Seven Bonus Takeaways from the 2024 Menopause Society Meeting

Keeping the facts flying...

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Bonus content!

There was a lot of interest in my previous post on my top eight takeaways from the menopause society meeting, and many of you told me that you liked the rapid-fire shorter answers, so here we are again with seven more takeaways from the 2024 Menopause Society Meeting. Why seven? This information just jumped out from my notes as important. Sometimes you just have to go with the flow.  

In no particular order: 

Hormonal Contraception for Symptoms in the Menopause Transition or Perimenopause. Several experts discussed that many of these symptoms were caused by swings in estradiol levels, as opposed to low levels.  Estradiol levels may be normal in some cycles in the menopause transition, and low in others, but they can even be higher than typical when two follicles develop, instead of one, producing larger amounts of estradiol. How do higher levels cause issues? One, they can produce breast tenderness, but they also contribute to the hormonal chaos of the menopause transition. This mean it’s possible to go from an excessively high level of estradiol one cycle to a very low level the next and then back again, or any permutation and combination of high, typical, and low levels of estradiol. (Side note: this is why hormone tests are not helpful in the menopause transition, because levels can quite literally be all over the place). These ups and downs in estradiol can contribute to irregular bleeding (as can fluctuations in progesterone), but can also cause mood issues, headaches, and breast symptoms to name a few. They may also even contribute to hot flashes. 

The optimal way to manage this hormonal chaos is estrogen-containing oral contraceptives, as they suppress ovulation and so replace the estradiol chaos from disordered ovulation with steady levels of estrogen and progestin. One of the speakers felt a progestin-only pill wasn’t as good an option as they believed it still allowed for follicular development, and hence some erratic production of estradiol, although there is a newer progestin-only pill with drospirenone and it is very effective at ovulation suppression, so I’m not sure that would be the case. 

While it’s not wrong to try MHT instead of estrogen containing contraception if someone has symptoms in the menopause transition, it won’t control irregular bleeding like hormonal contraception, steady the hormonal chaos, or provide contraception is that is needed. A lot of menopause influencers, especially health coaches, functional nutritionists, some naturopaths and integrative physicians shit on the pill, and I’m here to tell you that’s a major red flag. I personally think a lot of this pill-hate is because they can’t sell you a period repair kit if you are on the pill and there are no periods to repair, and it’s probably hard to charge $1,000 cash for a consult and then offer the pill and the therapy, which someone could theoretically get from their doctor who takes health insurance for $5. I know I sound like a broken record, but restricting therapies for women is not closing any gaps in medicine. If you want a deeper dive into estrogen containing contraceptives and the menopause transition, please check out this post, Estrogen Containing Contraceptives: The Multitasker of the Menopause Transition. I review in more detail how they can help, how they stack up against MHT, and provide approximate conversions from ethinyl estradiol to estradiol as well as the reason why the estradiol pill isn’t available in the United States. 

Estetrol for Symptoms of Menopause. This information was presented as two study abstracts, meaning this is not yet peer reviewed data, so there is always an asterisk. Estetrol is one of the four estrogens and is also known as E4. It has some curious properties, including it doesn’t stimulate breast tissue well, has lower potency than estradiol, and has less effect on the liver and proteins made by the liver, which suggests it may have less of a risk of clots. Estetrol is produced by the fetal liver. Don’t worry, it doesn’t come from the fetal liver, it’s made from soybeans and then converted into estetrol in a lab. You may here estetrol being referred to as “Plant-Based Estrogen,” as if this is a unique property or means something special. Referring to an estrogen as plant based is a stretch, because no one is grinding up soybeans in a mortar and pestle, it’s a complicated chemical conversion. In addition every estrogen, with the exception of Premarin, is made from soybeans. If you want to know more about how estrogens are made and why the language matters, check out this post of mine. Okay…back to the abstract. Post menopausal women were assigned to an oral dose of 15 mg of estetrol, 20 mg of estetrol, or placebo and at 12 weeks both doses of estetrol reduced hot flashes by 50% for about 82% of women versus 61% for placebo. Yes, the placebo response rates with medications for hot flashes are very high, which is why randomized double-blinded placebo controlled trials are so important. This also explains why so many people swear by supplements because the placebo rate is incredibly high. It also explains why supplement suppliers never run double blind studies with a placebo. There is a decent chance the placebo arm will do better.  

