Beyond Hot Flashes and Night Sweats: What is Menopause? | StanfordMed Matters

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hello and welcome to Stanford Med matters I'm  Dr Sharon hung the director of women's health  

for the primary care and population health  department at Stanford today we're diving  

into the intricacies of women's health joining  us is distinguished expert in the field Dr Karen  

Adams she's doubly boarded in obstetras in  Gynecology and lifestyle medicine she's a  

clinical professor at Stanford University  School of Medicine and is the director of  

menopause and midlife program at the Stanford  Healthcare it's a pleasure to have us with you  

today Dr Adams thank you so much for chatting  with me today about per menopause and hormone  

therapy Dr Hung it is absolutely my pleasure to  be here with you and uh you know I think we could  

go on for three or four hours but we'll do our  best to keep it keep it to a manageable amount  

right yes so I wanted to start by asking you what  motivated you to specialize in menopause and heal

aging yeah it's uh gosh it's probably been 15  years or so that I've been focusing in this  

area I started out as a general OBGYN physician  delivering babies doing surgery taking care of  

all ages of women and actually it's kind  of funny I one of my roles was to be the  

residency director I was in charge of training  residents for across the whole spectrum of OBGYN  

care and one of the things we were required  to teach was uh midlife and aging and because  

people get out of training and they're really  good at delivering babies and they're great  

at starting people on birth control and all of  that but they didn't see a lot of women 45 50  

and older and we really we looked around our  curriculum and we found we really didn't have  

that much and so I created a clinic for and we  called it the over 40 Clin back then and then  

it just kind of went from there it became my real  clinical interest and as I became more all of the  

the issues of the women that I was caring for  became more relevant to me myself as I aged my  

patients were aging I was aging it just got more  and more fascinating to me and I uh I have just  

really enjoyed that part of my career and it's  been really fun now because menopause is so much  

having a moment that um it's really great to be  at this stage of my career and at Stanford where  

I can really make a difference so um that's my  story that's that's how I got here that's really  

inspiring that you saw the need for such a clinic  and and started one oh my goodness and we can  

talk about that as we go on you know because the  Women's Health Initiative data came out and I know  

we're going to we're going to talk about that but  there were 15 years in there after in the early  

2000s until 15 years later that people didn't get  trained and what they got told in medical training  

and nurse practitioner training and all of it  was just no we're not going to do hormones and  

we're not going to talk about that and we're just  going to move on and so now we're really not only  

trying to educate um our patients but we're also  trying to educate providers people who didn't get  

training and so that's why things like this are  just you know I I just love doing something like  

this where it can really Elevate the conversation  all across the board yeah and I've already learned  

so much from you since you've joined Stanford  in the last year so we're so lucky to have you  

before we jump in um why don't we start with  some definitions what's the difference between  

premature menopause early menopause per menopause  right right right so the definition of menopause  

is no period for a year and you only know that  in the rear view mirror right you don't know when  

you're having that last period it's only a year  later that you say oh that was it you know so um  

so it's a year with no periods on average it's age  51 in the United States and um the time leading up  

to that is called the menopausal transition or  per menopause uh premature what we used to call  

premature ovarian failure We Now call it premature  menopause or premature ovarian insufficiency  

by definition happens before age 40 and that can  happen naturally for some different reasons um but  

it can also happen due to Medical intervention um  in particular uh Cancer Treatments often can cause  

premature ovarian insufficiency um or surgery if  you have your ovaries out for some reason um can  

put people into what we call surgical menopause  but any menopause that occurs earlier than age 40  

is considered premature and then early menopause  is anything that happens 45 and younger so that  

window of 40 to 45 is early menopause anytime  after 45 is considered normal so that that's  

kind of how we think about those definitions got  it thank you for reviewing that and so let's delve  

into per menopause how long does it typically last  boy right yes and so U to me 45 seems really young  

but that's that's when it really starts to kick  in so with menopause being on average age 51 uh  

the average transition time for per menopause  is somewhere around four years 4 to seven years  

so if you back up from 51 usually in the mid 40s  people are starting to experience that menopausal  

transition or per menopause so it's really  important to have a high index of Suspicion in  

your clinical care to to start thinking about  per menopause as a possible cause of symptoms  

and I think there's this assumption that Perry  menopause has to start with a decreased frequency  

of periods but what are some common symptoms  that women might notice before or during per  

menopause right right so the primary symptom  that 100% of people get in per menopause is that  

skipping period so uh and the reason that happens  is because if you think about your period as your  

fourth Vital sign you know and I know we think  about lot a lot more than three vital signs or  

four but but I think of that is the fourth Vital  sign or Avital sign so there's your temperature  

your pulse your blood pressure and your period  and when you have a period each month what that  

tells the patient and me is that the brain is  sending a signal to the ovary every month and  

it's doing that very consistently and the ovary  is responding very consistently every month and so  

the brain talks to the ovary the ovary responds  by making hormones and it's very predictable  

every 30 days every 28 to 30 days the same thing  happens estrogen goes up comes down you ovulate  

your progesterone goes up comes down you have a  period and that just happens very consistently now  

in per menopause the brain is still sending that  signal to the ovary the way it always has it's  

doing its thing but the ovary is aging and as the  ovary ages it responds less and less consistently  

