Is hormone therapy the cheat code to perimenopause?

Perimenopause can be overwhelming. Mood swings, insomnia and hot flashes can make you feel like a completely different person. Hormone therapy is one way a lot of women are treating the symptoms. Life Kit’s Marielle Segarra talks with Dr. Mara Gordon of NPR’s Real Talk with a Doc column about the risks and benefits. Follow us on Instagram: @nprlifekit https://www.instagram.com/nprlifekit/?hl=en Sign up for our newsletter here. https://www.npr.org/newsletter/life-kit Have an episode idea or feedback you want to share? Email us at [email protected] mailto:[email protected] Support public media with NPR+ and enjoy perks for over 25 podcasts like this one. This show’s perks include sponsor-free listening and convenient playlists of popular help topics like personal finance, getting healthy, and more. Learn more at plus.npr.org http://plus.npr.org/. See pcm.adswizz.com https://pcm.adswizz.com for information about our collection and use of personal data for sponsorship and to manage your podcast sponsorship preferences. NPR Privacy Policy https://www.npr.org/about-npr/179878450/privacy-policy

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• 0:01Speaker 00

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• 0:24Marielle Segarra?

  It seems like there's been a big shift in the past few years in the way that women talk about menopause and perimenopause. Honestly, I feel like even seeing women talk about it at all, that's new.

• 0:36Speaker 02

  It is totally new. And I've noticed it as a woman who just turned 40 and as a doctor. You know, when I learned about menopause in medical school 15 years ago, I learned that hormone therapy was dangerous and should be avoided at all costs. And I learned that the symptoms of menopause were no big deal and that women should just deal with them. And the tide is turning. I think people are really eager for treatment. They're really eager for open conversations about this period of life. And the science is changing, right? The science is showing that actually hormone therapy is much safer than we thought 15

• 1:21Speaker 02

  years ago.

• 1:22Marielle Segarra?

  Hey, it's Marielle Segarra. You're listening to Life Kit. And that was Dr. Mara Gordon. She's a family medicine doctor and the author of NPR's Real Talk with a Doc column. We're talking about hormone therapy, which is a way to treat the symptoms of perimenopause and menopause, like hot flashes, which can interrupt your sleep and make your day-to-day life miserable. You're at work, for instance, and you suddenly start sweating profusely in a situation where no one else is sweating. It's the constant like, take the sweater off, put it back on, because now you're cold after it's over. You're covered in sweat and you're cold.

• 1:55Speaker 02

  Yeah. It can really, really disrupt your quality of life.

• 1:59Marielle Segarra?

  All right, some quick definitions here. Menopause is defined as a year with no menstrual bleeds, although that definition can be confusing for women who already don't have a menstrual bleed, whether that's temporary or permanent. Maybe they've gone through cancer treatment or surgery, or they have PMOS. In those cases, doctors may say, yes, you're probably in menopause, based on your age and your symptoms, and sometimes a blood test. So that's menopause. And then perimenopause is the period leading up to menopause.

• 2:32Speaker 02

  It's the period of hormonal shifts that start to occur as women approach menopause. And it is different for every woman when perimenopause starts. I mean, there are hormonal changes up to 10 years before menopause, but I would say typically people are experiencing the most symptoms that sort of bring them to the doctor and say, hey, you know, I'm experiencing hot flashes, I'm experiencing sleep disturbances, I'm experiencing, you know, change in my mental focus, in my mood. Those, I would say, are typically three to five years before the onset of menopause.

• 3:17Speaker 02

  But again, every woman's different. And I have people coming to me in their early 40s, asking about symptoms and saying, hey, is this perimenopause?

• 3:25Marielle Segarra?

  One suggestion that I've seen a lot, especially on social media, is to do hormone therapy if you're going into perimenopause or menopause. What does hormone therapy involve?

• 3:38Speaker 02

  So when doctors talk about hormone therapy for menopause, we are typically talking about taking a medication that involves an estrogen and a progestin. And estrogen and progesterone are two hormones that are created in the body, and they tend to decline as women approach menopause. And as they decline, women experience a lot of different symptoms. Most notably, hot flashes are sort of the classic menopause symptom that women experience as the estrogen and progesterone decline. So in order to treat those symptoms, doctors offer an estrogen and what's called a progestin.

• 4:20Speaker 02

  And progestin just includes progesterone, which is made in the body, and what are called progestins, which are synthetic progesterones. And most women will take a combination of an estrogen and a progestin in order to treat the symptoms of menopause as their hormones decline and they approach their last period. And menopausal hormone therapy can come in different forms. So sometimes people will take pills by mouth, sometimes people will use a patch, there are creams. IUDs are considered a progestin because they emit a progestin that can help with menopausal symptoms.

• 5:02Speaker 02

  So there's tons of different options when we talk about menopausal hormone therapy, but they're typically involving those two hormones.

• 5:11Marielle Segarra?

  And what is hormone therapy good at treating? Which symptoms of perimenopause or menopause?

