No studies are telling us that everyone should be on vaginal estrogen, but it is also under-studied. I start discussing the vaginal changes of menopause around age 45 so people are aware. The risk of bladder infections starts to increase around age 60, so it's not an immediate thing. If someone still has fairly regular periods, is it really uncommon to see GSM, obviously, it's a case-by-case decision. Some people want to start vaginal hormones before symptoms, and other people want to wait. Until someone produces a clinical trial that tells us we should start everyone at. specific age, I will keep using that approach. If someone is on systemic estrogen and doing well and not having any symptoms, is having pain-free sex, and their vaginal pH is 4.5 (meaning they are getting estrogen in the vagina), then I don't recommend it. However, if someone has symptoms or gets bladder infections, then I do. Many people on a lower dose transdermal, say a 25 mcg patch, may need it. So this is really a case-by-case decision.
Urologist Dr. Rachel Rubin says that all women should be offered vaginal estrogen at age 45 to prevent GSM (vaginal atrophy) (Rubin quoted in the article). Some women find that HRT addresses their GSM issues, but most seem to still need vaginal estrogen. It wouldn't hurt to use vaginal estrogen in your case, but I'm not sure I would be motivated to without any symptoms.
There's a wonderful & informative Facebook group called "Vaginal Atrophy" where you could get additional thoughts.
Are there any studies that show a clear benefit on exercising with weights and other load bearing exercise for helping with bone density? I can’t have oestrogen therapy because of breast cancer 7 years ago. I use weights at the gym three times a week and also climb (indoor climbing) twice a week. Hoping this is enough...?
Weight-bearing exercises are excellent for bone health and reduce the risk of osteoporosis. There are also nonhormonal medications to protect the bones for those at high risk.
I wrote a post featuring The Vajenda and Dr. Gunter's books and podcast, as well what the book "Up to Speed: The Groundbreaking Science of Female Athletes" by Christine Yu has to say about lifting for women at midlife +. Some great info in there about weightlifting and overall training for active women and menopause: https://deepkimchi.substack.com/p/how-one-study-made-midlife-miserable
My beautiful 76 year old mum has just been contacted by her GP to say her DEXA from last week was “in the red”. Shes 3 years into a bisphosphonate holiday. Shes going to be likely started on injections. Shes no history of any conditions and is hugely active and healthy . There is a small part of me that wonders why it would not make physiological sense to give her a tiny touch of transdermal oestrogen too. I get it would be a gamble but seems to be a higher potential up side than downside. Would be most grateful for your opinion.
I am a 48 yo woman post surgical menopause at 46. My baseline DEXA last month showed mild osteopenia - T scores of 0.7-1.3 at hip and femoral head readings to 2.3 for lumbar spine. When you mention treating symptoms, is osteopenia considered one of the symptoms, absent hot flushes and night sweats? I do have fatigue on a 0.0375 patch and a very small frame of 130 lbs.
Is there any benefit or research that would indicate women who undergo surgical menopause have a baseline DEXA at, or near, the time of surgery? I am a volunteer patient advocate for women with pathogenetic BRCA 1/2 mutations, and I’ve had a hard time finding any recommendations. Thank you. You have been an INVALUABLE resource for navigating my menopause journey. Happy New Year!
Hot flashes are only one of the causes of sleep issues in menopause. It is not true that "Sleep issues are (only) related to the effect of hot flashes." I'm a member of the Facebook group Women's Health and HRT which has 14.5K members, and most of the sleep issues women report are not related to night sweats or hot flashes.
My temperature regulation issues went away with transdermal estrogen, but I still woke up in the middle of the night and was awake for 2 hours until I got my E to a decent level (it's now 95 pg/ml, which I was only able to achieve with E injections). My memory and word recall have improved, although that could be related to sleeping thru the night.
I can't see my original comment, so I'm not sure what you're referring to when you say "there's no literature to support your claim." However, as you know, menopause is widely understudied and has never been treated as a priority, despite the fact that women live 1/3 of their lives in peri or meno.
Your original comment is below. Estradiol injections are not recommended by any menopause society. There is no literature that supports monitoring estradiol levels and not recommended by the Menopause Society. In my experience, providers who push blood tests do so because they are unaware of the guidelines or to make money.
