Dr Jen, looking forward to this series very much. My GYN started me on MHT 4 months ago. I’m 53 and was experiencing significant VMS issues. I’m on oral estradiol and medroxyprogesterone. I’m tolerating it well and my symptoms have dramatically improved. However, at my next visit I would like to ask about switching to estradiol patch with micronized progesterone. NAMS guidelines indicate this is the safest route. Looking forward to reading more from you so I can make an informed decision. My endocrinologist also says the transdermal route will make it easier to regulate thyroid medication when I need it because transdermal delivers a more consistent dose (I was recently diagnosed with Hashimoto’s thyroiditis but numbers are still well within normal range at this point, but understand this will change over time).
We always recommend transdermal estradiol and progesterone as the first line therapy. Your endocrinologist is correct that the dosing is more consistent. It's very easy to make the switch. Sometimes people can get some bleeding when they switch, so make sure you report that to your health care provider.
Thank you for the great content. Would love to hear about about MHT for women in surgical menopause- especially for those in late 40s-early 50s that were already in perimenopause. Benefits of MHT at this point, what are the statistics for benefit to heart health etc. for these women.
If you are 45 or older, regardless of how you became menopausal (surgical or age-related) the guidelines for hormone therapy are worse. However, surgical menopause can sometimes cause more severe symptoms. I will be addressing the heart health aspect in upcoming posts.
If you are 45 or older, regardless of how you became menopausal (surgical or age-related) the guidelines for hormone therapy are the same. However, surgical menopause can sometimes cause more severe symptoms. I will be addressing the heart health aspect in upcoming posts.
I’m someone with a history of LCIS (a precursor to breast cancer but not cancer) and Tamoxifen use for 5 years who used vaginal Estradiol cream for about 15 years, but as I got older, I had more frequent GI reactions from the cream: bouts of cramping, diarrhea, and even occasional vomiting. Without the Estradiol cream, I had significant dryness, so I soldiered on trying to use the very minimum. In my early 60s I had stage 3 pelvic organ prolapses and eventually last summer had a hysterectomy and prolapse repairs. Without a uterus now, my doctor was willing to Rx the estrogen patch, starting with .037.5 and when that seemed to give me those same GI symptoms, .025. Now I cut the .025 patches so I’m getting approx .013-.015 in each patch, and my symptoms are negligible. My reasons for wanting to continue: I have osteopenia and my parents had serious osteoporosis, and I want something to help w vaginal health. I’m now 65, so it’s late to have started the patch, but systemically it feels to me like I get fewer side effects than with the estrogen cream. What do you think?
The patch in this dose will not help vaginal symptoms, so you might want to ask your doctor about vaginal estrogen. If you have osteopenia and a family history I would have a consultation with an endocrinologist as there are other excellent medications for osteoporosis that are non hormonal.
I'm a relatively new reader and also extremely excited about this series. I am very interested in hearing about alternatives to systemic progesterone/progestin for those who wish to take estrogen to treat symptoms, because of fears re: associated mood effects (I get very irritable in the luteal phase). I read your suggestion of estrogen patch + levonorgestrel iud, which sounds like something I'd be interested in except that progestins don't seem to help with insomnia. I think a post on insomnia in menopause and how MHT can help would be great (e.g., does estrogen possibly help or is it just progesterone? I find myself drowsy when on the pill). I'm also very interested in posts on MHT and vaginal health, and other things women can do to be proactive about this. Thanks for your amazing work. I have already learned so much from your posts and feel like I will be a better advocate for myself soon.
Also, sorry, I'm old school and HRT was always the acronym used...didn't notice til now that MHT is what you've been using, which I get and appreciate.
Dr. Jen, I hope at some point you can address hormone therapy as related to breast cancer survivors who are on hormone blocking drugs. I am taking anastrozole and the side effects are significant and appear to be worsening as time goes on. I recently sought relief in the form of testosterone pellets from BioTe.....ARF!! I have since stopped after reading your posts on that topic and now I am considering using a more regulated and measurable source. But I am still seeking truthful information about how to navigate this hormone blocked world which is not great: no sexual response, unable to sleep more than 5 or 6 hours a night after quitting all caffeine, and a fraction of my previous endurance and strength. If I exercise vigorously I am trashed for days after.
