I see so much misinformation and fear among women and health care providers over menopause and HRT. We need to change the conversation, and base it on facts and evidence. But first we as providers also need to start the conversation with women about menopause ! I see so many women who have needlessly suffered with peri-menopause and menopause because their providers told them to just "deal" with it or gave them outdated misinformation that scared them . I have also found that many women feel reluctant to complain about their symptoms , or feel embarrassed to talk about things like the sexual dysfunction that can occur.
Here is a follow up post in regards to risks and HRT. I follow the North American Menopause Society guidelines for my HRT recommendations as well as my years of clinical practice and personal experience with menopause, when counseling my patients. Decisions about HRT should be based on:
1. Most importantly the UNIQUE health risks and symptoms of each individual
2. The age and time from menopause
3. The goals of therapy
The evidence from extensive research shows us that for menopausal women younger then 60, or within 10 years of the onset of menopause, who do not have contraindications to HRT, that systemic HRT benefits outweigh risks for relief of menopause photoflashes and sleep disturbances and for prevention of bone loss. There are risks however to anything we do, so let's review what the latest research shows. We have come a long way from 2002 when the Women's Health Initiative (WHI) study was released. It caused needless widespread panic and concern among women ( and providers) taking ( and prescribing) HRT. It showed increase risks in heart disease, stroke and breast cancer. BUT THE DEVIL IS THE DETAILS! In the past 15 years since the headline grabbing initial results, additional studies, further analysis of the data and continued longer term follow up has been done. The picture has become much clearer and now we know that in younger menopausal women, near the age of menopause, using low dose and transdermal HRT in particular, that the benefits outweigh the risks in symptomatic women. A very important fact to point out about the WHI was that on average women were 63 years old and were 13 YEARS from the onset of menopause and MOST women did not have any symptoms of menopause. The women were given synthetic equine estrogen in the form of oral Prempro. That is different from more modern offerings of estradiol transdermal patches with an oral progesterone or a progestin combined in the patch. l
Proven benefits of systemic HRT
Known Risks of Systemic HRT
I hope this post helps clear up some of the myths about HRT. To summarize, it is important to remember that each patient's menopause transition is unique and treatment needs to be tailored to each patients unique needs and risks.
In the next installment, I will tackle some unique patient issues and HRT, like women with a strong family history, women with premature ovarian failure, women who are BRCA positive , and women who only have genitourinary symptoms.
For more information , check out The North American Menopause Society.
There is so much confusion, fear and misinformation out there about HRT for symptomatic menopause that I thought I would take some time to outline the approach I use in my practice. I have a special interest in menopause management. As I publicly discuss, I am a breast cancer survivor, diagnosed at the age of 28. Due to treatment, I am in menopause. So I personally relate to my patients who suffer from menopause symptoms, and I am highly sensitive to issue related to breast health, genetics, and risks associated with hormones. The good news for women is that the current evidence based guidelines clearly state that many women who are symptomatic can be effectively and safely treated with hormones. The safety of hormone replacement therapy depends largely on the age of the patient and duration of use . For the majority of women, there risks are very few and the potential benefits are many when HRT is given for a clear indication and therapy is started WITHIN a few years of starting menopause.
The proven benefits are control of menopausal symptoms, maintenance of bone mineral density, and reduced osteoporotic fractures, improved muscle mss and strength. From a recent editorial of the Menopause Journal, ( Vol. 24 No. 9, 2017) :
"The evidence suggests that , for menopausal women aged younger then 60 years or within 10 years of menopause one, without contraindications, systemic HRT benefits outweigh risks for relief of menopause hot flashes and sleep disturbance and for prevention of bone loss"
In my practice, I always start with a comprehensive medical and family history, make sure that all preventative health care is up to date ( i.e. recent pap, pelvic exam, breast exam, mammogram, colonoscopy). I also asses the patients cardiac risk use things like blood pressure, cholesterol levels, and other factors to estimate their 10 year risk of heart attack or stroke. One online model I use is the Reynolds Risk
(www.reynoldsriskscore.org). It is important look at the total picture of health, including that patient's diet, fitness level, stress and emotional health. Finally, it is very important to find the menopause symptoms that most bother the patient. For some it is terrible hot flashes and night sweats. For others, the main symptom is mood changes and increase in anxiety. For other women, particularly women who are a bit beyond 2 years into menopause, it is vaginal dryness and painful intercourse. By identifying what the most troublesome symptoms are, we can target treatment. Some patients may need systemic hormone replacement therapy , most often in form of an estrogen patch. Women taking estrogen patches or pills also need progesterone ( preferably ) or a progestin. For women who only have vaginal dryness, there are many vaginal only treatments that do no require taking systemic hormones . The bottom line is that each patients management must be individualized to their own needs, risks, and goals.
In my next weekly post, I will try to separate fact from fiction and will explain potential risks to HRT and give some tips on how to balance the risks vs. benefits when deciding on HRT.
For more information, check out this excellent video from the North American Menopause Society.