• 5:17Speaker 02

  So hormone therapy is really, really, really good at treating hot flashes. So the technical term for hot flashes is called vasomotor symptoms. It's usually hot flashes and night sweats, which affect a large percentage of women as they approach menopause. And hormone therapy is really, really good at taking those away.

• 5:40Marielle Segarra?

  I just want to pause here and say, they're terrible. I went through, I've gone through them, I have them still sometimes because of breast cancer treatment.

• 5:49Speaker 02

  Yeah.

• 5:50Marielle Segarra?

  But have you experienced them?

• 5:51Speaker 02

  I have not, but my patients tell me about them, and they can be really debilitating. And they can really disrupt your quality of life.

• 5:59Marielle Segarra?

  Yeah, it makes it hard to sleep. I don't know if that has come up for your patients. If you're waking up soaked in sweat, you know, every hour, you're never getting that restful sleep that you need.

• 6:14Speaker 02

  Totally. And sleep is so important. We need it to function, to feel like humans. And so to take that seriously as a doctor and to be able to offer my patients something that helps them feels really good. So hormone therapy can also help with what's called the genital urinary syndrome of menopause. This is extremely common in perimenopause and after the menopausal transition. And basically, the vulva becomes sort of dried out, and it can be really uncomfortable for women to have sex. It can cause symptoms that feel like a urinary tract infection. It can cause urinary tract infection. So hormone therapy can really, really help with that.

• 6:59Marielle Segarra?

  Takeaway one, hormone therapy can be an effective treatment for these symptoms, particularly hot flashes and pain in your urinary tract or your vulva. Mara has also reported that it can lower the risk of fractures for women who have a high risk of osteoporosis, and it can help keep bones strong, but that most medical organizations don't recommend it for that purpose alone. But of course, it comes with risks, and the thinking about those risks has changed as we've learned more. We'll talk about that after the break.

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• 8:47Marielle Segarra?

  Another supposed benefit of hormone therapy that folks may have seen is that it can lower your risk of heart disease. Is that true?

• 8:55Speaker 02

  So again, 15 years ago, when we thought that hormone therapy was much riskier than it actually turns out to be, the reason we thought it was so scary was because a lot of the studies that initially examined the outcomes with hormone therapy looked at much older women using it. So women in their 60s, even in their 70s. And we found back then that taking hormone therapy when you're 10 years from menopause actually can increase your risk of cardiovascular disease. And so that's why doctors were so scared of it. And what's now emerging in the science is something that doctors call the timing hypothesis, which means the time of life in which you use

• 9:40Speaker 02

  hormone therapy really, really matters for outcomes. So actually using hormone therapy for women in their 40s and 50s, right around the time when women transition into menopause, and often their symptoms are most pronounced. There's a lot of open questions about whether or not hormone therapy might actually be protective of the heart during this period. But the science isn't there to be able to promise that to women.

• 10:07Marielle Segarra?

  Takeaway two, hormone therapy is recommended as a treatment for the symptoms of perimenopause and menopause. But any other promises you've heard that it'll protect you against heart disease or help you live longer, that's just not proven. And the U.S. Preventative Services Task Force, the American College of Obstetricians and Gynecologists, and the Menopause Society do not recommend hormone therapy for longevity, heart health, or preventing chronic conditions, based on the data they have now. Also, it seems that hormone therapy might carry different risks depending on your age.

• 10:40Marielle Segarra?

  So for this younger age range, in your 40s, 50s, how risky is hormone therapy considered to be now? And what are the risks?

• 10:50Speaker 02

  So hormone therapy does have some risks, and it's really important to be open about it with patients and have that discussion about the risks and benefits so that people can make an informed decision. So typically, a woman who has had breast cancer herself, I would say, let's proceed with caution because there is some data to suggest that hormone therapy can increase the risk of breast cancer recurrence. A woman who has had a blood clot, I would proceed with caution because hormone therapy can increase your risk of blood clots. And a woman with really active cardiovascular disease, somebody who had a heart attack within a year,

• 11:33Speaker 02

  something like that, I would say, let's proceed with caution and hold off. And in those patients, I wouldn't say, hey, you have to live with this, you know, like, just deal with your hot flashes. We actually have lots of non-hormonal treatments for vasomotor symptoms that can really help people. And often I'll even try those in patients who have some concerns about menopausal hormone therapy. They aren't sure if they want to try hormones, but they're still having symptoms, will say, okay, let's try another medication that is not hormones first. And people often find that their symptoms totally go away without even needing to use hormones.

• 12:13Marielle Segarra?

  And yeah, I mean, it depends on the symptom, right? You have to treat the hot flashes specifically, and then the genital urinary symptoms specifically. If you fall into one of these higher risk categories where hormone therapy, at least systemic hormone therapy, wouldn't be a good idea for you, what about the localized kind, like an estrogen cream, if you're having painful sex?