Can you recommend any reliable resources for dealing with this? I have ordered your Menopause Manifesto.
Given that it appears MHT offers many health benefits, should it be taken if someone has no or few menopause symptoms? Should MHT be stopped periodically to see if symptoms persist?
Really excited about this topic! I signed up just for this one and I'll be starting MHT in a couple weeks. I am really curious about the use of birth control in place of MHT. It is so difficult to find information that doesn't revolve around preventing pregnancy. Obviously BC stops ovulation and MHT does not, but how does BC help with perimeno symptoms such as vaginal atrophy, low sex drive, poor sleep, hot flashes etc? I've also heard that the low-dose BC are worse for sex drive? Also really want to learn about the potential side-effects of MHT. So many sing it's praises, but no one talks about adjusting to these meds and how to know if they are working/helping or if you need an increased dose? Anyway! Thank you so much for all you do! I follow you on Instragram and love your posts.
This series is really informative, thank you. Could you say something about women under 40 with many debilitating perimenopausal symptoms, still having periods and normal blood test - is there any guidance/research at all on how to diagnose and treat? This was me from mid 30s after having a baby. Recently, at 39 I finally got HRT with significant improvement but I feel completely invisible in everything I read about menopause because I’m under 40 but don’t have POI. Thanks so much.
I don't think I can answer your question in this format. This is something that needs a one on one visit in the office with someone who has full access to your history and records.
Thanks, sorry I wasn’t clear. I am getting treatment so not looking for personal advice. I’m curious about if there is any guidance or research for doctors and patients in this category to help inform decision making as I haven’t been able to find any. Would be really grateful if you can point me to any. Thanks so much.
Wow. Thank you, Dr. Gunter, and I am looking forward to this series. So glad to finally realize that progesterone may able to be replaced by a SERM like Duvavee. When I was menstruating, for a long 38 years, I had terrible PMDD. It’s my fear about the possible effects of progesterone that keep me from filling the RX I got for a patch (with both estrogen and progesterone) back in January. So far I have not been able to get any helpful or consistent answers on what the effects of MHT might be for me in terms of--Will I have PMDD again?
If I get migraines from birth control hormones, would MHT trigger them as well? My vague understanding is that it's the synthetic hormones, although my regular cycle almost always includes one or two migraines.
I hope Dr. Jen responds or will do a post on this. I've experienced menstrual migraines for decades and my understanding is that they are triggered by the fluctuations. (I am very migraine prone at the onset of my period and sometimes when estrogen is rising again.) So I'd guess MHT could help if taken transdermally or like clockwork to minimize fluctuations...but I'm no expert. Would love to learn more.
Great intro. Yes, please discuss the various aspects of ET for vaginal sx, esp. for those who've had breast cancer in the past.
Since it's mentioned in the comments, please update us on progesterone for early trimester pregnancy support. I always wondered about its efficacy when I worked w/ MDs who were doing that.
I can't update on progesterone in early pregnancy as that is just not my wheelhouse. I would recommend following Dr. Lucky Sekhon on Instagram and her blog The Lucky Egg for more early pregnancy related concerns!
Dr Jen- I really appreciate your work. I was wondering if you might at some point cover how well transdermals hold up for folks who are very active- AKA really sweaty.
I am currently taking Lessina orally for VMS and insomnia with good results overall, but would be open to changing to transdermal if better. I maybe every couple of weeks will forget my Lessina dose a morning or two. I also have Hashimoto's and and on leveothyroxine. I was reluctant to try transdermal as I sometimes react locally to adhesives and train throughout hot Colorado summers for a yearly fall marathon.
I tried only vaginal dosing first for dryness, painful sex but changing to the systemic helped my hot flashes and insomnia.
The twice weekly adhesive patches tend to work better from a sticking standpoint than the ones changed each week. There are also prescription lotions and gels for transdermal.
What is the definition of MHT vs hormones through birth control. I recently started hormonal BC to help with some peri-like symptoms and increasingly worse PMS, but is this considered MHT?
The birth control pill is not considered MHT, but it can be used to treat symptoms in the menopause transition. It treats PMS by suppressing the hormonal fluctuations and replacing them with consistent levels. This is something that the doses of hormones in MHT can't do.
