung cancer. So that was very interesting, had a tight confidence interval, 12% reduction for colorectal cancer, 5% reduction for congestive heart failure. Um, that surprised me. I would have thought that would have been a little better. And interestingly, a 3% reduction for venous thromboembolism. I mean, I have seen women who had a provoked blood clot, have physicians say, Oh, you can't be on any hormones ever. And the DOP study, the Danish osteoporosis study, which was for 10 years and gave oral estrogen and oral progestin, granted it was to women uh under age 65, that showed reductions in deep venous thrombosis. So um, you know, we we can't be so absolute. There was 4% less atrial fibrillation, and importantly, 11% reduction in acute MI. Um, and only 2% reduction for dementia. And uh I think with the brain, even though we're learning new things about estrogen receptors in the brain traumatically increasing in post-menopause, and maybe the window of brain benefit may be greater. So I'm not an absolutist. I really try to diagnose the age of menopause historically, hormonally, and menstrually, and they're not always exactly the same. And some women are in menopause, but they're not really hormonally deficient because their ovaries and their adrenal glands make enough hormones, and their metabolism is such that they really don't get into deficiency symptoms till later. So I'm not so strict, always about the um years. I would certainly prefer to start hormone therapy within 10 years, if not six years, of menopause. Uh, but there's really no absolutes. And certainly in women who don't want systemic hormones, maybe they don't have hot flashes, they don't want to take anything. If they do need something for vaginal atrophy, I'm more likely to want to pick a vaginal estrogen these days, as opposed to uh vaginal DHEA, which is so excellent because it doesn't affect the uterus, it boosts estrogen and testosterone. We use it for low sex drive, uh, it's less expensive. Usually, not always, the commercial one can be more expensive, depending. But we can compound a slightly higher percent and still be compliant with the federal law. And the research shows the higher percent, 1% is better for climax and sexual function. But especially if a woman doesn't have a uterus or an endometrium, um, then I would really generally favor vaginal estrogen. And the women's health initiative showed that vaginal estrogen, um, compared to those who weren't on it and weren't on systemic hormones, had better outcomes. So it's really ridiculous to have any boxed warning on vaginal estrogen, you know, products like they have for heart attack and so forth. Now, looking at conjugated equine estrogens, uh, of which the brand name is Premarin, comes in lots of different doses. 0.625 is the maroonish brown tablet. That's kind of the standard. Um my whole career, I've always seen a decent subset of women who've taken Premarin. Versus transdermal bioidentical

