I can’t thank you enough for your clear, easy to understand information. You really cut through the clutter. I’ve been on Duavee for just over a month and have been a bit nervous about it as I haven’t been able to find much literature on it. I was prescribed it through the menopause clinic in Toronto and did ask questions about it. They were reassuring but I was still uncertain. Your article helped. You are my go to for all things menopause. I read the Menopause Manifesto and it was a lifesaver. I recommend it and your blog to all my friends!
Thank you for your kind words! I am just trying to provide some good info and hold the boat steady so people can catch their breath and find out the safest, best option for them.
The guidelines don't recommend starting therapy over the age of 60/more than ten years from menopause. There are non-hormonal medications for osteoporosis prevention, and based on your bone density, your provider should be able to tell you if you need medications or not. There is more in this article https://vajenda.substack.com/p/age-and-starting-menopausal-hormone
I just saw my gyn today. He is looking into help for me as I still get the night sweats too (five times last night) which he confirmed I could have for life! Dryness a given burning mouth as well. I was on MHT years ago but the WHI came out and we all dropped it asap. The wait time for a meno clinic here is 20 months, my clock does not stop (I am 68). He realizes risks of MHT but the risks without it (as he mentioned) is real too. NAMS states that women can have hot flashes for many years and using just vagifem for the dryness does not help with all of this. I think we have to make the decision and have support rom a health care prodessional. My issue is my thyroid replacement. He had no clue what the interaction could be, once again he will make some calls. At least I got that far. All my test results are negative, I have breast tests CBC's chol, all of them done each year and there is nothing holding me back from making this decision.
Do you have a preference for generic or brand name for the Estradiol patch? For brand name do you like Dotti, Vivelle, Sandoz or another brand? I don't understand why reviews I've read would have such variation when it's all the same drug. Thank you!
I’m 44 and experiencing joint pain, night sweats, breast pain, and brain fog. It’s worse in the week before my period, but a problem all month. My gyn recommended HBC. Is there a reason I should do that instead of going straight to HRT?
I have a boat load of friends who have doctors that lean towards prescribing mood stabilizers or anti-depressants for people who could be experiencing perimenopause symptoms. Do you have a post that talks about questions a patient can ask their doctor to influence a more wide ranging discussion instead of just treating symptoms that may appear as mental health but may be something else entirely?
I love this helpful advice. I started low-dose estrogen patch/medroxyprogesterone pill in 2022 due to never-ending hot flashes/night sweats (I struggled through it for a/b 8 years in perimenopause and when full menopause didn't resolve these issues, I asked for MHT). However, I discontinued them pretty quickly after getting COVID. Given that COVID raises everyone's risk for cardiovascular problems, including clotting (for at least 1 year), I was hesitant to mix these risks, esp with COVID post-infection risk data continuing to be published (and continuing to be alarming). Do you think this should change our risk calculus these days, given how frequent COVID infections are? (most people can expect 2/year these days). I'm currently just using vaginal estrogen (and suffering night sweats and some hot flashes, although fewer, now 10 years after onset of these symptoms), but considering re-starting the MHT. Still, I worry about post-COVID risks mixed w/ the MHT risks! Would love to have a blog post on this issue!
Hi there. Thanks for this article! Very informative! I'm about to turn 52, and have a question about estrogen therapy. I had a hysterectomy (uterus only) at age 49, and started getting menopausal symptoms (hot flashes and night sweats/disrupted sleeping, brain fog) in earnest at age 50. At that time, my nurse practitioner prescribed transdermal estrodiol (0.0375 mg/day), but follow-up blood tests indicated that my estrogen levels were abnormally high (Estrogen total, serum, 769.2; Estrodiol 276). I switched to the oral etrodiol, and a subsequent test showed my levels had lowered (Estrogen total serum: 555.5, Estrodiol: 59). But the nurse practitioner still thought it would be a good idea to stop the estrogen. I've tried using testosterone (topically), but it actually made my symptoms worse. I'm wondering if you'd advise trying an even lower does of transdermal or oral estrogen, or if I should stay away from estrogen. My hot flashes and night sweats seem to be getting better with time, but would love something to cut through the brain fog. I'd appreciate any advice you have on the matter, or questions I should ask my doctor. Thanks!
