Gynecological Potpourri

Migraines with aura and hormone therapy and more

This is the Jeopardy! version of potpourri, not the vagina-steaming kind!

A few weeks ago, I covered three subjects in a shorter format instead of one long post (find that post here), and several people said they liked that approach, so here we are again. While I love my deep dives (I really do like the research, reading, and linking everything together in a hopefully coherent format), not everything needs that level of whiteboard commitment. With that in mind, I have another series of shorter posts. These are topics that have come up recently in the comments or on social media (and often both).

I have migraines. Can I take menopausal hormone therapy (MHT)?

I’m asked this question about once a week, maybe more. In fact, while I was writing this, someone popped into my Instagram DMs to ask!

Here’s what you need to know. Migraines are not a contraindication to taking the recommended doses of MHT. Not even migraines with aura.

I am not sure where the incorrect concern about migraines being a contraindication to MHT started, but I do know that many women have been denied MHT because of a history of migraines. It’s true that migraines with aura are a contraindication to the estrogen-containing birth control pill because together they result in a significantly increased risk of stroke. However, the estrogen in standard doses of MHT is much lower than that in hormonal contraception, and the type of estrogen is also typically different (although there is a new pill with 17-beta estradiol, meaning an estrogen used in menopausal hormone therapy). Regardless, MHT is not hormonal contraception.

This is what the Menopause Society 2022 guidelines state:

Contraindications for oral and transdermal hormone therapy include unexplained vaginal bleeding; liver disease; prior estrogen-sensitive cancer (including breast cancer); prior coronary heart disease (CHD), stroke, MI, or VTE; or personal history or inherited high risk of thromboembolic disease.

No mention of migraines.

The Endocrine Society 2015 Guidelines list oral estrogen and migraines with aura in their “Caution should be exercised” section. This is likely because oral estrogens do carry a higher risk of stroke compared with transdermal (you can read more about that here) and migraines are a risk factor for cardiovascular disease for women.

It’s important to evaluate your personal risk factors for cardiovascular disease before starting hormone therapy (which is coming up next in our “Exploring The Hormone Menoverse” series), but for someone with no other risk factors, migraines–with or without aura–adds no additional risk. I would recommend starting with transdermal hormones because A) That is the recommended starting therapy as it is least thrombogenic (likely to cause blood clots) and B) Hormone levels are more consistent, especially with the patch, as compared with oral therapy, and often it’s the ups and downs that can trigger migraines, not the hormone levels per se.

There have been quite a few migraine questions, so I’ll be working on a more detailed post on managing migraines and hormone therapy in the menopause transition and menopause.

Vaseline for the Vulva? I thought it was Comedogenic.

Nope. 

This myth about petroleum jelly (a.k.a Vaseline) likely comes from two sources. One, people mistakenly equate greasiness with blocking pores or otherwise triggering acne (and hey, as someone who had very greasy skin on my face for years, something I used to refer to as the great oil reserve, I get it!). And two, a study published some years ago showed that Vaseline was comedogenic, meaning it could block the pores and contribute to blackheads. But this study was done on rabbit ears, and a later study on humans has shown this is not the case (and it is human skin we care about).  

While Vaseline is the trade name that most of us are familiar with, generically it is known as petrolatum and also as petroleum jelly in the United States and soft paraffin in the U.K. and Europe. It is occlusive, meaning it physically protects the skin and creates a seal that prevents water loss (98% of water loss in fact), so it’s great for hydration. It is also an emollient, meaning it smooths and softens the skin. It’s seriously a skin wonder drug. And no, you don’t need to be concerned that it is cancer-causing because it is a petroleum product. While unrefined petrolatum contains polynuclear aromatic compounds (PNAs) that are linked with cancer, the product you use on your skin has been refined to remove these products. Also, petrolatum has been used for almost 200 years, so if it were linked with cancer, we’d know by now.

Interesting side note: Robert Chesebrough, the chemist who refined the product in the 1800s and gave us what we know today as Vaseline, not only obviously worked around the unrefined product without the modern lab safety measures of today, but apparently ate a spoonful a day...and he lived to 96. Not that we should make decisions based on a single anecdote (and I definitely wouldn’t eat Vaseline), but the next time someone throws a silly anecdote about Vaseline being harmful you can respond in kind with this nugget. 