to those brain signals and so you know the brain's  talking to the ovary the ovar is sitting back  

going nah not going to do it not gonna not going  to respond and then it wakes up and it goes okay  

and and you get this huge surge of hormones and  then a big drop and it's completely unpredictable  

so you have a period and then two or three months  go by No period and then you have a period Then  

another few months and then maybe you have  period again for a few months and then they they  

so people say yeah it was weird I thought maybe  something was happening but then my periods came  

back so I figured it was fine and that's typical  for per menopause it's irregularly irregular it's  

sort of like the atrial fibrillation of hormones  and so because it's unpredictable and irregularly  

irregular and can you imagine the on average that  goes on for four years that's what triggers the  

symptoms and so people's periods are becoming  irregular but in addition to that even before  

periods have stopped completely 80% of people with  ovaries will experience hot flushes so hot flushes  

and night sweats happen to about 80% of people  and all through this vodcast I'm going to say  

women but I understand that not everybody who has  ovaries identify or call themselves women but if  

I say women I I want that to be understood to be  inclusive of anyone who has ovaries so anyone who  

has ovaries is going to start having hot flushes  80% of people have hot flushes and so 100% of  

people start skipping periods 80% of people have  hot flushes and night sweats so um those are sort  

of the big red flags for clinicians and then there  are some other symptoms in per menopause as well  

that we can talk about that sort of extend on into  menopause and so I think women get really confused  

when all this starts to happen and first question  they often ask is should I have some hormone  

testing how do you generally respond yes that's a  really really common question and it makes me sad  

actually that there are so many online portals  and things where people can spit in a thing and  

send it in because if you understand the physi  Theology of what's going on in per menopause and  

you understand that it is irregularly irregular  that things are up and down and all over the place  

then it starts to make sense that if I drew your  hormone levels every week for six weeks sometimes  

they're going to be up and sometimes they're going  to be down and they're going to tell me nothing  

other than what your period has already told  me which is that you are having irregular cycl  

now if I'm concerned that it could be thyroid  or it could be a foch chromosoma or something  

like that then I might get some testing but  if this is consistent with Perry menopause  

and she's had her thyroid levels checked and  that sort of thing hormone levels are not going  

to tell us anything you and me Dr Hung that we  don't already know from the way her periods are  

are behaving so hormone testing um is really not  use in this situation per menopause is a clinical  

diagnosis and I've seen some studies discussing  uh antim malarian hormone amh to predict the  

final menstral period what are your thoughts on  that right so amh is a marker of ovarian reserve  

and I say that with air quotes because what it  is primarily used for is to determine how well a  

woman or a person's ovaries will respond to a  stimulated cycle meaning IVF so it gives you  

some sense of how responsive those ovaries will  be if they try to be stimulated to harvest eggs  

for IVF but it's not used as a clinical marker  for perimenopause or menopause and there's  

no real correlation of it with any clinical  outcomes I do want to Circle back to symptoms  

because we talked about skipping periods we talked  about hot flushes and night sweats what we call  

vasam motor symptoms some people have them in the  day only some people have them only at night some  

people have both but they are pretty unmistakable  and if someone says yeah I'm kind of warm most of  

the time is that a hot flush the answer to that  is no because it is so clear I mean it's visible  

people can see it you know your face turns  red you're sweating through your blouse you're  

sweating through your hair and it can even feel  like a panic attack a little bit it can feel kind  

of uncomfortable it can feel like heart racing and  that sort of thing so 80% of people get that about  

68% of people in the per menopause and menopause  can get mood disturbance so anxiety irritability  

people can feel like they have PMS except it's  not predictable you know with PMS it's every you  

know every cycle right before your period it's  kind of cyclic and then you have your period  

you feel better and then it comes back around the  next month because again when you understand that  

hormones are irregularly irregular you can see why  those mood symptoms can also be kind of random and  

that's really disturbing to people because they  um they think they're losing their mind they're  

like I don't know from one day to the next how  going to feel and I I just feel like I'm PMSing  

all the time and it's because your hormones are  so unpredictable that it's it's really triggering  

those um those mental health symptoms so it is  really important I think for us to recognize that  

one in Four Women will experience an episode of  major depression in the per menopause and early  

menopause and people even without a history  of major depression are two times more likely  

to have it in this period of time than in other  times in their lives but uh there's also this  

thing called per menopausal mood instability which  doesn't meet the criteria for major depression but  

is um is manifested by mood symptoms so we need  to think about is this major depression or is it  

perimenopausal mood instability because um the the  um frequency of this is ranges from 40 to 68 % in  

the per menopause and I really want to highlight  this because this month there has been a series  

of articles that have been published in Lancet um  about menopause and one of the articles is about  

mental health conditions and U does per menopause  and menopause increase the risk for that and are  

those more frequent and they actually came out  and said that that's not true and that the risk  

of mental health issues in per menopause has been  overstated and I have to just say that that is a  

very controversial article and there are many many  menopause experts in the country myself included  

who disagree with their interpretation of those  findings and that there are hundreds of Articles  

linking menopause and um and mood disorders and so  that's controversial it's happening right now and  