I disagree that dose alone is sufficient without checking blood levels. Some women like me do not absorb well transdermally, even on max dose (i tried patch, gel, spray).
Also, just going by symptoms doesn't work because other than hot flashes, most meno symptoms can be caused by other things (eg sleep issues, joint pain, memory issues). Without blood tests, there's no way to know how much someone is absorbing.
There is no literature to support your claim. Estrogen also doesn't help memory issues; this has been studied. Sleep issues are related to the effect of hot flashes. If someone gets no relief with transdermal estrogen at an appropriate dose, then I would switch to oral therapy if safe for that person. If that doesn't work, then I would wonder if their symptoms might have other causes besides menopause. In addition, joint pain isn't well treated by estrogen. It helps some people, but not everyone.
Oh jeez. That QUACK of a "internist" (he's not board certified, though he claims that term) that my sister-law sees does all sorts of testing ($$$), and since he refuses all insurance, she pays out of pocket. *SIGH!* This is the guy that put her on HRT (compounded so it's safe-=-NOT) past age 60 until 71 when she was diagnosed with 3, count 'em 3 separate forms of breast cancer. Yes, ugly family history, but!!! It is to weep.
And thank you for all that you do. I have osteoporosis all over my family (both mom AND dad), so as soon as my rheumatologist says GO, off to "reclast" etc, I go. Both of THEIR moms had it as well.
Thank you for this article. I was just diagnosed with osteoporosis. Is MHT recommended to help for those with osteoporosis? I’m taking calcium and already do weigh bearing exercises. My doctor has prescribed Boniva and recommends MHT. I have a history of high blood pressure and strokes in my family.
MHT is not a recommended therapy for osteoporosis. It may help, but it has not been studied in clinical trials for osteoporosis treatment, just prevention. I don't think anyone would start it solely for osteoporosis if they are already taking an osteoporosis medication, but this could vary based on your T score and risk factors. High blood pressure is not a contraindication if controlled with medication. Age and ASCVD score are what matter the most.
If we know that Premarin 0.3 mg can stop bone loss, is the reason that it is not prescribed for osteopenia because the risks of side negative side effects (uterine cancer, stroke etc) outweigh the potential benefit? I have hot flashes, but they are tolerable. I also have osteopenia, which I found out when I badly fractured my ankle a year ago. I am very concerned about bone loss and wonder if I would be better off if my hot flashes were worse and I was prescribed Premarin. I am taking calcium and doing weight-bearing exercise.
If you had an ankle fracture and have osteopenia, you should really be reevaluated. A fracture of any kind (except a toe) will change your FRAX score. We do prescribe estrogen to prevent bone loss.
Premarin is a risky form of HRT because taking synthetic estrogen orally has risks (e.g. stroke). You would be much better off trying transdermal methods like patch, gel, or spray -- those are bioidentical (plus progesterone pills to protect your uterus). You would need to get blood tested to make sure you're absorbing well in order to address the osteopenia, some women like me don't absorb well transdermally.
HRT is not just for hot flashes! Many women never have hot flashes, but have other troublesome symptoms.
You are incorrect. Premarin is not synthetic; it is the only natural estrogen. Bioidentical is a marketing term. The first line of estrogen is transdermal estradiol, but oral Premarin, along with oral estradiol, absolutely has a place. You do not need blood tests for menopause management of MHT; that is not evidence-based.
Transdermal l estrogen (patch, gel) doesn't increase risk of stroke, and uterine cancer is rare as long as you also take progesterone. I know women that have reversed osteopenia by using estrogen.
Question on a different topic. Fascinating (and horrifying) article recently in The Guardian on GSM and UTIs etc in menopausal women (https://www.theguardian.com/society/2023/dec/17/millions-of-women-are-suffering-who-dont-have-to-why-its-time-to-end-the-misery-of-utis). Wondering what your take is on whether vaginal estrogen should be taken at a certain point, preventively, even if we’re already using systemic estrogen and don’t have any GSM symptoms, or is systemic estrogen enough?