There was also an improvement in blood markers for bone remodeling at 52 weeks. Estetrol has not yet been submitted to the FDA for treatment of any aspect of menopause, although Nextellis, the birth control pill, has 14.2 mg of estetrol combined with drospirenone (the progestin), so this might be an option for people who want to try an estrogen-containing contraceptive in the menopause transition, but have historically had side effects with the pill. 

Surgical Menopause Before Age 48. Dr. Maki suggested that while we consider premature menopause to be menopause before age 45 and we recommend estrogen therapy until at least the average age of menopause, for women who have their ovaries removed that age should be raised to 48. If you have your ovaries removed before age 48, then estrogen should be given until the average age of menopause (51-52) at which point patients should have a discussion with their health care professional about whether or not it should be continued. This raises the age of when we recommend estrogen for surgical menopause by three-four years. The relevant slide from the talk is below.

Compounded Semaglutide (Ozempic) or other GLP-1 (glucagon-like peptide-1 agonists). The key issue here is the compounded part. Don’t do it. Here’s why. When a compounding pharmacy makes an estradiol cream, they buy the raw estradiol from the same place as the pharmaceutical company. The issue with the compounded estradiol is the way the product is mixed may affect how it is absorbed and thus how effective and safe it is for you. However, there is no legitimate generic supplier for generic GLP-1 medications, so you have no idea what compound is being passed off as a so-called generic. It could be a knock-off, if you will, although how close to the original is unknown, but it could also be some designer compound that has never been tested in humans. It could contain bacteria or a stimulant. You have no idea what’s in it. Read more about this issue from the FDA. 

The Study on Tart Cherry Juice Study is Flawed. I had to include this, because when else am I going to get a chance to write this string of words. It sounds like the title of a Nancy Drew mystery: The Case of the Flawed Cherry Juice Study. Apparently there is a study looking at tart cherry juice for insomnia that gets quoted a lot in the land of alternative medicine, but…wait for it…I know you will be shocked… it’s a flawed study. I suppose if you like tart cherry juice, drink away, but otherwise, maybe think about CBT-I for insomnia or other evidence based options. 

Anxiety is Linked with Hot Flashes. According to data from SWAN (study of Women’s Health Across the Nation), anxiety peaks in late peri and early post menopause, but when the findings were controlled for hot flashes and night sweats, the increase in anxiety largely went away. This means that anxiety seems to be related to hot flashes. Whether this is causation or correlation is unknown. Hot flashes can feel like anxiety or even a panic attack, so it’s possible that when a hot flash starts, it creates a sensation that is misinterpreted by the body as anxiety, which then creates more anxiety. It’s also possible that there is a shared pathway in the brain for hot flashes and anxiety. How to manage this anxiety wasn’t addressed, and it’s also unclear if treating hot flashes will reduce anxiety. However, I think it’s a reasonable thing to see if anxiety resolves with treatment of hot flashes. But keep an open mind if it doesn’t and then another therapy may be needed. Anxiety in menopause is largely understudied, so more work is needed here. 

Depression. The time between the late menopause transition and early menopause is a window of vulnerability for depression (2 years before and 2 years after the final period). There are likely many interrelated factors from a causal perspective such as adverse childhood experiences (ACEs), socioeconomic factors, health conditions, poor sleep, stressful life events, and hot flashes/night sweats to name a few. The biggest risk factor seems to be a previous episode of depression, suggesting some women have a biological vulnerability. When there is no lifetime history of a major depressive disorder, the risk of depression is very low. A holistic or whole person approach was emphasized. Exercise as part of an evidence-based approach and a Mediterranean diet were discussed, although how someone with depression might get started with these approaches wasn’t mentioned. I hadn’t previously heard about the Mediterranean diet for depression, but it seems that more plants and lean proteins seem to be good for just about everything. The speakers discussed estrogen in the menopause transition, to treat hot flashes to see if that improves sleep and also as a treatment for depression, but they also emphasized that some women will need anti depressants. (In bold because some people with large accounts shit on antidepressants in the menopause transition and menopause). The quote that I wrote down was, a “tried and true depressive episode will need an SNRI or an SSRI.” Some women will need both hormone therapy and an antidepressant and one group for whom this combination approach was singled out as especially helped was women who have early menopause from surgery or chemotherapy. I also have a deep dive on depression and menopause here with a lot more information, and am happy to say it is up to date with what I heard at the conference. 

Thanks for your feedback about the shorter posts. I will try to do some more like this! And I’ll go through the rest of my notes and see if I can level up with one more set of updates like this, or not.