I just want to acknowledge that that's out there  there but that's not the final word um so so hot  

flushes mood disturbance sleep disturbance is  another symptom vaginal symptoms about 50% of of  

women experience vaginal dryness and actual pain  with intercourse so um it's a lot and sometimes  

these things are all happening even before periods  have stopped completely so again my message to the  

people listening to this podcast is have a high  index of Suspicion and don't discount this as  

possibly being per menopause um just because she's  still having periods now and then so that's a lot  

I'm gonna stop and take a breath and uh and yeah  we can you can you can think about that and see if  

there's anything you want to follow up on yeah  thank you for raising awareness about that I'm  

curious you mentioned you know it's important  to kind of tease out if it's per menopausal  

mood instability versus something like major  depression um the treatment differ depending on  

what you thought it was between the two yes oh  and I'm so glad you brought that up because in  

this there's a really wonderful article that was  published in the journal menopause back in 2018  

and it was the first ever guidelines for diagnosis  and treatment of per menopausal mood disorders and  

it's excellent and I really recommend it to our  listeners today um and what they found when they  

reviewed the world's data on this is that if it  is per menopausal mood instability and not major  

depression estrogen Works to stabilize the mood  in per menopause and we can talk more about that  

about ways we might treat that but estrogen is  as effective as um traditional anti-depressants  

in treating par menopausal mood instability but  you know the way we diagnose major depression  

is which with the phq9 and you go through and you  you get that sorted out but you know there's a lot  

of overlap in the symptoms with per menopause  you know there can be sleep disturbance and  

there can be feelings of sadness and that sort of  thing um so you want to use the phq9 to make that  

diagnosis of major depression and if somebody has  a history of major depression or if that's what  

you've diagnosed then those people really should  be treated primarily with anti-depressants and  

treat them as you would treat a person in major  depression and consider the use of estrogen if  

you're treating menopausal symptoms in addition  to the mood stuff so for example hot flushes and  

night sweats you might want to add the estrogen  in addition to your anti-depressant um or you may  

want to do choose one or the other because you get  some benefit with the vasomotor symptom treatment  

with anti-depressant with an SSRI or snri and then  only add the estrogen if uh they still need it for  

vasomotor symptoms but my important point for you  and for our listeners is major depression should  

be treated as major depression par menopausal  mood instability should be can be and should be  

treated with estrogen great I'll definitely look  into that article thank you for that advice one  

thing you mentioned was that some people can  might only hot FL at night or they can have  

symptoms that are associated with kind of panic  attacks and so as a primary care provider when I  

evaluate night sweats you know I do a work up with  you know chess x-ray CBC CMP you know all these  

things um do you feel like that's necessary and  also when people kind of describe these panicky  

palpitations I feel the need to do an EKG maybe  a zop patch do you feel like those AR necessary  

as part of the evaluation or is there something  about the history that can be reassuring that it's  

just part of their per menopause right oh I think  that's a great question and really honestly I have  

so much respect for pcps because my goodness you  guys do everything you do everything it's so easy  

for me to be an expert in menopause I you know I  haven't taken care of a man you know in decades  

30 years you know and when I think about when you  come into clinic and what is on your schedule and  

what you're going to deal with that day I all can  say is I bow to you I bow to you because it's a  

lot and you are the quarterback really for your  patience and you're the one who's deciding you  

know does this person need to see the gynecologist  or the cardiologist or the rheumatologist and I  

just I can't even imagine having said all that  I would say I would defer to your judgment as  

a PCP you know in terms of you know what do you  think about these palpitations I would I would  

just say yes you know know um sometimes that's  a manifestation of Perry menopause and menopause  

and Oprah is probably the most famous person  who has gone public saying she had a million  

dooll cardiac workup for palpitations when it  turned out that they were associated with her  

per menopause and menopausal transition and she  had a completely negative workup and then when she  

started on hormones her palpitations went away so  you know that is very very individual and I would  

have to say in my own practice it's not a common  presentation of of per menopause and it's not so  

much true that sense of your heartbeating out of  your chest and you can't catch your breath and  

that sort of thing um but there definitely is some  um association with that in hot fleshes and so um  

I think I would leave it to your clinical judgment  in terms of whether or not you think a further  

card work up is is indicated or if you would  maybe do a short-term trial maybe four to six  

weeks of hormone therapy and see if that resolves  the issue and then only work up um subsequently if  

that doesn't take care of the issue that seems  very reasonable to me in an otherwise low-risk  

person got it thank you and so we talked about  how skipping periods prolong Cycles are really  

normal bleeding Trends in per menopausal patients  what are some bleeding patterns that would compel  

you to order a transvagional ultrasound or even an  endometrial biopsy for further evaluation right I  

think that's a really important clinical question  and I don't think anybody will ever regret getting  

an endometrial biopsy or an ultrasound so  if you're thinking about it it's probably  

a reasonable thing to do uh but knowing what's  normal normal weird bleeding versus abnormal weird  

bleeding is useful and those are not technical  terms that's just my own description of it but  

