Gunter's Guide to the Hormone Menoverse

Table of Contents

I know menopause is hard for many. I know that some people struggle to get good care from their own providers. And I also know there are many meno-charlatans driving revenue and profit for their businesses by upselling hormones, implying or even incorrectly stating that every woman should be on hormones. The truth is, as usual, more complicated. Menopause hormone therapy can help many people, but not everyone. It can help some symptoms of menopause, but not all of them. For most people, hormones are what we consider to be a safe medication, meaning serious complications are in the rare or very rare range. But they are riskier for some people, and there can be other issues with their use, for example, bleeding problems or a negative effect on mood. While you don’t want to waste your time and money on a therapy that isn’t going to help you, one often undiscussed problem with hormones is when people are told they can help a specific situation when they can’t. And when the desired effect doesn’t happen (no surprise), the dose is often increased, then increased yet again, or the therapy is changed to a risky preparation (like pellets), and now the person has gone from a well-studied and tested treatment to one with much higher risks, often unbeknownst to them. The concept of rare and very rare side effects only applies to low-risk individuals taking standard doses and pharmaceutical preparations.

To help with the melee, I started a new series in June to walk you through the hormone menoverse step by step, covering what hormones can do, the risks, how to start, different preparations, and more. There is a great need here because it is a wide-ranging topic with some shades of gray and a lot of misinformation.

Presenting this information here allows me to take deeper dives into topics and also allows me to interact with you along the way. I can often offer clarification in the comments, and your comments give me ideas for additional posts and let me know when I need to explore a particular point in greater detail. Basically, your feedback helps me expand this in real time because I know if one of you has a question, then many of you likely have that same question! 

Here, I have organized the posts that have been written in the order in which they should be read if someone were starting at the beginning, and each one has a hyperlink for ease of access. They are also grouped into subject headings for reference later on or if you have a specific topic you wish to explore. I’ve listed future sections and topics that will get published as the series progresses. 

And remember, this is not individual medical advice and is not a substitute for advice or care from a medical provider.

Exploring the Menoverse

Table of Contents

Section One:  What menopausal hormone therapy can definitely do, can possibly do, and doesn’t do. This is the benefits part of the benefits vs. risks equation that you should consider before starting any medical therapy. 

1. Menopausal hormone therapy

   a. A very basic introduction

   b. Why we call it MHT instead of HRT

   c. Understanding the terms compounded and bioidentical

   d. Bioidentical and plant-based, these terms don’t mean what many people think they do. Essential reading so you can understand the marketing of MHT and make evidence-based decisions.

2. MHT vs. Estrogen Containing Contraceptives

   1. Menopausal hormone therapy vs. Estrogen-Containing Contraception: Understanding the difference.

3. Green light indications for MHT (government-approved indications)

   1. Treatment of hot flashes and/or night sweats

   2. Prevention of osteoporosis

4. Yellow light indications for menopause hormone therapy

   These are the softer calls. There is some data, but not enough to make a formal recommendation. So, for an appropriately informed person, it may be reasonable to try a course of hormones to see if they help.

   1. Joint Pain and Menopause: Understanding the Role of MHT.

      A deeper dive into estrogen for joint pain, as joint pain is a common “yellow light” indication.

   2. A deeper dive into estrogen for depression

   3. Brain fog: Spotlight on MHT.

5. When menopause hormone therapy isn’t indicated.

   This post reviews the symptoms that hormones don’t fix and the situations when we don’t recommend prescribing hormones. And some deeper dives into what people might read or hear about on-line.

   1. MHT and Dementia, untangling the disinformation

   2. More information on MHT and dementia, long term follow up from KEEPS

   3. Why MHT is not recommended for prevention of cardiovascular disease and why MHT is not better than statins

   4. MHT and weight gain/loss and metabolism

6. How long can you stay on hormone therapy?

   1. Estrogen

   2. Estrogen and a progestogen

7. Why are there hormone shortages?

Section 2: Contraindications and Risks: The second part of the benefit-to-risk ratio. 

1. Understanding the Women’s Health Initiative. A deep dive into “that” study that scare many women and providers away from hormone therapy. It is good to read this first so you understand the background.

2. Age and Starting MHT.

   A look at the recommendations to generally only consider MHT for those under age 60/less than 10 years from their final period.

3. Increased risks of blood clots and MHT

   Estrogen increases clots, which can have serious consequences. Oral estrogen is not safe for people at increased risk, but transdermal may be an option for some.

4. Liver disease and MHT

   Understanding how hormones might affect various liver diseases, with a spotlight on nonalcoholic fatty liver disease.

5. Cardiovascular disease and MHT

   Learn how to score your risk of cardiovascular disease and what that means for MHT

6. Breast Cancer Risk, Moving Beyond the WHI

   1. How to score breast cancer risk and why that matters BEFORE starting MHT

7. Endometrial Cancer

8. Gallbladder disease and MHT

   MHT is linked with an increased risk of gallbladder disease, and this risk is greatest with oral therapy.

Section 3:  Hormone Regimens

1. Getting Started on MHT

   1. Six Steps Before Starting MHT A basic introduction to MHT and a good place to start

   2. Getting started on MHT. A bit of a deeper dive into different hormone choices

2. The Estrogen Regimens

   1. Estrogen dose equivalents (how to switch between formulations)

   2. Duavee

      1. General information The Basics

      2. The facts behind the collection and production of Premarin

3. Progestogens

   1. What you Need to know about Progestogens (What they are, what they do)

   2. Progestogens, progesterone, and progestins. Video explanation

   3. Have you been prescribed topical progesterone? Read this first!!

   4. Side Effects from progesterone/progestins. What are the options?

   5. Progesterone for sleep

4. Estrogen-containing contraceptives

   1. Estrogen-containing contraceptives and why they are a great choice for the menopause transition

   2. Estrogen-containing contraceptives and bone health

5. Compounded therapies and pellets

   1. The problem with hormone pellets and why they are not recommended

6. Testosterone

   1. The Basics

   2. Testosterone for low libido

7. Troubleshooting common questions and concerns

   1. How to approach a complex set of symptoms in menopause (the post is 9 Steps to Wrangling a Complex List of Menopause Symptoms)

   2. Monitoring MHT: hormone levels can be misleading and chasing “perfect” numbers can easily lead to bad care

Section 4: Treating Genitourinary Syndrome of Menopause

1. The Basics of GSM and a review of treatment options

2. A deeper diver into Vaginal Estrogen products (inserts, the ring, and creams).

3. A deeper dive into vaginal DHEA and oral ospemifene.

4. What we know about vaginal estrogen for women with breast cancer.

5. What if I am taking vaginal estrogen and still have symptoms?

6. Vaginal estrogen for prevention of urinary tract infections

Section 5: The Menopause Transition

• When to start hormones

• How to manage bleeding issues

• When to stop contraception

• How to switch from the pill to menopause hormone therapy

• “I’m on the pill and still having symptoms of menopause. What now?”

  • Medications that can cause hot flashes

Section 6: Primary Ovarian Insufficiency

Section 7: Not included elsewhere

1. Migraines thyroid disease and MHT

That’s all I have mapped out for now, but I anticipate more sections once I have these basics covered. For example, what are the effects of long-term use of hormone therapy? Also, the questions you are all posting in the chat below will likely prompt me to add more, and of course, new research will as well.