There was no reason to check your estradiol levels. You may still be ovulating, and she likely caught that with the estradiol of 276. There is no reason to do a total serum estrogen, so the fact you have that test result tells me the person you are seeing might not be up to date. Also, estrogen doesn't help brain fog. We treat based on symptoms. So when a 52-year-old with hot flashes comes to me and is a candidate for estrogen, we start it without blood tests.
Thank you for the info, always appreciated. I wanted to ask a clarifying question. I hear a lot about how estrogen actually helps to prevent CVD risk and that a drop in estrogen during menopause can contribute to rising cholesterol levels. Is this supported by the research? And with MHT the risk is specifically about blood clots, while there may be other cardiac benefits of MHT?
I had messaged you before about spotting after starting HRT (0.05 patch and 100mg micro prog). I started HRT 2 months ago, light spotting after 2 weeks; I did inform my gyn and was told to monitor. 3 weeks later spotted again. Now 2 solid months in I started bleeding a few days ago but it’s a period, not spotting. I called my gyn again and was told to monitor and see her in f/u next month. The bleeding is slowing down but do I need to push to be seen asap? Do I need to stop the prog? I’m confused and frustrated and quite frankly fucking depressed. Would love your guidance.
Many factors go into managing bleeding on menopausal hormone therapy, including (but not limited to) age, family history, risk factors for endometrial cancer, and if the hormones are started before or after your final period. Only your provider who knows your personal history can tell you if this bleeding is a concern or not and the next steps.
I just turned 60 and had my last period 12 months ago, but I've been on Prometrium for the past year. I'd like to start transdermal estradiol (hot flashes getting ridiculously unbearable), so is it 60 years and/or 10 years since LMP? Are there any data for us late bloomers? Also one GYN says to stop vaginal estrogen and another one says to keep it. Who to believe? Thank you.
For someone having periods past 55, it is essential to try to make sure those are really periods and not bleeding after menopause which is being mistaken for periods. So that is up to you and your doctor to decide. If someone's last period was truly at age 59, and they had an ASCVD score < 5% and were at a low risk for breast cancer and no other health issues, then I would probably be ok offering transdermal estrogen for hot flashes. Obviously, only you and your doctor can decide what is right for you.
Offering support from another "late bloomer." I had my last period just before turning 60, so menopause at almost 61. Until they stopped, my periods had been regular, every month. Nonetheless, at age 58 my doctor had me undergo a transvaginal ultrasound to make sure all was okay, which it was. I started vaginal estrogen at age 61 and transdermal estradiol and progesterone a few years later, at age 64.
I just turned 53 and went through meno with uterus at 49. I am incredibly progesterone intolerant. I am still having night sweats, joint pain but I am extremely active and just flat mood and flat energy since meno. I’m not finding much on Duavee as far as reviews go. Would the estrogen in Duavee “possibly” help with joint/mood also? I know none of it is a guarantee but I am not finding any reviews by anyone that has taken it. I have a RX for it but I am scared to fill it.
Duavee is Premarin and that was the gold standard for MHT for years. It's excellent for symptom relief. Estrogen helps depression before menopause, but after it doesn't seem to have an effect (unless mood is related to sleeping poorly from night sweats, then it can). You can read more about estrogen and joint pain and menopause here https://vajenda.substack.com/p/muscle-and-joint-pain-in-menopause Generally, for someone who is a good candidate for estrogen (low ASCVD and low-risk breast cancer and not risk clots) trying estrogen for 6 months to see if it helps with joint pain is reasonable, but the decision is obviously up to you and your provider. I wouldn't go by reviews, because those are anecdotes and there are lots of both placebo and nocebo reports from medications online. If you read the piece I linked it will tell you what the data says and that is more accurate. Hope that helps!
I have been considering a trial of transdermal plus a progesterone for hot flushes, osteoporosis risk and possible help with joint pain. I haven’t found anything regarding risks of hormone therapy with a history of endometriosis. Have you seen research on this?
I'm in the process of getting the info for the 6 steps. And I'm very much looking forward to the future Menopause Transition section! Specifically wondering how to know if you've started the transition?
I'm 40, not on hormonal birth control, and my cycles vary by a few days each month (which is regular for me). But my periods vary wildly in duration and intensity. I'll have a month or two where my period is just 2 days of light bleeding. Then the next month is so heavy it's cramps and nausea and 7 days long. Rinse and repeat.