I when I see someone in per menopause if she is  skipping periods and having periods of time where  

she's going without a period I'm usually pretty  comfortable there um just you know saying this  

is par menopause and not getting further Imaging  or evaluation what is not normal per menopausal  

bleeding transitions are heavy gushy clotty crampy  periods um that are that are just really filling  

up a pad every hour or two I don't I don't usually  attribute that to um to per menopause and in fact  

you know ACOG talks about the Palm Coen pneumonic  which is the way you think about abnormal bleeding  

and there's a large differential diagnosis based  on that it's p m hyphen C OE I N I believe is  

what it is and I refer you to the ACOG um practice  bulletin on that but it goes through the L large  

differential diagnosis and hormonal bleeding is  is in that differential but other things it could  

be it could be fibroids it could be adenomiosis it  could be a poop it could be hyperplasia or cancer  

it could be a bleeding disorder it could be any  number of things and so the types of bleeding that  

you would see with those sorts of things are  prolonged bleeding bleeding 10 12 14 18 days  

that's not pairing menopause um completely random  bleeding uh with spotting in between you you bleed  

for a day you stop for two days you bleed for  three days you stop for a week you bleed again  

that's not per menopause you know per menopause is  prolonged cycle length where the period of time in  

between periods is extended it's not this random  unpredictable bleeding heavy gushy clotty that's  

not normal so in those situations I would get an  ultrasound and I would do an endometrial biopsy  

uh an an endometrial stripe thickness in this  setting is not predictive of anything because  

in per menopause the endometrial stripe can be  22 millimeters and that's not abnormal because  

there's so much cycling happening and so the only  time that 4 mm endometrial strip Ty is predictive  

of anything is in postmenopausal people who are on  continuous combined hormones or not on hormones at  

all that's the only time that's relevant in people  who are on cyclic hormones it's not relevant or  

people who are not fully menopausal it's not  relevant but in those in those postmenopausal  

people either not on hormones or on continuous  combined you can use that 4mm endometrial strip  

as the cut off in terms of whether or not to  biopsy with one other caveat and that is not  

in black women it's not relevant in black women  ever because they have a higher incidence of  

fibroids and non-endometrioid histology if  they do get diagnosed with an um endometrial  

uh cancer and so people who are black who have  abnormal bleeding never should have an ultrasound  

for the termination of an endometrial biopsy they  should always be biopsied if you're thinking their  

bleeding is abnormal um but otherwise you can use  an ultrasound to help you diagnose other types of  

pelvic pathology so you're going to want to get  it for a fibroid diagnosis or polyps or something  

like that um but the biopsy itself shouldn't be  determined uh by that 4 millimeter endometrial  

stripe unless you have that very specific  group of of patients again postmenopausal  

um either not on hormones or on continuous  combined it's a complicated answer but I hope I  

made it clear yeah those are useful reminders that  that 4 millimeter cut off is not useful during the  

per menopausal period if they're not on continuous  birth control and also not useful in black women  

exactly okay and um before we jump into hormone  therapy I wanted to ask you because patients  

often ask are there any benefits to certain food  special diets supplements to reduce their symptoms  

that they're experiencing during per menopause  right uh and and menopause as well you know there  

was a a a great position statement that came out  from what used to be the North American menopause  

Society now it is the menopause Society on  non- hormonal treatment of symptoms and um  

they talked about non- hormonal medications  but they also talked about herbs and suppl  

and various things and what they found is that  there's really not enough evidence to support  

anything um from an urban Botanical standpoint  so evening primrose oil black kohos red clover  

um all those kind of substances that people can  buy off the off the shelf uh really have not been  

shown to be beneficial for symptom management soy  is a little bit different in that there have been  

some good studies that have said that they have  that um soy supplementation has decreased U the  

incidence of hot flushes and the severity of hot  flushes but the difficulty there is there isn't  

consistency in the research in terms of how that  soy is delivered so some studies do half a cup of  

of actual soy beans others do soy protein powder  and different things so there hasn't been enough  

consistent data to come out to really uh allow  us to recommend soy for that uh reason but it's  

interesting and you know eating soy doesn't seem  harmful and so for some people that may make a  

difference in their symptoms but otherwise things  you buy in a bottle that you take as a pill or  

something there's really nothing there that um has  shown to be beneficial um one thing I did want to  

mention we talked a little bit about the symptoms  and diagnosing per menopause um in terms of  

treatment you know people come in and they really  are like miserable you know and so so if you put  

a per menopausal person on traditional hormone  therapy what we used to call HRT um we now call  

it hormone therapy or MHT menopausal hormone  therapy if you give them hormone therapy in  

the per menopause in a continuous way it's  about a quarter of the strength of the lowest  

birth control pill so it's a very small amount  of hormone and they're likely to have a lot of  

breakthrough bleeding it's not enough hormone to  suppress the brain ovary cycling so you're not  

going to get menstrual suppression you're also  not going to get contraception and until you've  

had that last period and you've had a year of  No period you potentially could have a what they  

call change of life pregnancy and so you want to  think about your your perimenopausal patient needs  

does she need contraception does she need cycle  control does she just want to know what's going on  

and she's okay sitting tight you know you want to  make sure you identify what those treatment goals  

are and then treat appropriately that sounds like  individualizing therapy during this transition is  

really important and you mentioned birth control  and I've learned from one of your prior talks that  

one of the preferred agents might be Yas to treat  per menopausal women during this time can you talk  

more about that right right Yas is an interesting  birth control pill all oral contraceptives have  

the same estrogen in them they have ethanal  estradi the thing that makes one pill different  

