I am a family doctor practicing full range general family medicine in Canada. I subscribed to The Vajenda to help guide my discussions with women in decision-making about HRT, menopause and other issues related to women's health. Just wanted to thank you very much for this, and other, articles. They are incredibly helpful in the discussions about treatment with women in my practice. I use many of them regularly.
Your lucky patients!!!!!! Please let all of your colleagues know! My doctor told me he read Dr. Jen's Vagina Bible, but then he tried to run a hormone test on me to see if I was in perimenopause (I was 49 and suffering MANY of the telltale symptoms).
Thank you so much for this! it is such battle against misinformation-The only recent check I've done was in a woman who had recurrence of horrible menopausal symptoms after being stable on her combi patch for years and had undetectable estradiol and progestin levels, so I did feel like that was helpful, albeit strange--heard of any bad batches/counterfeits? -I switched her to a different patch (she did not want to take oral) and she felt like new in several days!
I feel certain that a generic form for Lyllana that I received was a bad batch. I too had an alarming recurrence of symptoms. It was filled by Amazon and came from Grove Pharmaceuticals (out of Miami, Florida).
I'm in surgical menopause because of BRCA and I'm struggling with HRT. I don't feel like it's working for me at all on the patch but I'm scared of taking oral estradiol. This is helpful for framing my conversation with doctors but I feel like no one knows enough. Help!
Wondering about this aspect of your article "Even a 14 mcg patch or Premarin 0.3 mg offers protection for bone, albeit less. Bone is exquisitely sensitive to estrogen."
Is prescribing estrogen part of the standard of care for osteoporosis? I ask because I was diagnosed with osteoporosis based on a broken ankle from a standing height fall and have been prescribed alendronate sodium tablets once a week but when I asked my doctor (who is a rheumatologist, treats arthritis, autoimmune disorders and osteoporosis) she said estrogen is not standard treatment for osteoporosis. I am wondering if that statement is correct or if I am missing out on a potentially beneficial treatment.
Estrogen is not proven to treat osteoporosis, so it is not part of the standard of care per se, but it would not be wrong to add it in with the diagnosis assuming someone is under age 65. It is FDA approved for prevention of osteoporosis and should be considered for those at high risk. For example, I am taking MHT for that reason as I have an elevated FRAX score and my mother died from an osteoporosis related complication and her osteoporosis started early, likely in her mid 50s.
Thank you very much for answering my question. I am 57. As with any human, it is not simple because there is a history of both cardiovascular disease and stroke in my family - although I have not experienced either type of event yet. My family history with those types of events may be part of the reason that only the bone medication was recommended. At any rate, I REALLY appreciate your articles and comments, both of which help me navigate what I find to be a very confusing landscape. Thank you!
I have MHT for heart palpitations and night sweats. If I stick to one 100 patch I get sweats if I raise it by half a patch to 150 they go overnight. I was advised to go over the licensed level because of the low absorption issue. Am I putting myself at risk doing this?
What is also confusing (for me at least) is that hypothyroid and hyperthyroid (hot flashes for sure) have basically the same symptoms as peri and menopause. Oral estrogen will impact a woman who takes a thyroid replacement, but there is contradicting information regarding the use of transdermal delivery (including vaginal products) on thyroid levels. The list of possible side effects for any form of estrogen (as listed in the product monographs and package inserts) are also a concern for so many women.
I have been on thyroid replacement for 40+ years, and have levels checked 2x a year. I have used vaginal estrogen for 3 years and estrogen patch for 1.5 years with no impact one way or the other on my thyroid levels.
I appreciate your response. Thank you. I get conflicting information from medical people as well as pharmacists. The product monographs for transdermal estrogen as well as vaginal estrogen needs to be updated.
They do, especially the vaginal estrogen which has the information related to oral estradiol including even though it does not go systemic in a significant way. They are based on findings from the WHI (I believe). My endocrinologist said oral estradiol is the most likely to impact thyroid levels and even with that it doesn't mean someone couldn't use it, just they would maybe need more frequent monitoring of thyroid.