Does this indicate I'm starting in the transition? (I also have night sweats, dryness, among others.) Would MHT help? Or is it too early to start?
Thank you so much for all you do! So grateful for your time!
They were not dense before MHT, they gotten bigger as well as more dense in the last year so I hope they change back once I wean off my estrogen patch.
I have been cutting my 25mg patch in half to help ween.
Dr. Jen, I'm still confused about the dense breast tissue issue, which I've read that 50% of women have(!). So, mammograms don't detect breast cancer very well when we have dense breast tissue, but we're supposed to have a mammogram (I do the 3D ones) before starting MHT to rule out any breast cancer risk? Should we be paying out of pocket for ultrasounds?
I'm 51 and already on MHT for a couple years now, mainly for hot flashes (very late peri/early post-meno at this point), but also for osteoporosis prevention since my mom and her mom had it. I started at a .025 patch (plus progesterone because I have a uterus), tried increasing to .05 for a while to see if it would help with depression in the transition, but breasts were enlarged and sore all the time, so now I'm trying .0375 but might go back down to .025 because I'm always worried about breast cancer risk. I assume the lower dose estrogen patch = less risk.
But I just don't know how to weigh breast cancer risk on MHT with dense breast tissue if mammograms aren't reliable. My Gail score is around 2%. Couldn't do the other one because the link is broken. Thank you for any additional insights.
Mammograms save lives. And while they are not as good a screening tool for dense breasts as they are for those without dense breasts, they are still good, and their value shouldn't be dismissed. Estradiol levels in the blood seem related to breast cancer risk, but that is for people not on hormone therapy. There are recommendations for who should have additional screening with dense breasts, and I will be writing a post about that soon. Let me check on that link!
Thank you -- looking forward to your post about that! I will definitely continue to get my annual 3D mammogram, at a minimum. I've been reading that some states may start requiring insurance to pay for additional screenings for those of us with dense breast tissue.
I can’t thank you enough for your clear, easy to understand information. You really cut through the clutter. I’ve been on Duavee for just over a month and have been a bit nervous about it as I haven’t been able to find much literature on it. I was prescribed it through the menopause clinic in Toronto and did ask questions about it. They were reassuring but I was still uncertain. Your article helped. You are my go to for all things menopause. I read the Menopause Manifesto and it was a lifesaver. I recommend it and your blog to all my friends!
Thank you for your kind words! I am just trying to provide some good info and hold the boat steady so people can catch their breath and find out the safest, best option for them.
Once again - clear, concise info. - thanks so much.
Is MHT completely out of the question for over 70 - still have hot flashes and at risk for osteoporosis, but no other. issues?
I did have a 5 year stint or MHT at the beginning of menopause, but my doctor cited the studies regarding continued use and stopped it.
The guidelines don't recommend starting therapy over the age of 60/more than ten years from menopause. There are non-hormonal medications for osteoporosis prevention, and based on your bone density, your provider should be able to tell you if you need medications or not. There is more in this article https://vajenda.substack.com/p/age-and-starting-menopausal-hormone
I just saw my gyn today. He is looking into help for me as I still get the night sweats too (five times last night) which he confirmed I could have for life! Dryness a given burning mouth as well. I was on MHT years ago but the WHI came out and we all dropped it asap. The wait time for a meno clinic here is 20 months, my clock does not stop (I am 68). He realizes risks of MHT but the risks without it (as he mentioned) is real too. NAMS states that women can have hot flashes for many years and using just vagifem for the dryness does not help with all of this. I think we have to make the decision and have support rom a health care prodessional. My issue is my thyroid replacement. He had no clue what the interaction could be, once again he will make some calls. At least I got that far. All my test results are negative, I have breast tests CBC's chol, all of them done each year and there is nothing holding me back from making this decision.
Do you have a preference for generic or brand name for the Estradiol patch? For brand name do you like Dotti, Vivelle, Sandoz or another brand? I don't understand why reviews I've read would have such variation when it's all the same drug. Thank you!
I’m 44 and experiencing joint pain, night sweats, breast pain, and brain fog. It’s worse in the week before my period, but a problem all month. My gyn recommended HBC. Is there a reason I should do that instead of going straight to HRT?
I have a boat load of friends who have doctors that lean towards prescribing mood stabilizers or anti-depressants for people who could be experiencing perimenopause symptoms. Do you have a post that talks about questions a patient can ask their doctor to influence a more wide ranging discussion instead of just treating symptoms that may appear as mental health but may be something else entirely?