No studies are telling us that everyone should be on vaginal estrogen, but it is also under-studied. I start discussing the vaginal changes of menopause around age 45 so people are aware. The risk of bladder infections starts to increase around age 60, so it's not an immediate thing. If someone still has fairly regular periods, is it really uncommon to see GSM, obviously, it's a case-by-case decision. Some people want to start vaginal hormones before symptoms, and other people want to wait. Until someone produces a clinical trial that tells us we should start everyone at. specific age, I will keep using that approach. If someone is on systemic estrogen and doing well and not having any symptoms, is having pain-free sex, and their vaginal pH is 4.5 (meaning they are getting estrogen in the vagina), then I don't recommend it. However, if someone has symptoms or gets bladder infections, then I do. Many people on a lower dose transdermal, say a 25 mcg patch, may need it. So this is really a case-by-case decision.
Urologist Dr. Rachel Rubin says that all women should be offered vaginal estrogen at age 45 to prevent GSM (vaginal atrophy) (Rubin quoted in the article). Some women find that HRT addresses their GSM issues, but most seem to still need vaginal estrogen. It wouldn't hurt to use vaginal estrogen in your case, but I'm not sure I would be motivated to without any symptoms.
There's a wonderful & informative Facebook group called "Vaginal Atrophy" where you could get additional thoughts.
There is no study supporting starting vaginla estrogen at age 45 for every woman, nor is it in any guideline.
Are there any studies that show a clear benefit on exercising with weights and other load bearing exercise for helping with bone density? I can’t have oestrogen therapy because of breast cancer 7 years ago. I use weights at the gym three times a week and also climb (indoor climbing) twice a week. Hoping this is enough...?
Weight-bearing exercises are excellent for bone health and reduce the risk of osteoporosis. There are also nonhormonal medications to protect the bones for those at high risk.
I wrote a post featuring The Vajenda and Dr. Gunter's books and podcast, as well what the book "Up to Speed: The Groundbreaking Science of Female Athletes" by Christine Yu has to say about lifting for women at midlife +. Some great info in there about weightlifting and overall training for active women and menopause: https://deepkimchi.substack.com/p/how-one-study-made-midlife-miserable
Thank you for the info Michelle, I will check it out 👍
Thank you for the post! Is there an argument for checking estradiol levels for premature menopause (40 years old)?
No. The recommended starting dose is a 100 mcg estradiol patch or equivalent.
My beautiful 76 year old mum has just been contacted by her GP to say her DEXA from last week was “in the red”. Shes 3 years into a bisphosphonate holiday. Shes going to be likely started on injections. Shes no history of any conditions and is hugely active and healthy . There is a small part of me that wonders why it would not make physiological sense to give her a tiny touch of transdermal oestrogen too. I get it would be a gamble but seems to be a higher potential up side than downside. Would be most grateful for your opinion.
I am a 48 yo woman post surgical menopause at 46. My baseline DEXA last month showed mild osteopenia - T scores of 0.7-1.3 at hip and femoral head readings to 2.3 for lumbar spine. When you mention treating symptoms, is osteopenia considered one of the symptoms, absent hot flushes and night sweats? I do have fatigue on a 0.0375 patch and a very small frame of 130 lbs.
Osteopenia isn't a symptom, but prevention of osteoporosis is one of the reasons to prescribe/stay on MHT. I think you will find information that might help here https://vajenda.substack.com/p/menopausal-hormone-therapy-and-osteoporosis
Is there any benefit or research that would indicate women who undergo surgical menopause have a baseline DEXA at, or near, the time of surgery? I am a volunteer patient advocate for women with pathogenetic BRCA 1/2 mutations, and I’ve had a hard time finding any recommendations. Thank you. You have been an INVALUABLE resource for navigating my menopause journey. Happy New Year!
Hot flashes are only one of the causes of sleep issues in menopause. It is not true that "Sleep issues are (only) related to the effect of hot flashes." I'm a member of the Facebook group Women's Health and HRT which has 14.5K members, and most of the sleep issues women report are not related to night sweats or hot flashes.
My temperature regulation issues went away with transdermal estrogen, but I still woke up in the middle of the night and was awake for 2 hours until I got my E to a decent level (it's now 95 pg/ml, which I was only able to achieve with E injections). My memory and word recall have improved, although that could be related to sleeping thru the night.