Dr. Corinne Menn
I have been fielding a lot of questions from my patients about Zika virus and have been working with the Maven app for women to answer Zika concerns. I thought it would be helpful to post some excellent websites that cover all you need to know about Zika. I am also available on the Maven App for brief video consults with me about Zika or any other women's health concerns. Use code ZIKAANSWERS for a free appointment ( good until midnight tonight).
ACOG - ZIKA information for women
CDC- ZIKA updates
To get the Maven App for iPhone or iPad :
Just wanted to share this very inspiring blog post. Joanna is a wonderful massage therapist working here in Chappaqua and a breast cancer survivor as well. She dedicates time helping other women tackle the side effects of breast cancer treatment through massage. I stumbled upon this blog post about her and think it is a great read for anyone touched by cancer. I highly recommend Joanna for any massage therapy needs. Check it out here:
I often advise my patients, especially my young woman and teenagers to track their cycles with a period tracker app. Clue and Pink Pad Pro are two I like, but there are many out there. Not only can you track your cycle, but you can note when it is very heavy or painful, if you are getting headaches, PMS, irregular bleeding or any other symptoms that you might want to talk to your doctor about. Then when you see your physician, instead of guessing and trying to remember your symptoms, you can just pull out your phone! Many of these apps will also send you a reminder alert to take your birth control pills, or other medications. It can also be great for perimenopausal women who want to track their cycles as well as some of their menopause symptoms. The have been getting lots of buzz lately , check out this article from the NY Times today:
Too busy to get to the office? Grab your tablet or phone and find me on Maven, the first digital health clinic for women!
I am happy to be working with Maven, the first digital health clinic for women. Too busy to get the office? Live too far away to come in for an appointment? For the cost of a typical office co-pay, you can see me for a brief consultation using the Maven App on your phone. While this does not replace a office visit and physical exam, many simple issues can be dealt with using tele-health. This is a rapidly growing area in medical care, and I am proud to be a founding practitioner with Maven. Some things that can be easily addressed via tele-health appointments:
General medical questions ( because google is NOT a reliable source for burning questions!), advice about birth control options, simple UTI's, and brief follow up appointments that don't require a physical exam. Have some concerns about a medication? Want to ask that question you didn't feel comfortable asking your doctor at your last physical? Confused about birth control or hormone therapy? Have a question about sexual health that was not addressed well by your doctor? Maven is perfect for all these things. Maven also has many other practitioners, from nurse practitioners, midwives, pediatricians, psychologists, nutritionists,physical therapists and doulas. Get the Maven app now at www.mavenclinic.com . Please note, if you don't see availability for me on the app, just send a message via the contact form, and I will open up a time for you!
After Angelina Jolie's latest health news hit the headlines, the Young Survival Coalition interviewed me about my experiences as a young breast cancer survivor. Read the interview here
Glad to see that Angelina Jolie is publicly talking about her choice to have her ovaries removed to prevent ovarian cancer. She brings to light the important issues facing BRCA positive patients- including choices about surgery and its effect including premature menopause. I love that she says "health choices are a part of life, not to be feared". I think it is really important for patients to not be afraid to talk about their options and have all the medical information about their cancer risks. Check out the article here:
Results from a recent study support the idea that if hormone replacement therapy is given near the time that a woman enters menopause, that there is NOT an increase risk of cardiovascular risk. This data should reassure women that low dose, preferably trans-dermal menopausal hormone therapy is safe, effective and can help improve symptoms. Menopausal hormone therapy needs to individualized for each patient after a review of the patient's medical and family history, current health status and menopause symptoms. There is no one "correct" way to treat menopausal symptoms and I encourage women to consider their full range of options, from lifestyle and diet, over the counter supplements , to hormone replacement. There are many great options, and the bottom line is that you should not suffer with menopausal symptoms.
From the KEEP study-
KEEPS hormone therapy trial in newly menopausal women (September 2014)
The Women's Health Initiative (WHI), a set of menopausal hormone therapy (MHT) trials in older postmenopausal women (average age 63 years) reported an excess risk of coronary heart disease (CHD) with MHT. Emerging data, including secondary analyses from the WHI, now suggest that use of MHT in the early menopausal years is not associated with excess CHD risk. The Kronos Early Estrogen Prevention Study (KEEPS) is the first randomized trial of MHT in younger menopausal women (727 women ages 45 to 54 years) . When combined with cyclical monthly oral progesterone, low dose oral conjugated estrogen (0.45 mg daily) or transdermal estradiol (50 mcg daily) for four years relieved menopausal symptoms. While several markers of cardiovascular risk improved in the MHT group, there was no significant effect on surrogate markers of atherosclerosis progression (coronary artery calcium and carotid intima-medial thickness) when compared to placebo. This trial provides additional reassurance that early use of MHT is safe for the treatment of menopausal symptoms, though it does not support a role for MHT in prevention.
It was a great day yesterday at the first ever Young Survivors Conference hosted by Breast Cancer Options and the Young Survival Coalition. I was honored to be a speaker. For those of you interested, please see a copy of my presentation below. I will post the video of the conference and the other speakers's presentations when they become available. Thank you Hope Nemiroff Breast Cancer Options for putting this together! For more information check out www.breastcanceroptions.org and www.youngsurvival.org