It is not the ‘Australasian Menopause Society’s Practitioner’s Toolkit’. It is the Menopause Practitioner’s Toolkit produced by the Women’s Health Research Program, which is headed by Professor Susan Davis. You are accessing it on the AMS website (but it is available from other places, too).
We need more of THIS. Chances are good many people will feel like it’s drinking from the water hose when starting to understand menopause. It may not be or seem relevant at the time. Having the tool kit to evaluate new, fuzzy advice or advice where you forget what you heard before is like teaching someone to fish instead of giving them a fish!
Looking for guidance on breakthrough bleeding and hrt. Have been on for twelve years. Changed my entire depression picture. Was able to reduce Prozac on it. But have break thru bleeding a few times a year. I've had four sonograms and four endometrial biopsies...all fine. No changes in sonogram over all this time. No history of feminine cancers in family. Dr wants to take me off but mental health takes a huge hit when I've reduced patch strength. Dr now holding my higher Rx patch hostage unless I do another biopsy. Any advice.
You might want to discuss a hysteroscopy with your doctor to make sure you don't have a polyp and to have a more thorough sampling. You did not say what your endometrial thickness is or the results of the biopsy. There are other results that help tell us what is going on, for example proliferative or atrophic.
This is so helpful. I’m a mental health clinician who often speaks about things like “mood in midlife and menopause,” and I am a behaviorist that uses CBT for meno. I’m usually on a panel with an MSCP that fields questions out of my scope. On occasion I’ll do a talk on the basics of meno (with an emphasis on where to refer) and have had questions about using peptides to treat the MT. How might I answer a question like that without sounding snarky?
Dr Gunter - are you listening to WHAM with Dr Hirsh? Do you agree stopping MHT in older women (>65) can cause CVD? "even more harmful than continuing the MHT.
No idea what WHAM is. The WHI data do not support a spike in coronary deaths after stopping hormone therapy. The postintervention follow-up from both WHI trials showed neutral results for CHD, stroke, pulmonary embolism, and all-cause mortality after women discontinued treatment. This is the highest quality data that we have. There is observational data from Finland which is the likely source of the "rebound risk" claim. A Finnish national study of 1.97 million women-years reported a >2-fold increase in cardiac and stroke deaths in the first year after stopping MHT (median age at stopping: 59 years). Is this the reference that is being used? I wrote about the study here https://vajenda.substack.com/p/estrogen-the-heart-and-the-hype and this study cannot tell us why women stopped their medication. For example, if they stopped because of illnesses, then we might expect them to have higher rates of cardiac death and stoke. Besides being observational. the Finnish study doesn’t report on the type of MHT, so estrogen alone and estrogen plus a progestin are lumped together, and no doses are given. In one arm, women on MHT were compared to national averages—not age-, health-, or risk-matched controls, so that’s another issue. In this arm, when women under age 60 years stopped MHT, they had a 27% increased risk of death from heart attacks in the first year. That sounds alarming—until you consider that once the women got past that year, there was a 25% reduction in heart attack deaths. So, depending on how you slice the data, you could just as easily claim that stopping MHT protects the heart in the long-term. If stopping hormones killed women, the WHI would have told us.
Mass general brigham Women’s health and menopause 2026 conference. Really challenging all the fact based science based facts I’m learning from you and Dr Dunsmoor-su. My brain is broken! 😆 I’m desperate to stay up to date and factual for my patients.
That is atrocious. The WHI gives us excellent data here. The cardiovascular disease curves were identical for 3 years after stopping. We can't get better data than this!
Dr. Jen - there are other more appropriate posts on which I could post this question as a comment, but I'm afraid the question would be missed as the more appropriate posts are older!
Is there any evidence that either estradiol (transdermal or vaginal cream, as MHT) or sunlight can "aggravate" HSV-2 and cause worsening or more frequent outbreaks?
(Also, what's with all the info indicating that outbreaks lessen over time?? I'm 64 and have more now than I did when I likely contracted the virus in my 20's.)
I was considering adding vaginal estrogen cream to my very low dose (.025mg) transdermal estradiol (started due to an osteoporosis diagnosis) but, because I have a bit of "ick" attached to the idea of applying the cream where my outbreaks occur, and because of the concern that it may aggravate the virus, I stumbled on info about transdermal gels, specifically Estrogel. The product claims to "Treat moderate to severe menopausal changes in and around the vagina."