Progesterone Questions And Breast Risk

Dr. \ 44:02

estrogen, and there's something in it that they feel better. It's like more of a kick. And there's 10 different estrogens, and it's not directly comparable to just plain estradiol orally or by patch. And there was a 23% reduced risk of breast cancer diagnosis, while the so-called bioidentical estradiol um showed the 12% reduction. So less. So when I see women at high risk for breast cancer or breast cancer survivors, if I'm not worried about high triglycerides or blood clot, um, and they're specifically very concerned about their breast, I generally prefer oral conjugated uh estrogens. And I know that there was a big mantra for a long time that, oh, it's just safer if you use transdermal. Um, and it in some cases it may be marginally better, uh, but I don't think we can be so absolute. Now, interestingly, the study, there were women getting injectable estrogens, which that would be high dose. And I'm not sure why anybody was doing that, but apparently there are people doing that. So they had them in their database, and they did show an increased risk of heart disease with high dose injectables and also oral estrogens, increased the risk of stroke by 8% and dementia by 3%. And probably the memory loss in women over age 65 in the MIM study, the memory study, that was an offshoot of the Women's Health Initiative. If you increase the risk of stroke and pick off parts of the brain, obviously there's going to be more cognitive decline. So in women at high risk for stroke, uncontrolled hypertension, atrial fibrillation, uh smoking, diabetes, known carotid atherosclerosis, these would all be indications to use lower doses or transdermal. But I have plenty of healthy women who are 70, 80, and 90, and they want their oral estrogen and premarin and they've done well on it. And so it's an option. I mean, we have to sometimes take this hubris as if we think we know everything when we don't. It's so important to listen to the patient. Um in the study, overall, the use of estrogen alone was 10 times greater than estrogen progestin or only progesterone alone. And twice as many women were on vaginal estrogen than uh systemic. And that's again not surprising because so many women are just pulled off of it and told they can't take it. Um now, half of the women who had hysterectomies also had their ovaries and tubes out. So that reduces breast cancer when you take out the ovaries. When you take out the tubes and ovaries, that also reduces ovarian cancer. Um, so that's an important thing to note. It's not just the fact that they're taking estrogen therapy why they have a reduced ovarian cancer. But the women's health initiative looked at data prospectively in the randomized controlled trial with ovarian cancer. And the article, in fact, I'm I know I I did a summary on it on um speaking of women's health years ago. It was published in the Journal of the American Medical Association, and the data showed no difference in ovarian cancer on hormone therapy or not. But the conclusion, which is what a lot of people just read, or the news people who run with their little uh headlines, kind of non-scientific little tidbits to get people's attention for clickbait or attention on the news, said, Well, it may. Okay, well, that's not what it showed. Um now, um, conjugate quine estrogens in the women's health initiative was associated with a 6% mortality reduction in that 18 years of follow-up. And so that gives complete plausibility to the 9% reduction that was seen in this older group of 65 plus women with the use of medium dose oral estradiol. And um medium dose would be 0.625. And I do have women who don't want to reduce from that 0.625 after age 65. And I know some of you are listening and know that I'm talking about you, even though, of course, I'm not going to at all uh use anyone's name. Um it's just the point that we individualize uh therapy and and women should have choices. Now, the 19% reduction in death rate with estrogen therapy is completely consistent with over 30 observational studies as well as randomized controlled trials that we've had, including WHI and the Danish osteoporosis study, uh also a large database from Kaiser that have shown reduced death rates in users of hormone therapy. Now, looking at the women who used estrogen plus progestin, they had a 45% reduction for endometrial cancer. So if you're on a progestin, it generally means you have a uterus. And taking nothing at all versus estrogen plus progestin reduces uterine cancer. There was interestingly a 21% reduction in ovarian cancer with a tight confidence interval, 5% reduction for ischemic heart disease, 5% for congestive heart failure, and interestingly, 5% for venous thromboembolism. And the women who just use estrogen with natural progesterone, which people have promoted a lot of naturopaths and functional medicine people and alternative people, or people who, you know, were thinking, oh, it's just the synthetic progesterone, or it's just the conjugated estrogen that's the problem in the WHI, which I never said and I haven't moved from that. I just simply looked at the data. And interestingly, estrogen plus natural progesterone did show just a 4% reduction for congestive heart failure. And estrogen plus progesterone therapy, though, regardless of whether it was synthetic or natural, didn't show reductions in mortality. And so to me, if you don't need progesterone and you don't have a uterus, then there's got to be a pretty darn good reason to add progesterone. Um, like very, you know, some anxious women, some women who don't sleep very well, like the natural progesterone, some women with seizures. But for the most part, if you don't have a uterus or endometrium, you should you don't need the progesterone. Um and in this study of women over 65, whether women used estrogen with a synthetic progesterone or estrogen with a natural progesterone, it was still uh associated with an increased risk of being diagnosed with breast cancer by 10 to 19%. So a lot of people say, oh, natural progesterone is better for the breast. Well, I don't think we really have that evidence. Uh, progestin stimulates the breast. But mortality is the most important outcome as well as quality of life. Now, because hormone therapy, even though it has lots of preventive benefits, it's not 100% preventive. Anything that might have a side effect or stimulate the breast or the uterus or blood clot, you know, women are perfectly within their realm if they're comfortable and they're checking their bone and they're taking care of their vagina and they've been counseled on the risk, benefits, and alternatives. Uh, there's plenty of women over 65 who don't need hormone therapy. And there's still a lot we don't understand about um remaining ovarian function. We know there's a cardiovascular benefit to keeping your ovaries in general to age 65, unless you carry a genetic mutation. Um, and not everybody's wired the same, not everybody has the same metabolism. But I think what we do know, if you're suffering with symptoms and you have areas that you might want treatment and potentially preventive, then the package and the options that you have with local, systemic, high-dose, low-dose hormone therapy is really um quite a quite a bargain, medically speaking. Interestingly, they had some women who were just on plain natural progesterone. Um, and that had a 22% um reduction