Yes the endocrinologist I go to (and through all of my research etc into all this through a univeristy data base at my work) oral estrogen definitely can impact thyroid medication and a need to increase the dose. I was told many years ago when first starting the thyroid medication (replacement) I could not use it because of the thyroid level. That person thankfully has retired. I was over replaced with synthroid for many years and had to take things into my own hands not hers. Once again I appreciate your responses.
So confusing. I was on HrT for a year for bone health. I don’t have other symptoms. My ob tested my level and upped my dose. I bleed for 3 months. Freaked me out so stopped HrT and now wondering if I should start back on original low dose. Bleeding stopped and feel fine otherwise.
Something is not clear to me. If symptoms persist, should my doctor increase my Estrogel dosage and see if it helps? A doctor told me that all women are prescribed the same dosage... which seems very weird to me, but I don't have any medical training. I'm just trying to survive perimenopause!
It depends. Are the symptoms something that should definitely respond to estrogen and what dose? If someone is on a maximum licensed transdermal dose more will not help. It’s wise to discuss what symptoms are still bothersome and if they can reasonably be expected to be treated with estrogen increase the dose if someone isn’t on the max. If they are on the max, then switch to oral.
Is there a comprehensive list somewhere of what symptoms each hormone should and shouldn't help with? I know you share them in articles, but it would help me to have a complete list I could show my doctor. I absolutely love my doctor(and it took 4 years and many bad doctors before her to find her) she listens, respects my questions and concerns, but I know the clinic she works at is feeding her the Kool Aid(she talked about the Oprah show my last visit 🙄) I just would like something to share with her to back up why I'm not choosing to take all her recommendations. She asked me why I didn't want to take testosterone last visit.
Thank you! This is very helpful! I appreciate it! Now to see if I can find a cliff notes version of it to give my doctor a 1 page simplified version plus all the data.
This is so great! I try desperately to educate patients on this on the daily and always end up caving and ordering some lab for them because I don't have time or energy spending entire visits arguing everything in this excellent write up. I tend to then favor ordering FSH as a marker for absorption. From baseline ( prior to HRT) to after, suppression always occurs and I have relied on this to demonstrate ( more like appease) their absorption along with symptom relief as our benchmarks. Thoughts on the usefulness of FSH?
Great post! I agree completely. Some women/providers base so much on a serum estradiol level. Then they wonder why they feel poorly because they think they need more. It is very nuanced when testing in the serum based on timing and delivery method.
First time commenter, so firstly thank you: I have learned so much from these posts over the past few months, they've been truly helpful. Wonder if there's anything useful to learn about high estrogen levels, especially in context of greater swings in the menopause transition? (Not due to hormone treatment) My vague and unqualified impression is some of the symptoms (mood, in particular) can be similar to low estrogen.
« As BMI goes up, so do estradiol levels. » I didn’t know! Does it mean that overweight women in perimenopause should be dosed less in HRT? Thanks for the consistently rigorous and useful newsletters!
No, we treat based on symptoms. But the increase in estradiol for women with a higher BMI is likely one contributor to the higher risk of endometrial cancer.
Not necessarily low, it can also be a change. And there are individual sensitivities, so some have symptoms with lower levels and others do not. Estrogen tells the brain it isn't hot, so when that brake on heat, if you will, goes away, the systemic becomes more sensitive to heat. Estrogen works on KNDy neurons. But hot flashes can have other causes as well.
I am a family doctor practicing full range general family medicine in Canada. I subscribed to The Vajenda to help guide my discussions with women in decision-making about HRT, menopause and other issues related to women's health. Just wanted to thank you very much for this, and other, articles. They are incredibly helpful in the discussions about treatment with women in my practice. I use many of them regularly.
Your lucky patients!!!!!! Please let all of your colleagues know! My doctor told me he read Dr. Jen's Vagina Bible, but then he tried to run a hormone test on me to see if I was in perimenopause (I was 49 and suffering MANY of the telltale symptoms).