I am 63 and have been menopaused for 10 years. My current doctor seems just uninterested in anything that has to do with women's health. A year ago, after I was experiencing recurrent pain during intercourse, his nurse diagnosed a vaginal wall erosion and prescribed a combination of Zincofax, Polysporin and Hydrocortisone applied locally. With no real effect. I convinced my doctor -more than a year later - to prescribe me a vaginal cream (estradiol) that he gave me without any examination for 12 months.
Should I get an exam? How long this cream is supposed to be used and should it help for my condition? Should I check for any side effects? Are there any other things that I should do to get rid of this pain or should I accept it as a normal effect of getting older...? 🤔
If you have been using vaginal estrogen cream (a pharmaceutical prep and not a compounded one) in the right dose (according to the package insert) for 2 months and there is no change in pain with sex you need to be evaluated for other causes. I always recommend staying on the vaginal estrogen, but you need an exam. A pelvic floor physical therapist should also do an evaluation as muscle spasm is common. There are some other causes too, so I will put up a full post to answer your question more thoroughly.
I hope Dr. Gunter has time to respond to you. While I am not qualified to help with any of your (very good) questions, I’d like to just say that I have heard nothing but good things about the use of estrogen locally in the vagina for pain during intercourse. One of my sisters uses it and says it’s been wonderful. She also did sessions with a pelvic floor therapist for awhile and felt that was exceptionally helpful. (In fact, she was so enthusiastic about it that at the last family gathering, she could not refrain from singing its praises NOR could she refrain from demonstrating some movement techniques that i and my other sisters found simultaneously amusing and embarrassing.)
Dr Jen, looking forward to this series very much. My GYN started me on MHT 4 months ago. I’m 53 and was experiencing significant VMS issues. I’m on oral estradiol and medroxyprogesterone. I’m tolerating it well and my symptoms have dramatically improved. However, at my next visit I would like to ask about switching to estradiol patch with micronized progesterone. NAMS guidelines indicate this is the safest route. Looking forward to reading more from you so I can make an informed decision. My endocrinologist also says the transdermal route will make it easier to regulate thyroid medication when I need it because transdermal delivers a more consistent dose (I was recently diagnosed with Hashimoto’s thyroiditis but numbers are still well within normal range at this point, but understand this will change over time).
Thank you for all you do!
We always recommend transdermal estradiol and progesterone as the first line therapy. Your endocrinologist is correct that the dosing is more consistent. It's very easy to make the switch. Sometimes people can get some bleeding when they switch, so make sure you report that to your health care provider.
Just in case anyone reading this doesn’t recognize the initialism, VMS stands for “vasomotor symptoms,” aka hot flashes/flushes and night sweats.
Thank you for the great content. Would love to hear about about MHT for women in surgical menopause- especially for those in late 40s-early 50s that were already in perimenopause. Benefits of MHT at this point, what are the statistics for benefit to heart health etc. for these women.
If you are 45 or older, regardless of how you became menopausal (surgical or age-related) the guidelines for hormone therapy are worse. However, surgical menopause can sometimes cause more severe symptoms. I will be addressing the heart health aspect in upcoming posts.
Thank you for your reply. I am confused by the word “worse”. Guidelines aren’t as clear or benefit of MHT at this point isn’t as good?
I mean the same! Sorry. Should read:
If you are 45 or older, regardless of how you became menopausal (surgical or age-related) the guidelines for hormone therapy are the same. However, surgical menopause can sometimes cause more severe symptoms. I will be addressing the heart health aspect in upcoming posts.
Oops sorry, I mean the same!
Thank you!!
