What is Menopause?

0:07 Julia Cormano: In this episode of Motherhood TV, we are fortunate to have Dr.

0:12 Kathryn McCaulay, clinical professor of obstetrics, gynecology,

0:16 and reproductive sciences here at UC San Diego

0:18 Health and the director of the menopause program,

0:21 to talk with us about hormone therapy for menopause.

0:25 Dr.

0:25 McCaulay is who I turn to with all

0:27 of my most complicated questions about menopause hormone therapy,

0:30 and I'm so glad she's here.

0:32 Dr.

0:32 McCaulay, would you tell us what is menopause, and what is hormone therapy?

0:38 Dr.

0:38 Kathryn McCaulay: Menopause is the cessation of menstrual cycles.

0:43 It's the end of the reproductive time period for women.

0:46 It's defined as a clinical diagnosis defined as 12 consecutive months without

0:51 a menstrual period in a woman who's in the appropriate age range for menopause,

0:55 which is anywhere from over 40 to late 50s, but typically between about 45-58,

1:02 with the average age being around 51-52 years old.

1:05 Twelve consecutive months without a period,

1:08 that defines that we say that one has then reached the menopause.

1:11 After that time point, we refer to it as postmenopause.

1:15 Julia Cormano: What is hormone therapy?

1:18 Dr.

1:18 Kathryn McCaulay: Hormone therapy is using

1:21 estrogen products or end progesterone products,

1:24 depending on whether or not progesterone is needed.

1:26 If one has had a hysterectomy, they don't need to use the progesterone.

1:29 But it's basically a formulation of estrogen.

1:32 Different types.

1:33 We typically use estradiol, which is structurally similar to what

1:37 the ovary produces in different formulations.

1:39 It can be in pill form,

1:41 transdermal patch or transdermal gel form, even a vaginal ring form.

1:46 Progesterone is typically oral, but we do have some progesterone-

1:49 and estrogen-containing patches with different versions of progesterone.

1:53 Julia Cormano: When should a patient

1:55 be considering hormone therapy for menopause?

1:58 Dr.

1:58 Kathryn McCaulay: A woman who is either

2:00 in the menopause transition or has now stopped menstruating,

2:03 she's reached menopause and is having bothersome vasomotor symptoms,

2:07 that's hot flashes and night sweats.

2:09 That's our primary indication for using hormone therapy.

2:12 Treating those symptoms, hot flashes are very common.

2:15 It can happen up to 75-85% of women

2:19 could experience hot flashes or night sweats or both.

2:23 Those are the women who I think will most

2:27 likely be seeking treatment for those types of disruptive symptoms,

2:30 particularly when the night sweats start disrupting sleep.

2:33 Women can come in for other reasons, too, sometimes related to the hot flashes.

2:37 Depression has been related to hot flashes, sleep disturbances,

2:41 as I mentioned, mood changes, brain fog, fatigue.

2:45 There can be a whole constellation of symptoms.

2:47 But, primary indication is to treat Bs and motor symptoms.

2:50 Another indication is to prevent osteoporosis.

2:53 Some women who are at particularly high risk for osteoporosis

2:55 may be seeking guidance regarding using hormone therapy to prevent osteoporosis.

3:00 Julia Cormano: I'm so glad you brought that up.

3:02 I feel like we hear frequently from patients the idea or the question,

3:07 should I be taking hormone therapy just

3:09 for general health as I transition into postmenopause?

3:12 What are your thoughts on that?

3:14 Dr.

3:14 Kathryn McCaulay: We really individualize our recommendations to women.

3:17 As of currently, the current guidelines,

3:21 the national guidelines for prescribing menopausal hormotherapy,

3:25 don't really highlight using hormone therapy for disease prevention.

3:29 For osteoporosis, there can be an exception there, I think,

3:33 because it is one of the FDA-approved

3:35 indications for using certain estrogens to prevent osteoporosis.

3:39 But primarily for symptom treatment is what we're recommending.

3:43 Though there is a lot of talk about, possibly,

3:46 should we be using hormone therapy to prevent heart disease,

3:49 to prevent dementia?