Pellets Warning Resources And Next Steps

Dr. \ 52:11

in mortality and a 19% reduction of risk for lung cancer. Uh, and just progesterone naturally alone, a 10% reduced risk for breast cancer diagnosis. So um, but synthetic progestins only, and I suspect maybe those were women who might have had bleeding or endometrial hyperplasia. So maybe it's a marker for obesity, because those are the only women I can think of over age 65 who would only be on a synthetic progestin, had an 11% increased risk for mortality, 21% increased risk of breast cancer diagnosis, and 14% increased risk for lung cancer diagnosis. And I think that that could be a marker for uh body mass index and obesity. Because certainly obesity increases death rates, it increases cancer risk, you know, insulin resistance increases lots of different problems. So overall, taking a certain uh therapy or prescription, it's not a cause and effect, but looking at these associations and seeing that you have a 30% or 20% or 11% reductions in death rates in women on these different types of hormone therapy, to me is extremely reassuring for women who want or need hormone therapy. And denying hormone therapy, really, especially local vaginal estrogen, is completely ageist and completely sexist. And it's really against our motto of be strong, be healthy, and be in charge. Now, I have published an official review or column on speaking of women's health.com, and we have a lot of additional resources. Um, my book, which is podcasted. Of course, I podcasted and updated that book before we had the study, but most of what I say is completely, you know, consistent. I did a review a few years ago on the 20th anniversary of the Women's Health Initiative. I did a pretty pointed review uh called What Does Metapausal Hormone Therapy Have to Do with Politics? Are the women's health investigators collectivist? Um, well, some of them are something or other because um a few of them certainly have recanted or have uh been honest about the data and haven't been fear-mongering, but for a long time, the you know, NIH perspective was very anti-hormone. I did a column on uh new women's health analysis. This time estrogen saves lives, which of course it did. They just took a while to get us the data. Did a column on in the latest report from the Women's Health Initiative, the data contradict the conclusions. That was the one on ovarian cancer. Um, also, uh, we published a link to a scientific study that I did with some colleagues on a case study of risk and effectiveness of compounded bioidentical hormones. That was all the rage after the Women's Health Initiative because women still were hormone deficient, but they were terrified of prescription hormones. And certainly unregulated hormones are way riskier than getting prescription hormones, even high-dose prescription hormones, even if you're over 65. And now the latest rage, unfortunately, and I think a lot of it's driven by finances, is pellets of giving women male levels of testosterone. And when you get that rush of testosterone, yes, you're gonna feel like you can take on the world and you've got energy and you're interested in sex. Um, but long term, that's not natural, that's not the female state. And not all women, but many women get punished with androgenic side effects of, you know, androgenic hair thinning, chin whiskers, deepening of the voice, um, irritability, acne, um, weight gain, you know, testosterone puts on muscle and can put on weight. So um go running the other direction if somebody is trying to sell you a pellet, please. So thank you for listening and tuning in to another episode of Here Women's Health. We're so grateful for your support. And you can share this podcast with others. Um, you can donate to our nonprofit to King Woman's Health. And please leave us Pipe Star Wing and to catch all the latest um from Speaker Women's Health. Please subscribe or follow us and get the notifications so you know when we have a new podcast. It's free to subscribe, uh, and then you won't miss any future episodes. And I'll see you back next time in the Sunflower House.