Thanks for the detail. I missed the letters to the editor responses and post-analysis.
Thank you so much for this! it is such battle against misinformation-The only recent check I've done was in a woman who had recurrence of horrible menopausal symptoms after being stable on her combi patch for years and had undetectable estradiol and progestin levels, so I did feel like that was helpful, albeit strange--heard of any bad batches/counterfeits? -I switched her to a different patch (she did not want to take oral) and she felt like new in several days!
I feel certain that a generic form for Lyllana that I received was a bad batch. I too had an alarming recurrence of symptoms. It was filled by Amazon and came from Grove Pharmaceuticals (out of Miami, Florida).
I'm in surgical menopause because of BRCA and I'm struggling with HRT. I don't feel like it's working for me at all on the patch but I'm scared of taking oral estradiol. This is helpful for framing my conversation with doctors but I feel like no one knows enough. Help!
Wondering about this aspect of your article "Even a 14 mcg patch or Premarin 0.3 mg offers protection for bone, albeit less. Bone is exquisitely sensitive to estrogen."
Is prescribing estrogen part of the standard of care for osteoporosis? I ask because I was diagnosed with osteoporosis based on a broken ankle from a standing height fall and have been prescribed alendronate sodium tablets once a week but when I asked my doctor (who is a rheumatologist, treats arthritis, autoimmune disorders and osteoporosis) she said estrogen is not standard treatment for osteoporosis. I am wondering if that statement is correct or if I am missing out on a potentially beneficial treatment.
Thank you!
Estrogen is not proven to treat osteoporosis, so it is not part of the standard of care per se, but it would not be wrong to add it in with the diagnosis assuming someone is under age 65. It is FDA approved for prevention of osteoporosis and should be considered for those at high risk. For example, I am taking MHT for that reason as I have an elevated FRAX score and my mother died from an osteoporosis related complication and her osteoporosis started early, likely in her mid 50s.
Thank you very much for answering my question. I am 57. As with any human, it is not simple because there is a history of both cardiovascular disease and stroke in my family - although I have not experienced either type of event yet. My family history with those types of events may be part of the reason that only the bone medication was recommended. At any rate, I REALLY appreciate your articles and comments, both of which help me navigate what I find to be a very confusing landscape. Thank you!
HRT offers heart protection as well!
I have MHT for heart palpitations and night sweats. If I stick to one 100 patch I get sweats if I raise it by half a patch to 150 they go overnight. I was advised to go over the licensed level because of the low absorption issue. Am I putting myself at risk doing this?
What is also confusing (for me at least) is that hypothyroid and hyperthyroid (hot flashes for sure) have basically the same symptoms as peri and menopause. Oral estrogen will impact a woman who takes a thyroid replacement, but there is contradicting information regarding the use of transdermal delivery (including vaginal products) on thyroid levels. The list of possible side effects for any form of estrogen (as listed in the product monographs and package inserts) are also a concern for so many women.
I have been on thyroid replacement for 40+ years, and have levels checked 2x a year. I have used vaginal estrogen for 3 years and estrogen patch for 1.5 years with no impact one way or the other on my thyroid levels.
I appreciate your response. Thank you. I get conflicting information from medical people as well as pharmacists. The product monographs for transdermal estrogen as well as vaginal estrogen needs to be updated.
They do, especially the vaginal estrogen which has the information related to oral estradiol including even though it does not go systemic in a significant way. They are based on findings from the WHI (I believe). My endocrinologist said oral estradiol is the most likely to impact thyroid levels and even with that it doesn't mean someone couldn't use it, just they would maybe need more frequent monitoring of thyroid.
Yes the endocrinologist I go to (and through all of my research etc into all this through a univeristy data base at my work) oral estrogen definitely can impact thyroid medication and a need to increase the dose. I was told many years ago when first starting the thyroid medication (replacement) I could not use it because of the thyroid level. That person thankfully has retired. I was over replaced with synthroid for many years and had to take things into my own hands not hers. Once again I appreciate your responses.