Thank you Dr Jen for this. You are really doing an amazing job. Love it 🥰
I’m someone with a history of LCIS (a precursor to breast cancer but not cancer) and Tamoxifen use for 5 years who used vaginal Estradiol cream for about 15 years, but as I got older, I had more frequent GI reactions from the cream: bouts of cramping, diarrhea, and even occasional vomiting. Without the Estradiol cream, I had significant dryness, so I soldiered on trying to use the very minimum. In my early 60s I had stage 3 pelvic organ prolapses and eventually last summer had a hysterectomy and prolapse repairs. Without a uterus now, my doctor was willing to Rx the estrogen patch, starting with .037.5 and when that seemed to give me those same GI symptoms, .025. Now I cut the .025 patches so I’m getting approx .013-.015 in each patch, and my symptoms are negligible. My reasons for wanting to continue: I have osteopenia and my parents had serious osteoporosis, and I want something to help w vaginal health. I’m now 65, so it’s late to have started the patch, but systemically it feels to me like I get fewer side effects than with the estrogen cream. What do you think?
The patch in this dose will not help vaginal symptoms, so you might want to ask your doctor about vaginal estrogen. If you have osteopenia and a family history I would have a consultation with an endocrinologist as there are other excellent medications for osteoporosis that are non hormonal.
I'm a relatively new reader and also extremely excited about this series. I am very interested in hearing about alternatives to systemic progesterone/progestin for those who wish to take estrogen to treat symptoms, because of fears re: associated mood effects (I get very irritable in the luteal phase). I read your suggestion of estrogen patch + levonorgestrel iud, which sounds like something I'd be interested in except that progestins don't seem to help with insomnia. I think a post on insomnia in menopause and how MHT can help would be great (e.g., does estrogen possibly help or is it just progesterone? I find myself drowsy when on the pill). I'm also very interested in posts on MHT and vaginal health, and other things women can do to be proactive about this. Thanks for your amazing work. I have already learned so much from your posts and feel like I will be a better advocate for myself soon.
Also, sorry, I'm old school and HRT was always the acronym used...didn't notice til now that MHT is what you've been using, which I get and appreciate.
Dr. Jen, I hope at some point you can address hormone therapy as related to breast cancer survivors who are on hormone blocking drugs. I am taking anastrozole and the side effects are significant and appear to be worsening as time goes on. I recently sought relief in the form of testosterone pellets from BioTe.....ARF!! I have since stopped after reading your posts on that topic and now I am considering using a more regulated and measurable source. But I am still seeking truthful information about how to navigate this hormone blocked world which is not great: no sexual response, unable to sleep more than 5 or 6 hours a night after quitting all caffeine, and a fraction of my previous endurance and strength. If I exercise vigorously I am trashed for days after.
Can you recommend any reliable resources for dealing with this? I have ordered your Menopause Manifesto.
Given that it appears MHT offers many health benefits, should it be taken if someone has no or few menopause symptoms? Should MHT be stopped periodically to see if symptoms persist?
We don't recommend stopping it periodically, just if you wan to stop.
I will address whether people with no symptoms should take it in the next few posts.
Really excited about this topic! I signed up just for this one and I'll be starting MHT in a couple weeks. I am really curious about the use of birth control in place of MHT. It is so difficult to find information that doesn't revolve around preventing pregnancy. Obviously BC stops ovulation and MHT does not, but how does BC help with perimeno symptoms such as vaginal atrophy, low sex drive, poor sleep, hot flashes etc? I've also heard that the low-dose BC are worse for sex drive? Also really want to learn about the potential side-effects of MHT. So many sing it's praises, but no one talks about adjusting to these meds and how to know if they are working/helping or if you need an increased dose? Anyway! Thank you so much for all you do! I follow you on Instragram and love your posts.
I think I will be able to address a lot of that in some upcoming posts, so stay tuned!
This series is really informative, thank you. Could you say something about women under 40 with many debilitating perimenopausal symptoms, still having periods and normal blood test - is there any guidance/research at all on how to diagnose and treat? This was me from mid 30s after having a baby. Recently, at 39 I finally got HRT with significant improvement but I feel completely invisible in everything I read about menopause because I’m under 40 but don’t have POI. Thanks so much.
I don't think I can answer your question in this format. This is something that needs a one on one visit in the office with someone who has full access to your history and records.
Thanks, sorry I wasn’t clear. I am getting treatment so not looking for personal advice. I’m curious about if there is any guidance or research for doctors and patients in this category to help inform decision making as I haven’t been able to find any. Would be really grateful if you can point me to any. Thanks so much.
Looking forward to this series! I would love to hear what you have to say about HRT in symptomatic perimenopausal women.
