A vegan diet for PCOS, gabapentin for menopause symptoms, and more.

Answering your questions

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I put the call out for questions and received some great ones, so here are some rapid-fire responses. 

When is it too late to start MHT? 3 years + since the last period. Is it better to skip it? Dangerous?

We recommend starting menopause hormone therapy (MHT) within ten years of the final period/before age 60, as starting it later is associated with an increased risk for dementia and heart disease. Before that, as long as someone is a good candidate for MHT, any risks are generally outweighed (or at least offset) by the benefits. 

There are people for whom we don’t recommend MHT, regardless of age. For example, those who are at high risk for heart disease. To determine risk, we use something called an ASCVD score (more on that here), and a score > 10% means we shouldn’t start MHT, and 5-10% means we should only consider transdermal therapy. Another contraindication to MHT is a previous heart attack.

There are other reasons why MHT may not be recommended or when there needs to be a more in-depth discussion about risks. You can read more about those in my Menopause Hormone Therapy Guide.

There is a UK Doctor promoting veganism to help PCOS…thoughts?

I have no idea who that is, and I haven’t Googled. 

There are no quality studies telling us that a vegan diet is superior for polycystic ovarian syndrome (PCOS). 

There is some research looking at diet and PCOS. The DASH diet (Dietary Approaches to Stop Hypertension) emphasizes lower-fat proteins (fish, poultry, and lean cuts of meat), plant-based proteins, vegetables, fruits, whole grains, nuts, and vegetable oils and limits food high in saturated fat (such as fatty meats and full-fat dairy) and sugar-sweetened beverages and desserts. There are several studies that show it can reduce insulin resistance and improve the hormonal profile of people with PCOS. Benefits have also been seen with a vegetarian diet and a vegan diet. The takeaway here is that a heart-healthy diet is optimal for PCOS, and people can achieve that in a variety of ways. 

Can I take hormonal birth control pills without a placebo to avoid PMDD?

Yes.

There are two main theories behind premenstrual disorders (PMS and PMDD or premenstrual dysphoric disorder). One is that the decrease in estrogen in the second phase of the menstrual cycle (luteal phase) contributes to a dysregulation of the serotonin system, and the other is that some people have an increased sensitivity to progesterone and/or its metabolite, allopregnanolone, which then negatively affects their GABAergic system. And, of course, for some people, it could be both.

Combined oral contraceptives, meaning the pill with estrogen, have been studied for premenstrual disorders. They are believed to help by suppressing ovulation and preventing the normal fluctuations in estrogen and progesterone during the menstrual cycle. Studies tell us that they improve symptoms, although they may not be as effective as some of the antidepressants at treating severe mood symptoms. Many oral contraceptives have been studied for premenstrual symptoms, but the only one that is FDA-approved is a 24-day pill (24 days of hormones and 3 days off each cycle) that contains 20 mcg ethinyl estradiol and 3 mg drospirenone. This doesn’t mean this pill is necessarily better; rather, the company did the studies and submitted the data to the FDA for approval. 

Some people definitely feel better when they take the pill continuously, allowing them to skip hormonal fluctuations altogether, and most providers typically offer this alternative when discussing oral contraceptives as therapy for premenstrual disorders.

What are your thoughts on using gabapentin for very mild menopause symptoms? 

Gabapentin is an option for people with hot flashes, and it can also be used for those experiencing difficulties sleeping. The advantage of gabapentin is it is hormone-free, as not everyone can take hormones or feels good while taking them. Often, symptoms improve with quite a low dose of gabapentin. For perspective, for chronic pain, gabapentin is often given at a dose of 600 mg three times a day or even 900 mg three times a day, but with hot flashes, I often start people with 300 mg at night or even 100 mg if they are worried about side effects. If you are taking one dose a day, it is usually given at night. For people with many hot flashes during the day, I typically recommend taking it two or three times a day. 

You can read more about gabapentin here in a previous post

Estrogen detoxing - Is it even a thing, and do you need a supplement?

Not at all! However, if it is being discussed by a medical professional, it is a reliable sign that they aren’t capable of understanding hormones, are a grifter, or both. I say grifter because there is almost always a special test to pay for to help you determine which supplement you “need” to help you “detox.” These tests are about as helpful as reading tea leaves. 

I wrote this longer post about how estrogen is removed from the body and why estrogen detoxing is not a thing, so I recommend checking it out for anyone who wants to know more. 

What are your thoughts on the mail-in pap smear initiative in BC, Canada?

It is mail-in HPV (human papillomavirus) testing, and I think it’s great. HPV testing is replacing Pap smears for cervical cancer screening. If you want to know more, check out this previous post.

Being careful after using estrogel. Can my husband touch where I applied the gel after 15 minutes?

EstroGel is a transdermal estradiol that is applied daily to the skin. To evaluate the risk of someone else absorbing the estrogen from touching the skin, the company did a study evaluating 24 postmenopausal women who applied 1.25 g of EstroGel once daily on their arm for 14 days, and on each day, one hour after application, 24 healthy postmenopausal women not using hormone therapy touched the treated skin for 15 minutes. These women experienced no change in their estrogen levels from the skin-to-skin contact. The package insert recommends that after EstroGel is applied, no one should “make contact with the area of skin where you applied the gel for at least 1 hour after application.” So your husband shouldn’t touch where you applied the gel for one hour.  

Is there anything women entering their 30s can do now to make menopause easier?

This is a great question. The three actions people can take to improve their health overall are getting the recommended amount of exercise, eating a heart-healthy diet, and not smoking. In one study, only 8% of menopausal women did all three. These things touch many domains affected by menopause, such as depression, heart disease, risk of diabetes, dementia, and osteoporosis. If I were to pick one thing I wished I had started in my 30s instead of my late 40s, it would be strength training. Start early if you can, but starting it anytime has amazing benefits. If you want some inspiration about how it is never too late to start, check out Joan Macdonald (who is TrainWithJoan on Instagram). 

References

Shang Y, Zhou H, Hu M, Feng H. Effect of Diet on Insulin Resistance in Polycystic Ovary Syndrome. J Clin Endocrinol Metab. 2020;105(10):3346–3360. doi: 10.1210/clinem/dgaa425

Cowan S, Lim S, Alycia C, Pirotta S, Thomson R, Gibson-Helm M, Blackmore R, Naderpoor N, Bennett C, Ee C, Rao V, Mousa A, Alesi S, Moran L. Lifestyle management in polycystic ovary syndrome - beyond diet and physical activity. BMC Endocr Disord. 2023 Jan 16;23(1):14.

Management of premenstrual disorders. Clinical Practice Guideline No. 7. American College of Obstetricians and Gynecologists. Obstet Gynecol 2023;142:1516–33.

Estrogel Package Insert https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/021166s010lbl.pdf