Now wondering if I could replace the patch + cream with just Estrogel - if it also might help stabilize my bones AND provide relief for my GSM symptoms (minor incontinence)?
Of course, if what you find indicates that ANY estrogen therapy can aggravate HSV-2, maybe that's not my answer...
Great resource to help women navigate this space. The only point I would dispute is regarding validating a doctor’s credentials- it suggests that you only value the opinion of those who have done research in the area, but not the many clinicians who specialise in menopause care (though not actively involved in research) and treat patients on a daily basis. How a study fits into existing clinical practice- not just the body of existing literature- is equally important.
The point is about people who disagree with the guidelines. What other work have they shown that supports being against the guidelines and what are their credentials to disagree? If they are an active researcher in the space, I am much more interested in knowing more than someone who has done no research and who is quoting old papers.
I take onboard your point. Quoting old papers I agree- particularly if there are more recent and robust studies . But clinical experience and expertise should also be taken into consideration. Guidelines are a guide to clinical practice- and in many other areas of medicine reputable clinicians don’t always agree with the details of all guidelines.
This guideline is a way for people to quickly verify content. If a reputable physician actually has good data the other parts of this checklist should apply. If someone is only using their clinical expertise, that is the lowest quality data and of course I would question what that physician says if they are an outlier. Doctors making claims base don their own expertise when we have data that say otherwise is how we get things like ivermectin or practices telling everyone they should be on testosterone. If the data is there, someone should be able to prove it.
We need more of THIS. Chances are good many people will feel like it’s drinking from the water hose when starting to understand menopause. It may not be or seem relevant at the time. Having the tool kit to evaluate new, fuzzy advice or advice where you forget what you heard before is like teaching someone to fish instead of giving them a fish!
I love this rundown, thank you! It's a great guideline for so many other spaces as well.
It is not the ‘Australasian Menopause Society’s Practitioner’s Toolkit’. It is the Menopause Practitioner’s Toolkit produced by the Women’s Health Research Program, which is headed by Professor Susan Davis. You are accessing it on the AMS website (but it is available from other places, too).
Thank you, will make the change
We need more of THIS. Chances are good many people will feel like it’s drinking from the water hose when starting to understand menopause. It may not be or seem relevant at the time. Having the tool kit to evaluate new, fuzzy advice or advice where you forget what you heard before is like teaching someone to fish instead of giving them a fish!
Looking for guidance on breakthrough bleeding and hrt. Have been on for twelve years. Changed my entire depression picture. Was able to reduce Prozac on it. But have break thru bleeding a few times a year. I've had four sonograms and four endometrial biopsies...all fine. No changes in sonogram over all this time. No history of feminine cancers in family. Dr wants to take me off but mental health takes a huge hit when I've reduced patch strength. Dr now holding my higher Rx patch hostage unless I do another biopsy. Any advice.
You might want to discuss a hysteroscopy with your doctor to make sure you don't have a polyp and to have a more thorough sampling. You did not say what your endometrial thickness is or the results of the biopsy. There are other results that help tell us what is going on, for example proliferative or atrophic.
This is so helpful. I’m a mental health clinician who often speaks about things like “mood in midlife and menopause,” and I am a behaviorist that uses CBT for meno. I’m usually on a panel with an MSCP that fields questions out of my scope. On occasion I’ll do a talk on the basics of meno (with an emphasis on where to refer) and have had questions about using peptides to treat the MT. How might I answer a question like that without sounding snarky?
Dr Gunter - are you listening to WHAM with Dr Hirsh? Do you agree stopping MHT in older women (>65) can cause CVD? "even more harmful than continuing the MHT.