Wow. Thank you, Dr. Gunter, and I am looking forward to this series. So glad to finally realize that progesterone may able to be replaced by a SERM like Duvavee. When I was menstruating, for a long 38 years, I had terrible PMDD. It’s my fear about the possible effects of progesterone that keep me from filling the RX I got for a patch (with both estrogen and progesterone) back in January. So far I have not been able to get any helpful or consistent answers on what the effects of MHT might be for me in terms of--Will I have PMDD again?
If I get migraines from birth control hormones, would MHT trigger them as well? My vague understanding is that it's the synthetic hormones, although my regular cycle almost always includes one or two migraines.
I hope Dr. Jen responds or will do a post on this. I've experienced menstrual migraines for decades and my understanding is that they are triggered by the fluctuations. (I am very migraine prone at the onset of my period and sometimes when estrogen is rising again.) So I'd guess MHT could help if taken transdermally or like clockwork to minimize fluctuations...but I'm no expert. Would love to learn more.
Great intro. Yes, please discuss the various aspects of ET for vaginal sx, esp. for those who've had breast cancer in the past.
Since it's mentioned in the comments, please update us on progesterone for early trimester pregnancy support. I always wondered about its efficacy when I worked w/ MDs who were doing that.
I can't update on progesterone in early pregnancy as that is just not my wheelhouse. I would recommend following Dr. Lucky Sekhon on Instagram and her blog The Lucky Egg for more early pregnancy related concerns!
Thanks; I found the info I was looking for.
Dr Jen- I really appreciate your work. I was wondering if you might at some point cover how well transdermals hold up for folks who are very active- AKA really sweaty.
I am currently taking Lessina orally for VMS and insomnia with good results overall, but would be open to changing to transdermal if better. I maybe every couple of weeks will forget my Lessina dose a morning or two. I also have Hashimoto's and and on leveothyroxine. I was reluctant to try transdermal as I sometimes react locally to adhesives and train throughout hot Colorado summers for a yearly fall marathon.
I tried only vaginal dosing first for dryness, painful sex but changing to the systemic helped my hot flashes and insomnia.
The twice weekly adhesive patches tend to work better from a sticking standpoint than the ones changed each week. There are also prescription lotions and gels for transdermal.
What is the definition of MHT vs hormones through birth control. I recently started hormonal BC to help with some peri-like symptoms and increasingly worse PMS, but is this considered MHT?
The birth control pill is not considered MHT, but it can be used to treat symptoms in the menopause transition. It treats PMS by suppressing the hormonal fluctuations and replacing them with consistent levels. This is something that the doses of hormones in MHT can't do.
I am 63 and have been menopaused for 10 years. My current doctor seems just uninterested in anything that has to do with women's health. A year ago, after I was experiencing recurrent pain during intercourse, his nurse diagnosed a vaginal wall erosion and prescribed a combination of Zincofax, Polysporin and Hydrocortisone applied locally. With no real effect. I convinced my doctor -more than a year later - to prescribe me a vaginal cream (estradiol) that he gave me without any examination for 12 months.
Should I get an exam? How long this cream is supposed to be used and should it help for my condition? Should I check for any side effects? Are there any other things that I should do to get rid of this pain or should I accept it as a normal effect of getting older...? 🤔
If you have been using vaginal estrogen cream (a pharmaceutical prep and not a compounded one) in the right dose (according to the package insert) for 2 months and there is no change in pain with sex you need to be evaluated for other causes. I always recommend staying on the vaginal estrogen, but you need an exam. A pelvic floor physical therapist should also do an evaluation as muscle spasm is common. There are some other causes too, so I will put up a full post to answer your question more thoroughly.
I hope Dr. Gunter has time to respond to you. While I am not qualified to help with any of your (very good) questions, I’d like to just say that I have heard nothing but good things about the use of estrogen locally in the vagina for pain during intercourse. One of my sisters uses it and says it’s been wonderful. She also did sessions with a pelvic floor therapist for awhile and felt that was exceptionally helpful. (In fact, she was so enthusiastic about it that at the last family gathering, she could not refrain from singing its praises NOR could she refrain from demonstrating some movement techniques that i and my other sisters found simultaneously amusing and embarrassing.)