3:50 But I don't think we're really there yet

3:52 with all the clinical trials to support that.

3:55 Julia Cormano: Got it.

3:56 What are some of the risks

3:57 that a patient should consider before starting hormone therapy?

4:00 Dr.

4:01 Kathryn McCaulay: Risks are, for the most part, low,

4:04 and that's why the FDA has recently taken the black box warning

4:07 off of hormone therapy because

4:09 in the younger symptomatic woman who's otherwise healthy,

4:12 who doesn't have any contraindications to using hormone therapy,

4:15 the risks are really quite low.

4:17 There is a concern based on data from the Women's Health Initiative trial

4:20 and other studies that there may be a small increase in breast cancer risk,

4:23 particularly depending on which formulation of hormone therapy you use.

4:27 But overall, that's not a high risk in a woman

4:29 who's not at high risk for breast cancer.

4:32 I would caution a woman who has any contraindications to hormone therapy

4:36 that she should be looking at nonhormonal

4:39 treatment options for her vasomotor symptoms.

4:41 Unfortunately, we have several nonhormonal treatments.

4:44 The contraindications would be somebody

4:45 with a history of an estrogen-sensitive cancer, such as breast cancer.

4:50 A patient with a history of a venous thromboembolism,

4:53 like a DVT or pulmonary embolism or a stroke,

4:57 a woman who has active liver disease,

4:59 and a woman who has undiagnosed vaginal bleeding.

5:01 You'd want to evaluate that first before starting hormone therapy.

5:04 Julia Cormano: That makes sense.

5:05 If a patient has initiated hormone therapy,

5:08 how long should they expect to need that hormone therapy?

5:12 What would your advice be?

5:14 Dr.

5:14 Kathryn McCaulay: It's individualized.

5:16 Even the menopause society has a statement published that we

5:20 don't recommend that women just routinely have a stop age,

5:23 that they have to stop at 65 or they have to stop at 60.

5:26 Because some women may have hot flashes lifelong.

5:29 Ten percent of women continue to have hot

5:31 flashes more than the average duration of 7.5 years.

5:34 I think it's a case-by-case situation.

5:37 We don't necessarily tell women all women need to be on it for life,

5:41 but there are some women who may need to be on it really long term.

5:44 But most women, in my experience in my practice,

5:47 may take it for the 10 years during their 50s during

5:51 the worst part of the menopause transition and then reassess around 60.

5:55 But it's again going to be individualized.

5:57 Julia Cormano: That makes sense.

5:58 What are things for a patient to consider

6:00 if they're thinking about stopping hormone therapy?

6:03 Dr.

6:04 Kathryn McCaulay: I think one thing to consider

6:06 is how they want to stop the hormone therapy.

6:10 For most patients, if there's no immediate indication,

6:13 no contraindication that's come up such as breast cancer,

6:16 those patients obviously would quickly stop

6:18 the hormone therapy or just abruptly stop,

6:20 which there's no physical risk to doing that, but there's psychologically,

6:24 or concern about vasomotor symptoms returning more quickly.

6:27 Women do get concerned about that.

6:29 If there's not any immediate need to stop abruptly,

6:32 I'll usually recommend just a slow wean.

6:34 Fortunately, we have a variety of doses of estrogen,

6:37 so we wean down patients to lower dosages over time

6:40 and see how they do in terms of their hot flashes.

6:43 But I think return of symptoms is something

6:46 that women would want to be looking out for.

6:49 Then also recognizing that for vaginal health,

6:52 if they're using a very low dose of a vaginal estrogen for, say,

6:55 vaginal dryness or painful intercourse,

6:58 that's actually something that can be safely used for life long-term.

7:01 They can continue on that formulation.

7:03 That's localized, even if they're stopping

7:05 their systemic hormone therapy for hot flashes.

7:09 Julia Cormano: That makes sense.

7:10 We're so fortunate to have so many choices to be able to offer patients.

7:14 Thank you for your expertise today and sharing that with us.

7:17 Dr.

7:17 Kathryn McCaulay: Absolutely.