No idea what WHAM is. The WHI data do not support a spike in coronary deaths after stopping hormone therapy. The postintervention follow-up from both WHI trials showed neutral results for CHD, stroke, pulmonary embolism, and all-cause mortality after women discontinued treatment. This is the highest quality data that we have. There is observational data from Finland which is the likely source of the "rebound risk" claim. A Finnish national study of 1.97 million women-years reported a >2-fold increase in cardiac and stroke deaths in the first year after stopping MHT (median age at stopping: 59 years). Is this the reference that is being used? I wrote about the study here https://vajenda.substack.com/p/estrogen-the-heart-and-the-hype and this study cannot tell us why women stopped their medication. For example, if they stopped because of illnesses, then we might expect them to have higher rates of cardiac death and stoke. Besides being observational. the Finnish study doesn’t report on the type of MHT, so estrogen alone and estrogen plus a progestin are lumped together, and no doses are given. In one arm, women on MHT were compared to national averages—not age-, health-, or risk-matched controls, so that’s another issue. In this arm, when women under age 60 years stopped MHT, they had a 27% increased risk of death from heart attacks in the first year. That sounds alarming—until you consider that once the women got past that year, there was a 25% reduction in heart attack deaths. So, depending on how you slice the data, you could just as easily claim that stopping MHT protects the heart in the long-term. If stopping hormones killed women, the WHI would have told us.
Mass general brigham Women’s health and menopause 2026 conference. Really challenging all the fact based science based facts I’m learning from you and Dr Dunsmoor-su. My brain is broken! 😆 I’m desperate to stay up to date and factual for my patients.
Happy to chat- share info with you. Mandy
That is atrocious. The WHI gives us excellent data here. The cardiovascular disease curves were identical for 3 years after stopping. We can't get better data than this!
Dr. Jen - there are other more appropriate posts on which I could post this question as a comment, but I'm afraid the question would be missed as the more appropriate posts are older!
Is there any evidence that either estradiol (transdermal or vaginal cream, as MHT) or sunlight can "aggravate" HSV-2 and cause worsening or more frequent outbreaks?
(Also, what's with all the info indicating that outbreaks lessen over time?? I'm 64 and have more now than I did when I likely contracted the virus in my 20's.)
Let me look into it!
Were you able to find any evidence that I need to worry about aggravating my HSV-2 if I start estrogen cream? Thank you!
Can I amend my question?
I was considering adding vaginal estrogen cream to my very low dose (.025mg) transdermal estradiol (started due to an osteoporosis diagnosis) but, because I have a bit of "ick" attached to the idea of applying the cream where my outbreaks occur, and because of the concern that it may aggravate the virus, I stumbled on info about transdermal gels, specifically Estrogel. The product claims to "Treat moderate to severe menopausal changes in and around the vagina."
Now wondering if I could replace the patch + cream with just Estrogel - if it also might help stabilize my bones AND provide relief for my GSM symptoms (minor incontinence)?
Of course, if what you find indicates that ANY estrogen therapy can aggravate HSV-2, maybe that's not my answer...
Came across this today as an example.The longevity space is fraught with unproven therapies being peddled to women and men alike. https://www.businesswire.com/news/home/20260310550128/en/Wisp-Debuts-Women-Centric-Longevity-Suite-Via-New-Healthy-Aging-Vertical?utm_campaign=shareaholic&utm_medium=copy_link&utm_source=bookmark
Great resource to help women navigate this space. The only point I would dispute is regarding validating a doctor’s credentials- it suggests that you only value the opinion of those who have done research in the area, but not the many clinicians who specialise in menopause care (though not actively involved in research) and treat patients on a daily basis. How a study fits into existing clinical practice- not just the body of existing literature- is equally important.
The point is about people who disagree with the guidelines. What other work have they shown that supports being against the guidelines and what are their credentials to disagree? If they are an active researcher in the space, I am much more interested in knowing more than someone who has done no research and who is quoting old papers.
…Can you do a post on insufficient fmo3 enzyme and hrt?
I take onboard your point. Quoting old papers I agree- particularly if there are more recent and robust studies . But clinical experience and expertise should also be taken into consideration. Guidelines are a guide to clinical practice- and in many other areas of medicine reputable clinicians don’t always agree with the details of all guidelines.
This guideline is a way for people to quickly verify content. If a reputable physician actually has good data the other parts of this checklist should apply. If someone is only using their clinical expertise, that is the lowest quality data and of course I would question what that physician says if they are an outlier. Doctors making claims base don their own expertise when we have data that say otherwise is how we get things like ivermectin or practices telling everyone they should be on testosterone. If the data is there, someone should be able to prove it.
Fantastic process. So helpful!
We need more of THIS. Chances are good many people will feel like it’s drinking from the water hose when starting to understand menopause. It may not be or seem relevant at the time. Having the tool kit to evaluate new, fuzzy advice or advice where you forget what you heard before is like teaching someone to fish instead of giving them a fish!