Also, petrolatum is a by-product of petroleum production, meaning no one is drilling just for Vaseline; it’s using a waste product for another purpose. While we should all be concerned about the use of fossil fuels, giving up on petrolatum isn’t going to have any impact. 

There were lots of “Yes, please!” when I asked if people were interested in a guide to vulvar moisturizers. So watch this space for more. 

What is the Best Menopausal Hormone Therapy for Women with Thyroid Disease?

Unfortunately, we have very few clinical trials here, which is discouraging given that 3.1% of women ages 12-49 have hypothyroidism, and the incidence only increases with age.  

Based on the data that we do have, transdermal estradiol (in approved doses) seems to have no impact on thyroid function. Oral estrogen may have an impact for 30-40% of women, but these are small studies, so some people taking oral estrogen may require adjustment in their dose of thyroid hormone. This means transdermal estrogen is the preferred choice for those with thyroid disease. If there is a compelling reason to take oral hormone therapy, then checking thyroid function at 6 and 12 weeks is likely indicated, but obviously, this should be discussed with your own provider

There is some suggestion that progesterone could also have an impact, although, considering the doses used for menopausal hormone therapy, the effect is likely not clinically meaningful. Progesterone appears to suppress thyroid-stimulating hormone slightly, and one small study using progesterone as part of MHT led to a slight increase in T4 and a slight decrease in TSH. However, these changes were not considered clinically meaningful and remained within the normal range. This means that most people with thyroid conditions can likely be assured that the standard dose of transdermal estradiol and oral progesterone shouldn’t have an impact. However, as the information we have is based on relatively small studies, anyone starting MHT who isn’t feeling well should likely have their thyroid function checked to make sure they are not an outlier.  

And as always, if you have questions, leave them below. I try to reply to the easier ones directly in the comments (obviously, nothing in the post or in the comments is individual medical advice). For those that are more complex, I tuck them away and try to incorporate them in future posts.

Coming up next in the hormone menoverse, evaluating cardiovascular risk factors before starting MHT. 

References

The 2022 hormone therapy position statement of The North American Menopause Society. Menopause: The Journal of The North American Menopause Society. Vol. 29, No. 7, pp. 767-794.

Cynthia A. Stuenkel et. al. Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism. 2015; 100:3975–4011.

Elgendy IY, Nadeau SE, Bairey Merz CN, Pepine CJ. Migraine Headache: An Under‐Appreciated Risk Factor for Cardiovascular Disease in Women. JAHA 2019;8: doi.org/10.1161/JAHA.119.014546.

Kligman AM. Petrolatum is not comedogenic in rabbits or humans: A critical reappraisal of the rabbit ear assay and the concept of "acne cosmetica.” J Soc Cosmet Chem 1996;47:41-48.

Jayakumar KL, Micheletti RG. Robert Chesebrough and the DermatologicWonder of Petroleum Jelly. JAMA Dermatology 2017;153:1157.

Norman A. Mazer. Interaction of Estrogen Therapy and Thyroid Hormone Replacement in Postmenopausal Women. Thyroid.Apr 2004.27-34.

Steingold KA, Matt DW, DeZiegler D, Sealey JE, Fratkin M, Reznikov S. Comparison of transdermal to oral estradiol administration on hormonal and hepatic parameters in women with premature ovarian failure. J Clin Endocrinol Metab 1991;73:275–280.

Marquesee E, Braverman LE, Lawrence JE, Carroll JS, Seely EW. The effect of droloxifene and estrogen on thyroid function in postmenopausal women. J Clin Endocrinol

Metab 2000;85:4407–4410.

Arafah BM. Increased need for thyroxine in women with hypothyroidism during estrogen therapy. N Engl J Med 2001;344:1743–1749.

Kaminski J, Junior CM, Pavesi H, Drobrzenski B, Amaral GMD. Effects of oral versus transdermal estradiol plus micronized progesterone on thyroid hormones, hepatic proteins, lipids, and quality of life in menopausal women with hypothyroidism: a clinical trial. Menopause. 2021 Jun 28;28(9):1044-1052. doi: 10.1097/GME.0000000000001811. PMID: 34183565.

Aoki Y, Belin RM, Clickner R, Jeffries R, Phillips L, Mahaffey KR. Serum TSH and total T4 in the United States population and their association with participant characteristics: National Health and Nutrition Examination Survey (NHANES 1999-2002). Thyroid. 2007 Dec;17(12):1211-23. doi: 10.1089/thy.2006.0235. PMID: 18177256.