I can't see my original comment, so I'm not sure what you're referring to when you say "there's no literature to support your claim." However, as you know, menopause is widely understudied and has never been treated as a priority, despite the fact that women live 1/3 of their lives in peri or meno.
Your original comment is below. Estradiol injections are not recommended by any menopause society. There is no literature that supports monitoring estradiol levels and not recommended by the Menopause Society. In my experience, providers who push blood tests do so because they are unaware of the guidelines or to make money.
I disagree that dose alone is sufficient without checking blood levels. Some women like me do not absorb well transdermally, even on max dose (i tried patch, gel, spray).
Also, just going by symptoms doesn't work because other than hot flashes, most meno symptoms can be caused by other things (eg sleep issues, joint pain, memory issues). Without blood tests, there's no way to know how much someone is absorbing.
There is no literature to support your claim. Estrogen also doesn't help memory issues; this has been studied. Sleep issues are related to the effect of hot flashes. If someone gets no relief with transdermal estrogen at an appropriate dose, then I would switch to oral therapy if safe for that person. If that doesn't work, then I would wonder if their symptoms might have other causes besides menopause. In addition, joint pain isn't well treated by estrogen. It helps some people, but not everyone.
Oh jeez. That QUACK of a "internist" (he's not board certified, though he claims that term) that my sister-law sees does all sorts of testing ($$$), and since he refuses all insurance, she pays out of pocket. *SIGH!* This is the guy that put her on HRT (compounded so it's safe-=-NOT) past age 60 until 71 when she was diagnosed with 3, count 'em 3 separate forms of breast cancer. Yes, ugly family history, but!!! It is to weep.
And thank you for all that you do. I have osteoporosis all over my family (both mom AND dad), so as soon as my rheumatologist says GO, off to "reclast" etc, I go. Both of THEIR moms had it as well.
Alas, no. This guy is in the Columbia, SC metro. But Quackdom seems to be an epidemic these days.
Thank you for this article. I was just diagnosed with osteoporosis. Is MHT recommended to help for those with osteoporosis? I’m taking calcium and already do weigh bearing exercises. My doctor has prescribed Boniva and recommends MHT. I have a history of high blood pressure and strokes in my family.
MHT is not a recommended therapy for osteoporosis. It may help, but it has not been studied in clinical trials for osteoporosis treatment, just prevention. I don't think anyone would start it solely for osteoporosis if they are already taking an osteoporosis medication, but this could vary based on your T score and risk factors. High blood pressure is not a contraindication if controlled with medication. Age and ASCVD score are what matter the most.
If we know that Premarin 0.3 mg can stop bone loss, is the reason that it is not prescribed for osteopenia because the risks of side negative side effects (uterine cancer, stroke etc) outweigh the potential benefit? I have hot flashes, but they are tolerable. I also have osteopenia, which I found out when I badly fractured my ankle a year ago. I am very concerned about bone loss and wonder if I would be better off if my hot flashes were worse and I was prescribed Premarin. I am taking calcium and doing weight-bearing exercise.
If you had an ankle fracture and have osteopenia, you should really be reevaluated. A fracture of any kind (except a toe) will change your FRAX score. We do prescribe estrogen to prevent bone loss.
Premarin is a risky form of HRT because taking synthetic estrogen orally has risks (e.g. stroke). You would be much better off trying transdermal methods like patch, gel, or spray -- those are bioidentical (plus progesterone pills to protect your uterus). You would need to get blood tested to make sure you're absorbing well in order to address the osteopenia, some women like me don't absorb well transdermally.
HRT is not just for hot flashes! Many women never have hot flashes, but have other troublesome symptoms.
You are incorrect. Premarin is not synthetic; it is the only natural estrogen. Bioidentical is a marketing term. The first line of estrogen is transdermal estradiol, but oral Premarin, along with oral estradiol, absolutely has a place. You do not need blood tests for menopause management of MHT; that is not evidence-based.
Transdermal l estrogen (patch, gel) doesn't increase risk of stroke, and uterine cancer is rare as long as you also take progesterone. I know women that have reversed osteopenia by using estrogen.