from another is the progestin and uh Yas the brand  name YZ is ethanal estradiol and dispone which is  

a different type of progestin than in the other  types of pill and it's the only one that is FDA  

approved for treatment of pmdd of premenopausal  men or premenopausal dysphoric disorder which is  

you know PMS RIT large very severe PMS so it has  a nice kind of beneficial effect on mood disorders  

at all times of a woman's reproductive life but it  so we extrapolate that to think that that's going  

to be the most effective for mood disorders in  the per menopause per menopausal mood instability  

so that's usually my go-to and continuous uh  dosing of it is ideal because symptoms tend to  

recur in the pill-free interval so when they're  taking placebos so a continuous dosing of YZ is  

really a nice way to provide both contraception  and menstrual suppression symptom management  

cycle control all of that if the patient doesn't  really want to take a um a combined birth control  

pill another option is a leon nestal containing  IUD which is great for providing again uh cycle  

control and contraception and then along with that  you might offer an estral patch um usually I would  

go to a 0.05 bi-weekly patch so a patch and an  IUD or if you wanted to try hormone therapy you  

could do that but I would recommend cycling with  a continuous patch 005 bi-weekly patch and then  

adding the progestin uh probably prometrium 200  milligrams Days 1 through 14 of each month and  

that would then provide some cycle control uh for  that irregular cycling but again would not provide  

contraception so birth control pills or iuds are  nice ways to manage per menopause so that you get  

contraception as well as symptom management and  uh cycle control I see good to know that there's  

a number of options so you mentioned menopausal  hormone therapy so I wanted to jump in and talk  

about safety of hormone therapy 20 years ago  now the Women's Health Initiative found and  

it was widely publicized that hormone therapy  increased the risk of cardiovascular disease  

and breast cancer and this really decreased the  use of hormone therapy in menopausal women could  

you talk about the findings and flaws from the  study sure sure and you know boy what an earth  

Quake right when that came out in the early 2000s  I was in practice then and that's why part of the  

reason I'm out here teaching about menopause was I  was in the group of people who did get trained you  

know before the Women's Health Initiative came out  uh but yeah boy the the phone rang off the wall  

that day in the clinic and it was on The Today  Show and Good Morning America and the numbers that  

hit the paper the media were pretty impressive  you know they were like a 29 % increased risk  

of of coronary heart disease a 41% increase in  stroke a 26% increase in breast cancer and so  

people freaked out and kind of all went off their  hormones and it was really quite quite the quite  

The Firestorm and that's why 15 years went by and  people didn't get trained and a lot of people went  

off their hormones and the ones who did worried  about it but you know what we know now we have  

the perspective of 20 years you know and that's  been really valuable because we've got more data  

we've refined the data and so now uh we think of  it a little bit more um nuanced in a little more  

of a nuanced way first of all I would say those  numbers those percent increases sound alarming  

and when we talk to patients about it it's helpful  to talk about the absolute risk and when you think  

about the absolute risk it's about eight extra  cases of breast cancer or heart attack or stroke  

per 10,000 women so and when people hear that they  think oh 10,000 women that's like half a football  

stadium you know eight extra cases that's not that  much you know and especially when you think about  

breast cancer the risk is greater with a sedentary  lifestyle or alcohol intake or obesity than it is  

with estrogen and we have so much control over  those things and we don't tend to fear you know  

that nightly glass of wine in the way we worry  about taking estrogen so helping people put that  

in perspective is I think really super important  and when I say alcohol intake I mean more than one  

glass of wine per night for a woman so anything  more than seven drinks per week will increase  

her risk of breast cancer and obesity increases  the risk of breast cancer by ninefold so you know  

talking with our patients about that I think is  really super important in the 20 years since the  

Women's Health Initiative there have been no  increased breast cancer deaths in people who  

have taken the hormones nor there have been there  has not also I've got double negatives going there  

also has not been an increased risk of deaths from  cardiovascular disease in people who have taken  

hormones and there has been a decreased all cause  mortality death from all causes in people who are  

taking hormones so that's I think also important  data now that we have in terms of followup the  

other thing that I think is is important to keep  in mind is now we know that younger women behave  

differently on hormones than older women and when  you think about who was enrolled in the Women's  

Health Initiative they enrolled women between  the ages of 50 and 79 and they had not been on  

hormones so they were starting women in their 70s  on hormones and guess what when they stratified  

the data by age the people who were under 60 under  age 60 when they started hormones or less than 10  

years out from their menopausal transition behaved  very differently on hormones than those older  

women they had fewer heart attacks strokes and  cardiovascular events comp compared to the older  

women so now the way the sort of more modern  menopause management is if somebody does not  

have any absolute contraindications to being on  estrogen and they're under age 60 or less than 10  

years out from menopause not only are they going  to get symptom management but they're going to  

have a healthier heart and they're going to  have bone protection so there's there's not  

only symptom benefits but there's also long-term  health benefits um although the US preventative  

Services Task Force um gives prevention of chronic  conditions a grade of D for hormones so we don't  

give hormones just because you know we think  they're going to have a healthier heart but  

80% of people are hot flushing so you're going  to want to give them hormones anyway and then  

they are going to acrew those benefits so that I  think is really important because if you're under  