• 12:37Speaker 02

  Local low estrogen cream that's used in the vagina is safe for almost everybody. So even if you have had breast cancer, even if you have serious heart disease, local estrogen that's used to treat the genital urinary symptoms, totally safe because it's not absorbed throughout the whole body. So it doesn't affect the organs that might be at higher risk from systemic hormone therapy. I would also offer certain classes of antidepressants can be helpful to treat hot flashes called SNRIs. And can really, really help reduce hot flashes and night sweats. So I'll often recommend that as my first line

• 13:23Speaker 02

  treatment to women who have one of those conditions that might make hormone therapy a little bit riskier. And there's a medication called Viosa that was FDA approved in 2023. And it can really help reduce hot flashes. And it contains no hormones. So it's safe for women who have one of those conditions that might make hormones higher risk. I don't prescribe it much because it's often quite expensive. But that's another option that hopefully will become more affordable in the coming years.

• 13:56Marielle Segarra?

  Takeaway three, if you have a history of breast cancer, or blood clots, or some other conditions, your doctor will likely not recommend systemic hormone therapy. But that doesn't mean you have to suffer. Local estrogen cream may be an appropriate treatment if you're having pain in your urinary tract or your vulva. And there are other medications you can take for hot flashes, including SNRIs and a drug called Viosa.

• 14:21Marielle Segarra?

  What about other kinds of treatments, like acupuncture or certain supplements? Both of those were recommended to me by my cancer hospital.

• 14:28Speaker 02

  I mean, I think with all of these treatments that don't have a ton of research on them, I think we just don't know what the evidence is going to show. And I don't want to dismiss them out of hand. If acupuncture is helpful for my patient, by all means, do acupuncture. You know, if a supplement is helpful for my patient, and it's affordable to you, by all means. I think what I take issue with is a lot of companies really aggressively market these treatments that don't have a ton of science to back them up and sort of overpromise on what they can offer people. And that's when I say, hey, you know, don't, don't, don't take advantage of the fact

• 15:13Speaker 02

  that there's this swelling of interest around menopause. Don't, don't abuse it. We're, we've earned women's trust back. We, meaning healthcare providers, we're slowly earning back the trust of women and saying, hey, we take your symptoms seriously. We take your concerns seriously. And we want to treat them with evidence-based treatments. And when, you know, companies come in and say, here, buy this stuff that I am marketing and making a lot of money off of, we lose women's trust if it isn't effective.

• 15:48Marielle Segarra?

  What would you say to a woman who's experiencing these symptoms of perimenopause and not making headway in getting treatment? Maybe their doctor is dismissing their concerns, or maybe they just like, haven't found the right treatment for them yet?

• 16:09Speaker 02

  In that scenario, I would recommend that somebody look for doctors who have gotten certified by the Menopause Society. So the Menopause Society is an organization that offers training resources, lots of up-to-date information about menopause. It's really where I go to look up the most evidence-based and up-to-date science about menopause. And doctors can take a test that gets them certified with the Menopause Society and says, hey, this doctor really knows what they're doing when it comes to menopause care. And that's a good place to start. Look for a doctor who has that certification in your area. And there's a lot of telehealth companies that offer

• 16:53Speaker 02

  menopause care, which is really cool now that we have the technology to be able to offer telehealth services. Menopause care is something that really lends itself to telehealth because a lot of it is just talking with my patients and understanding what their symptoms are. There's often not that much that changes with a physical exam in terms of the recommendations I make. So finding a telehealth provider who is Menopause Society certified is another good way to go.

• 17:21Marielle Segarra?

  Mara, thank you so much for this.

• 17:23Speaker 02

  My pleasure.

• 17:24Marielle Segarra?

  All right, y'all, time for a recap. Takeaway one, hormone therapy can be an effective treatment for the symptoms of perimenopause and menopause, particularly hot flashes and pain in your urinary tract or your vulva. But of course, it comes with risks, and the thinking about those risks has changed as we've learned more. Takeaway two, any other promises you've heard about hormone therapy, that it'll protect you against heart disease or help you live longer, that is not proven. Also, it seems that hormone therapy might carry different risks depending on your age. Takeaway three, if you have a history of breast cancer, or blood clots, or some other conditions, your doctor will likely not recommend systemic hormone therapy. But that doesn't mean you have to suffer. Local estrogen cream may be an appropriate

• 18:08Marielle Segarra?

  treatment if you're having pain in your urinary tract or your vulva. And there are other medications you can take for hot flashes, including SNRIs and a drug called Viosa. Lastly, if you're having symptoms of what you think is perimenopause, and you can't seem to get treatment, look for a doctor who's certified by the Menopause Society. And if there isn't one in your area, consider a telehealth visit because you may not need a physical exam to get help. All right, that's our show. Hey, if Life Kit is a part of your weekly ritual, why not make it official on the NPR app? You'll hear about every episode the moment it's ready. Just turn on notifications and we will handle the rest. See you there. Download the NPR app today. This episode of Life Kit was produced by Kayla Latimore.

• 18:53Marielle Segarra?

  Our digital editor is Malika Gharib, and our visuals editor is CJ Riekele. Megan Kane is our senior supervising editor, and Lauren Gonzalez is our executive producer. Our production team also includes Andy Tagel, Margaret Serino, and Sylvie Douglas. Engineering support comes from Peter Alina. Fact checking by Andrea Lopez-Cruzado. I'm Mary El Segarra. Thanks for listening.

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