So confusing. I was on HrT for a year for bone health. I don’t have other symptoms. My ob tested my level and upped my dose. I bleed for 3 months. Freaked me out so stopped HrT and now wondering if I should start back on original low dose. Bleeding stopped and feel fine otherwise.
There was no reason for your doctor to test and this is exactly how levels can be harmful!
Something is not clear to me. If symptoms persist, should my doctor increase my Estrogel dosage and see if it helps? A doctor told me that all women are prescribed the same dosage... which seems very weird to me, but I don't have any medical training. I'm just trying to survive perimenopause!
It depends. Are the symptoms something that should definitely respond to estrogen and what dose? If someone is on a maximum licensed transdermal dose more will not help. It’s wise to discuss what symptoms are still bothersome and if they can reasonably be expected to be treated with estrogen increase the dose if someone isn’t on the max. If they are on the max, then switch to oral.
Is there a comprehensive list somewhere of what symptoms each hormone should and shouldn't help with? I know you share them in articles, but it would help me to have a complete list I could show my doctor. I absolutely love my doctor(and it took 4 years and many bad doctors before her to find her) she listens, respects my questions and concerns, but I know the clinic she works at is feeding her the Kool Aid(she talked about the Oprah show my last visit 🙄) I just would like something to share with her to back up why I'm not choosing to take all her recommendations. She asked me why I didn't want to take testosterone last visit.
The Menopause Society Guidelines state what symptoms/conditions have evidence for using MHT. https://menopause.org/wp-content/uploads/professional/nams-2022-hormone-therapy-position-statement.pdf
Thank you! This is very helpful! I appreciate it! Now to see if I can find a cliff notes version of it to give my doctor a 1 page simplified version plus all the data.
that is not true at all that all women are given the same dosage. The patches come in several different strengths as does oral and gel formulations.
This is so great! I try desperately to educate patients on this on the daily and always end up caving and ordering some lab for them because I don't have time or energy spending entire visits arguing everything in this excellent write up. I tend to then favor ordering FSH as a marker for absorption. From baseline ( prior to HRT) to after, suppression always occurs and I have relied on this to demonstrate ( more like appease) their absorption along with symptom relief as our benchmarks. Thoughts on the usefulness of FSH?
It's not studied, so what level corresponds with symptom relief? We don't know.
why not just use symptoms as your marker?
Sounds like you may have already read the Menopause Manifesto or the rest of the hormone guide section of this substack!
I'm a total fangirl!
Fanboy here. But I’m a little biased.
As my post indicated it is usually patients pushing for labs.
It is a real concern and they hear it so much on social media they assume it must be valid
Great post! I agree completely. Some women/providers base so much on a serum estradiol level. Then they wonder why they feel poorly because they think they need more. It is very nuanced when testing in the serum based on timing and delivery method.
First time commenter, so firstly thank you: I have learned so much from these posts over the past few months, they've been truly helpful. Wonder if there's anything useful to learn about high estrogen levels, especially in context of greater swings in the menopause transition? (Not due to hormone treatment) My vague and unqualified impression is some of the symptoms (mood, in particular) can be similar to low estrogen.
I honestly don’t know how this study got to print SMH.
« As BMI goes up, so do estradiol levels. » I didn’t know! Does it mean that overweight women in perimenopause should be dosed less in HRT? Thanks for the consistently rigorous and useful newsletters!
No, we treat based on symptoms. But the increase in estradiol for women with a higher BMI is likely one contributor to the higher risk of endometrial cancer.
So surprised this was in Menpause. Would think their peer review was a bit more robust. Great article!
Yeah, I was so shocked.
Are hot flashes strictly a function of low estrogen?
Not necessarily low, it can also be a change. And there are individual sensitivities, so some have symptoms with lower levels and others do not. Estrogen tells the brain it isn't hot, so when that brake on heat, if you will, goes away, the systemic becomes more sensitive to heat. Estrogen works on KNDy neurons. But hot flashes can have other causes as well.