60 and less than 10 years out from menopause  or less than 10 years years out from menopause  

um you can feel pretty confident in the absence  of absolute contraindications that that you know  

you're going to get benefits great yeah thank  you for those great counseling points I think  

it's always hard to kind of convince patients of  the benefit risk ratio so keeping in mind that  

the absolute risk increase is only about eight and  10,000 that obesity being sedentary drinking more  

than one glass a day our bigger risk factors for  breast cancer is so important to tell our patients  

absolutely absolutely and I think it's hard as a  clinician to really parse all that out and have  

that conversation with people when you're also  you know you're also wanting to make sure their  

lipor is is managed and you know uh all the other  things so I would just encourage clinicians to say  

boy you know menopause that's a an important  topic and really an important conversation  

let's get you back in relatively quickly and have  that conversation because boy if you've got a 20  

minute follow-up visit and you've got things they  want to talk about this is this is a lot but if  

you can work on your talking points and say eight  extra cases per 10,000 women these are the other  

things that are risking increasing your risk for  breast cancer so keep it in perspective and then  

maybe we'll put you into the ascvd calculator we  help you figure out what your overall risk is for  

cardiovascular conditions and really if somebody's  got a low or moderate cardiovascular risk I don't  

have any problem problem putting them on hormones  and especially if they're under 60 so yeah so you  

know I would just say your your practice pearls  are give this the time it deserves maybe consider  

having them come back for that followup uh  don't hesitate to start your low-risk people  

on hormones and then have them follow up with a  gynecologists that would be fine to do refer to  

the for the complicated people but uh but really  I I think getting familiar with your preferred  

approach for hormone therapy which for most of us  is a transdermal and either an oral progestin or  

an IUD and getting comfortable with that that  is absolutely within the purview of a primary  

care person you mentioned using a risk calculator  to think about cardiovascular risk and I'm just  

curious do you ever use um a risk calculator such  as the bcsc score to decide if the benefits of  

hormone therapy might outweigh the risks of bre  cancer um Oh you mean like the Gale model or the  

the breast cancer surveillance Consortium or or  anything to help you determine if someone has a  

family history of breast cancer you know sometimes  they'll ask me oh I don't have a personal history  

but I have you know my mom had breast cancer at  70 do you still think hormone therapy is right for  

you how do you generally navigate that yes exactly  so absolute contraindications for hormone therapy  

are if the patient themselves has breast cancer  most of us would not give that person hormone  

therapy even if they're triple negative because  even if their breast cancer is triple negative  

if it metastasizes they have about a 20% chance  of having the metastasis become hormone receptor  

positive so most of us don't touch um we we don't  give hormones to people who have breast cancer  

that's just in general other than local if it's in  the vagina it's a tablet or a ring or cream that  

doesn't absorb into the bloodstream and we don't  consider that a contraindication but for systemic  

hormones breast cancer if the patient has breast  cancer not a family history and we'll talk about  

that a person who has had a heart attack or a  stroke somebody who's had a cardiov cardiovascular  

event someone who has had a blood clot a DBT  a Venus thromboembolic event a PE something  

like that those are the broad categories also um  active liver disease would be a contraindication  

for oral gallbladder conditions so those are  sort of the big the big um contraindications  

breast cancer risk is complicated and nuanced  and so that conversation really has to be um uh  

you know you have to tease out what the patient's  concerns are and So a family history even if she's  

braa positive is not an absolute contraindication  but most of us use some type of Gale model or the  

tyroc USIC model to help stratify that breast  cancer risk if they're low risk we usually do  

consider hormone therapy if they're moderate risk  you can if they're high risk in general we tend to  

avoid and high risk would be over 20% lifetime  risk of breast cancer according to uh whatever  

pick your model that you like to use tyroc USIC  does tend to come up back with a higher risk score  

than the gay model because it factors in many  generations of breast cancer history and things  

like that so um that's important I think to talk  to your patients about especially since the braa  

positive patients often have surgical menopause  they've had their ovaries removed and they're  

going to be wildly symptomatic they're going to  be hot flushing in the recovery room and so you  

have to really think about that and talk about  the pros and cons of starting on hormones if you  

choose to start on hormones then I think that that  is a very appropriate thing to do for a few months  

see how it how the patient assesses the quality of  life versus Their Fear of breast cancer and how do  

they feel being on it you know they're the ones  who have to kind of live in that body but many of  

my patients are perfectly comfortable once we've  had the discussion going ahead and being on it at  

least until the average age of menopause or until  until we decide that it's time to stop and we have  

that conversation together to figure that out  great so it sounds like it's really important to  

keep in mind that family history even being bracka  positive is not a major contr indication and using  

one of these models can be very helpful to help us  decide exactly exactly and and it's always a risk  

benefit discussion you know this is I think where  the art of medicine really comes in because you  

know you could have two patients who have exactly  the same situ situation and treat them differently  

based on what the patient priorities are so  that's I think a really important point and and  

yes I'm glad you clarified that and so you know  sometimes women ask if starting hormone therapy  

is going to help with all the other symptoms they  dealing with from per menopause the weight gain  

the insomnia the mood fluctuations what should  we tell them right um I try to under promise  

and overd deliver just in general in my life you  know and so so I feel very comfortable telling  

people your hot flushes and night sweats are  going to improve dramatically they may not go  

away completely but they will improve dramatically  if you're having vaginal symptoms the vagina loves  

estrogen and that will also get better you know  now not if they've got recurrent yeast infections  

or something so you want to sort out what the  vaginal symptoms are and how what do you think  

you're really dealing with genito urinary syndrome  of menopause if you're dealing with dryness pain  

with penetration and sexual activity feeling  like they have a UTI all the time and and um  

their urine is negative um those symptoms respond  beautifully to estrogen you get about a 65 to 70%  