I love this helpful advice. I started low-dose estrogen patch/medroxyprogesterone pill in 2022 due to never-ending hot flashes/night sweats (I struggled through it for a/b 8 years in perimenopause and when full menopause didn't resolve these issues, I asked for MHT). However, I discontinued them pretty quickly after getting COVID. Given that COVID raises everyone's risk for cardiovascular problems, including clotting (for at least 1 year), I was hesitant to mix these risks, esp with COVID post-infection risk data continuing to be published (and continuing to be alarming). Do you think this should change our risk calculus these days, given how frequent COVID infections are? (most people can expect 2/year these days). I'm currently just using vaginal estrogen (and suffering night sweats and some hot flashes, although fewer, now 10 years after onset of these symptoms), but considering re-starting the MHT. Still, I worry about post-COVID risks mixed w/ the MHT risks! Would love to have a blog post on this issue!
Does having a radial scar (removed, benign) put someone at higher risk for breast cancer and if so, is it >1?
Hi there. Thanks for this article! Very informative! I'm about to turn 52, and have a question about estrogen therapy. I had a hysterectomy (uterus only) at age 49, and started getting menopausal symptoms (hot flashes and night sweats/disrupted sleeping, brain fog) in earnest at age 50. At that time, my nurse practitioner prescribed transdermal estrodiol (0.0375 mg/day), but follow-up blood tests indicated that my estrogen levels were abnormally high (Estrogen total, serum, 769.2; Estrodiol 276). I switched to the oral etrodiol, and a subsequent test showed my levels had lowered (Estrogen total serum: 555.5, Estrodiol: 59). But the nurse practitioner still thought it would be a good idea to stop the estrogen. I've tried using testosterone (topically), but it actually made my symptoms worse. I'm wondering if you'd advise trying an even lower does of transdermal or oral estrogen, or if I should stay away from estrogen. My hot flashes and night sweats seem to be getting better with time, but would love something to cut through the brain fog. I'd appreciate any advice you have on the matter, or questions I should ask my doctor. Thanks!
There was no reason to check your estradiol levels. You may still be ovulating, and she likely caught that with the estradiol of 276. There is no reason to do a total serum estrogen, so the fact you have that test result tells me the person you are seeing might not be up to date. Also, estrogen doesn't help brain fog. We treat based on symptoms. So when a 52-year-old with hot flashes comes to me and is a candidate for estrogen, we start it without blood tests.
Thank you for the info, always appreciated. I wanted to ask a clarifying question. I hear a lot about how estrogen actually helps to prevent CVD risk and that a drop in estrogen during menopause can contribute to rising cholesterol levels. Is this supported by the research? And with MHT the risk is specifically about blood clots, while there may be other cardiac benefits of MHT?
The current recommendation is not to prescribe MHT for cardiovascular reasons (meaning preventative care).
I had messaged you before about spotting after starting HRT (0.05 patch and 100mg micro prog). I started HRT 2 months ago, light spotting after 2 weeks; I did inform my gyn and was told to monitor. 3 weeks later spotted again. Now 2 solid months in I started bleeding a few days ago but it’s a period, not spotting. I called my gyn again and was told to monitor and see her in f/u next month. The bleeding is slowing down but do I need to push to be seen asap? Do I need to stop the prog? I’m confused and frustrated and quite frankly fucking depressed. Would love your guidance.
Many factors go into managing bleeding on menopausal hormone therapy, including (but not limited to) age, family history, risk factors for endometrial cancer, and if the hormones are started before or after your final period. Only your provider who knows your personal history can tell you if this bleeding is a concern or not and the next steps.
I just turned 60 and had my last period 12 months ago, but I've been on Prometrium for the past year. I'd like to start transdermal estradiol (hot flashes getting ridiculously unbearable), so is it 60 years and/or 10 years since LMP? Are there any data for us late bloomers? Also one GYN says to stop vaginal estrogen and another one says to keep it. Who to believe? Thank you.
There is no reason to stop vaginal estrogen.
For someone having periods past 55, it is essential to try to make sure those are really periods and not bleeding after menopause which is being mistaken for periods. So that is up to you and your doctor to decide. If someone's last period was truly at age 59, and they had an ASCVD score < 5% and were at a low risk for breast cancer and no other health issues, then I would probably be ok offering transdermal estrogen for hot flashes. Obviously, only you and your doctor can decide what is right for you.