Improvement in the vagina with systemic hormone  therapy so you don't even have to give them local  

necessarily um if you're doing a patch and a  prometrium pill or a patch and an IUD you're  

going to see about 60 to 70% Improvement in the  vagina with that and that may be all they need so  

I usually wait on adding local estrogen until I've  seen them back in six weeks and see if it's made  

any difference so hot flushes and vaginal symptoms  I feel comfortable promising that that's going to  

get better most of the time mood gets better most  of the time sleep improves most of the time joint  

pain improves isn't that interesting 50% of  per menopausal people report myalgia muscular  

skeletal um symptoms joint pain and um and I and  you know the data is starting to acre that that  

gets better with hormone therapy so um so I feel  pretty comfortable saying I hope you're going to  

sleep better I hope your mood gets better I hope  your joint pain gets better so but we'll get back  

together again in four to six weeks and see how  that's going libido I wish right and that's a  

whole another talk I think you had a talk on that  estrogen does not have an independent effect on  

libido other than its ability to treat pain so I  always say it's totally normal not to do want to  

do something that hurts and if you're having  pain we need to treat that but it's not going  

to get your 30y old libido back or you know I I  wish it would um and so you know that I don't I  

don't promise I don't promise it's going to help  brain fog although sometimes it does um and that  

often is because people are sleeping better and  so it's hard to say was that a primary effect you  

know on cognition or is it just she's sleeping  better and her mood's better therefore she's  

concentrating better so you know I usually just  say this is what I expect let's get you back and  

let's see how you're feeling and see what's better  and what isn't great and um let's jump to kind of  

the other Spectrum so you know sometimes we  think that you know we have to really cut off  

the hormone therapy after five to 10 years  or once someone turns 60 can you talk about  

discontinuation when you start to have that risk  communication with the patient right right so this  

is really an important Point as well because this  is not one of those situations where you're going  

to say to the patient you know you're all good  come back in 5 years for your papsmear because  

it's always a risk benefit discussion so when I  have someone on hormones even if it's just local  

estrogen in the vagina I want to see them once a  year for sure and sooner if anything changes you  

know if they're having issues or questions I know  I want them to be able to reach out to me but once  

a year I want to look at their health history as  anything new happened in the past year do that  

benefit discussion again and make sure that we  are figuring out what we um what we together  

think is the right thing for that patient it's  really um unfortunate that we don't have any  

guidelines as far as how long to keep someone on  it and um when to stop you know most people feel  

pretty comfortable with the five to sevene window  for sure because that's really when we started to  

see a little bit of an uptick in the breast  cancer cases but but there's no age at which  

we automatically stop hormones and you know at  age 65 it's on the Beers Criteria for Medicare  

which is unfortunate it's like these are high-risk  conditions that you should or high-risk drugs that  

you should stop after age 65 and hormone therapy  is still on it we can't get them to take it off  

um but there's no clinical guidelines that say we  should stop hormone therapy at age 65 or at any  

particular time it's always that risk benefit  discussion and you know I have some people on  

it in their 70s and I think it's very different  starting someone at age 50 and keeping them on  

it through their 70s versus starting someone at  age 70 there is no benefit to starting someone on  

hormones um more than 10 years out from menopause  or after age 65 most of us would not do that it  

tips toward risk to start someone at that stage  of things because it destabilizes the plaques  

and the coronary arteries and that's why we think  those people had more heart attacks and strokes  

and clots because they were started at a later  age and so starting someone after 65 uh not only  

confers pretty significant cardiovascular risk  um it also increases the risk of dementia some  

some authors Say by about um a third some people  say it double the risk of dementia so uh so not  

starting Den noo after age 65 But continuing we  think is a very different situation and although  

we don't have the data um to support us on that  most of us most of our clinical experience shows  

that that um that to be the case that people do  quite well starting at the age of menopause and  

then just staying on it I think that's important  to remember that there's not necessarily an age  

where we have to start taking the hormone  therapy off and to really also individualize  

that transition right I love how you summarize  my paragraphs it helps me remember I appreciate  

that so much such a great listener I really I'm  so impressed and it's like we should write this  

in a paper right and then I write all the blah  blah blah and you write the take-home messages

and then I wanted to spend our last few minutes  talking about non hormonal treatments earlier you  

nicely outlined all the Contra indications to  hormone therapy and so for those patients what  

are some of the non- hormonal options that  you go to yes and so it's just so wonderful  

that we have something better to offer those  patients than we used to it used to be really  

a tough conversation to have with our breast  cancer patients who are hot flushing and night  

sweating and really uncomfortable and we just say  you know we just estrogens off the table for you  