Offering support from another "late bloomer." I had my last period just before turning 60, so menopause at almost 61. Until they stopped, my periods had been regular, every month. Nonetheless, at age 58 my doctor had me undergo a transvaginal ultrasound to make sure all was okay, which it was. I started vaginal estrogen at age 61 and transdermal estradiol and progesterone a few years later, at age 64.
I just turned 53 and went through meno with uterus at 49. I am incredibly progesterone intolerant. I am still having night sweats, joint pain but I am extremely active and just flat mood and flat energy since meno. I’m not finding much on Duavee as far as reviews go. Would the estrogen in Duavee “possibly” help with joint/mood also? I know none of it is a guarantee but I am not finding any reviews by anyone that has taken it. I have a RX for it but I am scared to fill it.
Duavee is Premarin and that was the gold standard for MHT for years. It's excellent for symptom relief. Estrogen helps depression before menopause, but after it doesn't seem to have an effect (unless mood is related to sleeping poorly from night sweats, then it can). You can read more about estrogen and joint pain and menopause here https://vajenda.substack.com/p/muscle-and-joint-pain-in-menopause Generally, for someone who is a good candidate for estrogen (low ASCVD and low-risk breast cancer and not risk clots) trying estrogen for 6 months to see if it helps with joint pain is reasonable, but the decision is obviously up to you and your provider. I wouldn't go by reviews, because those are anecdotes and there are lots of both placebo and nocebo reports from medications online. If you read the piece I linked it will tell you what the data says and that is more accurate. Hope that helps!
Thank you so much! Appreciate all you do advocating for us <3
I have been considering a trial of transdermal plus a progesterone for hot flushes, osteoporosis risk and possible help with joint pain. I haven’t found anything regarding risks of hormone therapy with a history of endometriosis. Have you seen research on this?
I'm in the process of getting the info for the 6 steps. And I'm very much looking forward to the future Menopause Transition section! Specifically wondering how to know if you've started the transition?
I'm 40, not on hormonal birth control, and my cycles vary by a few days each month (which is regular for me). But my periods vary wildly in duration and intensity. I'll have a month or two where my period is just 2 days of light bleeding. Then the next month is so heavy it's cramps and nausea and 7 days long. Rinse and repeat.
Does this indicate I'm starting in the transition? (I also have night sweats, dryness, among others.) Would MHT help? Or is it too early to start?
Thank you so much for all you do! So grateful for your time!
Thank you for your reply!
They were not dense before MHT, they gotten bigger as well as more dense in the last year so I hope they change back once I wean off my estrogen patch.
I have been cutting my 25mg patch in half to help ween.
Thanks for all your work and information sharing!
Dr. Jen, I'm still confused about the dense breast tissue issue, which I've read that 50% of women have(!). So, mammograms don't detect breast cancer very well when we have dense breast tissue, but we're supposed to have a mammogram (I do the 3D ones) before starting MHT to rule out any breast cancer risk? Should we be paying out of pocket for ultrasounds?
I'm 51 and already on MHT for a couple years now, mainly for hot flashes (very late peri/early post-meno at this point), but also for osteoporosis prevention since my mom and her mom had it. I started at a .025 patch (plus progesterone because I have a uterus), tried increasing to .05 for a while to see if it would help with depression in the transition, but breasts were enlarged and sore all the time, so now I'm trying .0375 but might go back down to .025 because I'm always worried about breast cancer risk. I assume the lower dose estrogen patch = less risk.
But I just don't know how to weigh breast cancer risk on MHT with dense breast tissue if mammograms aren't reliable. My Gail score is around 2%. Couldn't do the other one because the link is broken. Thank you for any additional insights.
Mammograms save lives. And while they are not as good a screening tool for dense breasts as they are for those without dense breasts, they are still good, and their value shouldn't be dismissed. Estradiol levels in the blood seem related to breast cancer risk, but that is for people not on hormone therapy. There are recommendations for who should have additional screening with dense breasts, and I will be writing a post about that soon. Let me check on that link!
Thank you -- looking forward to your post about that! I will definitely continue to get my annual 3D mammogram, at a minimum. I've been reading that some states may start requiring insurance to pay for additional screenings for those of us with dense breast tissue.