now we have a new drug that was FDA approved last  May it's the first drug in its class it's called  

fezolinetant it is a a neurokinin b blocker and  so it's non hormonal it works in the brain at  

the uh neurotransmitter level before it ever  gets to um FSH and estrogen and all of that so  

uh so it works in a very novel way it's a once a  day dosing which is super easy which is nice the  

only people who should not take it are people  who have endstage renal disease or people who  

have liver function abnormalities liver liver  disease because in the trials people who were put  

on this drug um a small percentage of them had an  increase in their liver function so when you start  

someone on this medication it's 45 milligrams  a day you want to follow liver functions at 3  

months 6 months and 9 months and if it's going  to go up it typically goes up in that in that  

window of time if you keep people on the drug a a  certain percentage of them will resolve and their  

liver functions will go back to normal so you  don't automatically have to take them off but if  

they're elevated at 9 months you want to continue  following that at 3month levels at intervals and  

then if it's persistently up over the next couple  of times then you want to discontinue the drug so  

um but it's it works almost as well as estrogen to  treat vasomotor symptoms and um and that's been a  

real game Cher because ssris and snris the other  ones we typically offer for hot Flush Management  

really in the trials in people who were having 10  hot flushes per day with ssris or snris it went  

down by on average one or two and so they went  from 10 to eight or nine a day which you know is  

pretty underwhelming right particularly when you  think about the side effect profile of ssris and  

snris and the sexual dysfunction that people get  with it so my other go-to oh the one thing about  

fysal linan is it's um super expensive and as most  new drugs are Medicare um doesn't cover it and  

uh most a lot of insurances don't however um there  is a coupon online and people can go online and  

download the coupon take it to the pharmacy and  that does bring the cost down and the coupon is  

um is renewable so you know it's not like a  oneoff um they actually can continue to use  

it but we are looking forward to the time when  a generic is available so if fezal linan is an  

option for your patient that would be my first  choice my second choice is usually Gaba pent  

and I don't know Dr Hung do you use Gabapentin  in your practice for vasom motor symptoms have  

you found it to be effective or do you have  any experience with it yeah yeah I always  

like using drugs that have a two for one purpose  so particularly if someone is having difficulty  

sleeping with their hot flashes they're many  hot flashing at night I will reach for Gaba  

Penton qhs to start with and I'm curious what  doses you have found to be most effective for  

Gaba pent and for for vasom motor symptoms right  right right exactly oh my goodness when I was a  

new practitioner in this realm I read somewhere  that that I don't know two or 300 tid was good  

for hot flushes and I started someone on that  and they could practically not get up out of  

the chair they were so dizzy and so I learned  oh dear you know I I learned as we all do at  

the beginning you know um in that non- hormonal  position statement that um the menopause Society  

published last year there's a lovely table that  I refer people to for pharmacologic non hormonal  

therapies and how to start people on them and how  to dose it so I I refer you to that um and I I  

follow those guidelines I wish I had had those  guidelines back as a young practitioner so you  

start with a dose at night and depending on how  well you think your patient would tolerate it uh  

you know there's a you have to balance want them  to feel better pretty quickly but you don't want  

them to have a lot of side effects so you start  with a dose at night and you can pick 10000 or  

300 I I usually feel pretty comfortable saying 300  at night in a one-time dose because the main side  

effect is going to be drowsiness and you want them  to sleep so so um that would be fine but if you  

want to be extra cautious you can start at a lower  dose and then if you do the lower dose I give it  

about a week and then if they're tolerating it and  I feel like I need to bump the dose up then I add  

a dose in the morning and have them do that for a  week and then if I still think they need more then  

you can do morning midday and evening but you know  people forget that midday dose and so I I tend to  

try to stick with a morning and an evening dose  and and bump it up if um if I feel like they can  

tolerate a higher dose so 100 200 300 300 bid is  usually a pretty dose for managing uh vasomotor  

symptoms so you know but it's a project right  starting them and increasing them and all of  

that so I'm just really happy that we have physol  nitant now to um to offer there's another drug in  

that in that category that's going to be coming  out it's in phase three trials now and is coming  

to Market and it's called lisin tant I believe I'm  saying that correctly and uh and it is actually  

very promising in terms of sleep as well as  phasa motor symptoms so that stay tuned for  

that one that one's going to be coming to Market  uh probably in the next year or so and and that  

may give us a little bit of a twofer there to be  able to treat the vasom motor symptoms and improve  

sleep yeah and you were right at the beginning I  wish we had four or five hours to delve further in  

but I just wanted to thank you so much for your  advice and wisdom wi that you've shared with us  

during this hour it was a pleasure to talk to you  as always oh it's my pleasure Dr Hong like I say  

I bow to you I think what you do is amazing and I  I guess our take-home message to our audience is  

find find your collaborators find the people who  will help you take good care of these patients  

and work together and I'm always delighted  when somebody sends me an email or shoots  

me a patient chart or texts me and says hey you  know what would you do I just think that's just  

that's what we should do for each other and so  at Stanford we're working on ways to formalize  

that so that people have access to that expertise  in the menopause realm like they do in some other  

EC consults and things so I'm looking forward to  building that as we as we go forward and thank you  

so much for the opportunity to have this time with  you I really enjoyed it thank you byebye [Music]